key: cord-0707738-fyjv3gsw authors: Kuru, Betul; Kale, Ahmet; Basol, Gulfem; Gundogdu, Elif Cansu; Yildiz, Gazi; Mat, Emre; Usta, Taner title: Is it safe to perform elective gynaecologic surgery during the two peaks of COVID‐19 pandemic? date: 2021-09-15 journal: Int J Clin Pract DOI: 10.1111/ijcp.14816 sha: 975f2366726afe0b3194efd6b952d2e101071f7a doc_id: 707738 cord_uid: fyjv3gsw PURPOSE: In December 2019, the COVID‐19 pandemic started in China and spread around the World. Operations were postponed in most surgical clinics to reduce the risk of contamination and increase the number of beds available in hospitals. We investigate whether elective gynaecologic surgery is safe or not under safety measures. METHODS: A total of 765 patients were operated on electively between 15 March and 30 October 2020 at our inpatient gynaecology clinic. We took the SARS‐CoV‐2 Reverse Transcriptase (RT) Polymerase Chain Reaction (PCR) test of the nasopharyngeal swab before and after the surgery. Patients were questioned for COVID‐19 symptoms by phone calls on the 7th, 15th, 30th and 60th days postoperatively. RESULTS: The average age of patients was 45.6 ± 11(19‐81). Sixty‐two (8.1%) operations were performed due to gynaecologic malignancies. Three patients (0.39%) were detected as SARS‐CoV‐2 RT PCR positive within 7 days after surgery. The patients did not need ICU admission or any further treatments. CONCLUSION: Our study offers a novel perspective on elective surgery during a pandemic. The risk assessment of patients should be meticulously done and substantiated on objective variables. According to our study, in a carefully selected patient population, operating under appropriate precautions, elective gynaecologic surgical procedures during the two peaks of the COVID‐19 pandemic do not pose a risk to the patients. COVID-19. 1 Furthermore, surgery induces an early systemic inflammatory response and causes immune function impairment. 7, 8 Surgical patients who had COVID-19 have higher mortality rates than those who had only COVID-19. 9 In the light of these reports, elective and non-urgent surgeries were postponed in many countries and Turkey. Postponing surgery was thought to be essential to reduce the possibility of infection related to hospitalisation and surgery and was also critical in increasing the number of available beds and staff in the hospital. In addition, operating rooms could be transformed into intensive care unit (ICU) beds to meet the increased ventilator requirement. On the other hand, it is widely assumed that rescheduling elective surgeries will have a noticeable impact on the waiting lists of all surgery clinics. Moreover, delaying surgical procedures for an undetermined time negatively impacts patients' underlying health situation and psychology, particularly for patients with malignancy. 10 Even in benign diseases, postponement of operations may lead to workforce loss and a decrease in the patients' quality of life. The goal of the present article is to summarise our experience with elective gynaecologic surgeries during the two waveforms of the COVID-19 pandemic. In the present article, we describe the preoperative preparations of patients, the preventive measures were presented, which were taken by both health-care providers and patients, and the information was given about the postoperative time, especially complications, more precisely SARS-CoV-2 infection. Patients were questioned for symptoms of COVID-19 or close contact with any COVID-19 infected persons before the procedures and referred to the COVID-19 outpatient clinic in the event of suspicious cases. If the patients were diagnosed with COVID-19, they would be re-evaluated for surgery after 28 days from the diagnosis ( Figure 1 ). Other than the informed consent specific to the scheduled operation, an informed consent form for COVID-19 was created consisting of five parts. The risk of nosocomial SARS-CoV-2 contraction, the general risks of the COVID-19, risk of possible future delays in routine or emergency care, the responsibility of notifying any symptoms to attending surgeon or other health-care professionals about the virus before or after the operation were the main components of the written informed consent form. Best-and worst-case scenarios were clarified for a patient-oriented shared decision-making model. Additionally, and more importantly, patients were encouraged to ask questions expressed fears, concerns and preferences. In our study, we presented our elective gynaecologic surgery experience during the COVID-19 pandemic. We per- On the operation day, the safety measures started with the transport of the patient. The transportation staff and all the medical staff in the operating room wore double examination gloves, hooded protective gowns, rubber boots, safety glasses, protective shields, FFP2 or N95 respirators, and standard surgical masks. The patients were transported directly from their room to the operating theatre to avoid any risk of contamination. The surgeries were performed in an isolated operating room consisted of a chief surgeon, an assistant surgeon, one resident, a chief anaesthesiologist, an assistant anaesthesiologist, one scrub nurse and one circulating nurse. The surgeons and nurses entered the operating room after the anaesthesiologist invited them. Either by laparoscopy or laparotomy, electrocautery was used minimally to reduce the smoke development. If essential, electrocauterisation was not prolonged in one location and not used with high voltage settings. Additional safety measures were taken to minimise the exposure of aerosols during the laparoscopic procedures. All instruments and suction systems were checked before laparoscopy. The abdomen was insufflated through the Verres needle, the intra-abdominal pressure was maintained at the possible lowest level, and the Verres needle was closed during removal. Suitable holes were created to ensure leakfree trocars, and at the introduction, the trocars were ascertained to be closed. Instrument changing was kept at minimum. Before the end of the surgery or converting to laparotomy, pneumoperitoneum and smoke were evacuated through a closed suction system. After the operation finished, the patients recovered in the operating room, and same as before surgery, directly transferred to their room, bypassing the postoperative unite. After surgery, a patient-controlled analgesia device was applied to relieve pain and minimise contact with the medical staff. No companions or visitors were allowed in the inpatient clinic to reduce the risk of SARS-CoV-2 infection after the operation. After each operation, all operating theatre surfaces were disinfected with diluted chlorine bleach (≥500 ppm). 