key: cord-302104-wjad5q9q authors: Pavan, Nicola; Crestani, Alessandro; Abrate, Alberto; Nunzio, Cosimo De; Esperto, Francesco; Giannarini, Gianluca; Galfano, Antonio; Gregori, Andrea; Liguori, Giovanni; Bartoletti, Riccardo; Porpiglia, Francesco; Simonato, Alchiede; Trombetta, Carlo; Tubaro, Andrea; Ficarra, Vincenzo; Novara, Giacomo title: Risk of Virus Contamination Through Surgical Smoke During Minimally Invasive Surgery: A Systematic Review of Literature on a Neglected Issue Revived in the COVID-19 Pandemic Era date: 2020-06-05 journal: Eur Urol Focus DOI: 10.1016/j.euf.2020.05.021 sha: doc_id: 302104 cord_uid: wjad5q9q CONTEXT: The coronavirus disease 2019 (COVID-19) pandemic raised concerns about the safety of laparoscopy due to the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) diffusion in surgical smoke. Although no case of SARS-CoV-2 contagion related to surgical smoke has been reported, several international surgical societies recommended caution or even discouraged the use of a laparoscopic approach. OBJECTIVE: To evaluate the risk of virus spread due to surgical smoke during surgical procedures. EVIDENCE ACQUISITION: We searched PubMed and Scopus for eligible studies, including clinical and preclinical studies assessing the presence of any virus in the surgical smoke from any surgical procedure or experimental model. EVIDENCE SYNTHESIS: We identified 24 studies. No study was found investigating SARS-CoV-2 or any other coronavirus. About other viruses, hepatitis B virus was identified in the surgical smoke collected during different laparoscopic surgeries (colorectal resections, gastrectomies, and hepatic wedge resections). Other clinical studies suggested a consistent risk of transmission for human papillomavirus (HPV) in the surgical treatments of HPV-related disease (mainly genital warts, laryngeal papillomas, or cutaneous lesions). Preclinical studies showed conflicting results, but HPV was shown to have a high risk of transmission. CONCLUSIONS: Although all the available data come from different viruses, considering that the SARS-CoV-2 virus has been shown in blood and stools, the theoretical risk of virus diffusion through surgical smoke cannot be excluded. Specific clinical studies are needed to understand the effective presence of the virus in the surgical smoke of different surgical procedures and its concentration. Meanwhile, adoption of all the required protective strategies, including preoperative patient nasopharyngeal swab for COVID-19, seems mandatory. PATIENT SUMMARY: In this systematic review, we looked at the risk of virus spread from surgical smoke exposure during surgery. Although no study was found investigating severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or any other coronavirus, we found that the theoretical risk of virus diffusion through surgical smoke cannot be excluded. Introduction 19 The severe acute respiratory syndrome coronavirus 2 20 (SARS-CoV-2) and the disease it causes, coronavirus disease surgery, Zheng et al [6] recently reported recommendations 33 for laparotomic and laparoscopic surgery to prevent the risk 34 of aerosol dispersal containing viruses. Specifically, surgical 35 smoke was considered to pose a risk of including active 36 virus, and laparoscopic surgery was considered to increase 37 the risk of contagion due to higher particles of the surgical 38 smoke and the risk of aerosol dispersal through pneumo- 39 peritoneum leakage. Consequently, the authors recom- 40 mended special attention, including minimizing the use 41 of electrocautery, reduction of pneumoperitoneum pres- 42 sure, and generous use of suction devices to remove smoke 43 and aerosol during operations, especially before converting 44 from laparoscopy to open surgery or any extraperitoneal 45 maneuver [6] . Although, to our knowledge, no case of SARS- 46 CoV-2 contagion related to those mechanisms has been 47 reported during surgical procedures, several international 48 surgical societies recommended caution or even discour-49 aged the use of a laparoscopic approach during the pan-50 demic [7] [8] [9] [10] [11] . The issue of the potential risk of surgical smoke has 51 mostly been neglected in surgery in the last decades. 52 However, it is becoming popular due to the present pan- Procedures," "General Surgery," "Surgical Procedures, Oper-84 ative," "surgery." Multiple "free text" searches were also 85 performed, searching for the following terms individually in 86 all fields of the records: "surgical hazard," "surgical bypro-87 ducts," "surgical smoke," and "virus". preclinical data [36, 37] . tion should be better studied and implemented [42] . Third, 292 although the present systematic review followed a strict 293 methodology, the overall quality of the findings is mainly Study concept and design: Pavan, Novara, Ficarra. Acquisition of data: Pavan, Crestani, Abrate, De Nunzio, Esperto. Analysis and interpretation of data: Novara, Giannarini, Galfano, Gregori. American College of Surgeons. 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