11 The subsequent surgery patient was taken to the operating room 30 minutes after the end of the disinfection. The Enhanced Recovery after Surgery protocol (ERAS) was applied after operations. 12 The patients were encouraged for early mobilisation at the sixth postoperative hour. On the first postoperative day, the patients were transferred to another newly disinfected and well-ventilated room. The discharge was decided when the patient was able to take care of herself since our aim was the continuation of social isolation as much as possible after the discharge. Specifically, the importance of not accepting any visitors in their homes during the recovery period was explained repeatedly. Six hours before discharge, the last SARS-CoV-2 RT PCR test was taken from the patients. If the test was positive, the discharge was postponed, thorax CT was carried out, the Infectious Disease consultation was requested, and the patients were kept under surveillance for at least 5 more days to detect possible symptoms. After discharge, patients were questioned for COVID-19 symptoms by phone calls on the 7th, 15th, 30th and 60th days postopera- Preoperatively, all patients were SARS-CoV-2 RT PCR negative in this study. The average age of patients was 45.6 ± 11 . The most common indication for surgery was abnormal uterine bleeding (25.3%), unresponsive to conservative medical management. Patients' clinical characteristics, including age, medical comorbidities, previous abdominal surgeries and surgery indications, were displayed in Table 1 . Sixty-two (7.7%) operations were performed due to gynaecologic malignancies. Additionally, 74 (9.7%) surgeries were planned for the excision of premalignant lesions. Independently from precancerous and malignancy procedures, 412 (51.4%) underwent hysterectomy for benign gynaecologic diseases. The distribution of surgical procedures was detailed in Table 2 . Table 4 . The common symptoms such as fever, cough, sore throat, dyspnoea, headache, myalgia, gastrointestinal symptoms, anosmia or ageusia were not detected during these 5 days. Although thorax CTs revealed bilateral ground-glass opacities, their transcutaneous hemoglobin oxygen saturations were remained normal in room air. ICU admission was not required, and at the end of the 5-day observation, patients were discharged by notifying the home health-care services. The goal of the present article was to investigate whether it is safe or not to perform elective surgeries during the COVID-19 pandemic under safety precautions. Our results showed that the incidence of early postoperative COVID-19 was 0.39%. All the SARS-CoV-2 RT PCR positive patients after elective surgery in this study were asymptomatic and did not require ICU admission. In contrast with our results, Lei COVID-19 undergoing surgery tend to have worse outcomes. Especially respiratory problems, ICU admission and overall mortality seem to be higher. 9 can be compensated in 45 weeks. 16 Based on this modelling, a pandemic that could last up to a year will likely take more than 3 years to eliminate the workload that will arise. 20 Furthermore, pneumoperitoneum desufflation can contaminate the operating theatre with blood and bodily fluids, and aerosols are more concentrated in pneumoperitoneum. 21 Over and above, electrocautery can create surgical smoke particle-sized 0.07-6.5 microns. This particle can contain viral particles as HIV, poliovirus or HPV. 22 When all this information is evaluated together, there is a theoretical risk of contagion of the virus with the smoke and aerosol during laparoscopy. On the other hand, Cheng and colleagues identified SARS-CoV-2 in environmental samples; however, the same authors did not detect SARS-CoV-2 in air samples in the very same area. 23 Similarly, in another study involving 75 465 COVID-19 cases, airborne transmission of the virus was not reported. 24 We cannot ignore the fact that laparoscopy has fewer adverse cardiac and pulmonary side effects, and patients have a shorter recovery period and hospitalisation time. Using personal protective equipment, checking instruments and suction systems before the operation, preventing gas leakage from Vessel needle or trocars, maintaining pneumoperitoneum at the lowest levels, using electrocautery minimally and evacuating the gas with a closed suction system after the operation or in case of converting to laparotomy are facile and feasible precautions. 25 In conclusion, these safety measurements are also effortless methods that can prevent all the theoretical ways of virus transmission described above. Our study has two main limitations that must be acknowledged. differs according to the swab sample collecting day. 26 Moreover, the false-negativity reduces 8 days after the infection, on an average of 3 days after the onset of symptoms. 27 In line with these information, it could not be concluded whether the infection was contracted in the hospital or had not been detected with the tests before the surgery. Although these limitations, our study cannot be ruled out entirely. Our study gives information on the incidence and the clinical features of the patients with COVID-19, which were detected after surgery during the two peaks of the COVID-19 pandemic in Turkey. We think that our study can provide selective information with a large number and variety of patients to make surgery decisions in possible future pandemics. In our study, we presented our elective gynaecologic surgery experience during the COVID-19 pandemic. We performed elective operations on non-COVID-19 patients, and we gave information about the clinic features of the patients diagnosed with COVID-19 after the operation. Taken together, our study offers a perspective on elective gynaecologic surgery during the two peaks of a pandemic. According to our study, in a carefully selected patient population, operating under appropriate precautions does not pose a risk to the patients. None. 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