key: cord-0744593-oqzjt16n authors: Botteri, Emanuele; Podda, Mauro; Sartori, Alberto title: The COVID-19 pandemic should not take us back to the pre-laparoscopic era date: 2020-05-11 journal: J Trauma Acute Care Surg DOI: 10.1097/ta.0000000000002783 sha: 5b11071f92cc38400140f7b65084903701f283ac doc_id: 744593 cord_uid: oqzjt16n nan We read with interest the manuscript published by Salomone Di Saverio et al in your Journal [1] . We believe that there could not be disagreement on two points: 1. All patients requiring emergency undelayable surgical procedure should be tested for . Awaiting the results of the testing should not delay surgical treatment whenever this is urgently needed. 2. Non-Operative Management strategy of urgent surgical diseases should be considered and proposed to the patient when it's safe and efficient, as it's already done in a majority of centers [2] . However, we have concerns regarding several other points raised in the paper, which we would like to discuss in a constructive way: (2), partial colectomy(4), radical gastrectomy (1), but all recovered [3] . Regarding operators' safety, we reiterate once again that COVID-19 has never been isolated so far from the peritoneal cavity of infected subjects undergoing abdominal surgery, consequently its virulence is not known. Even in case of contamination, i.e. due to bowel opening, laparoscopy offers for sure many more chances to protect operators as all gases are confined into a cavity, compared to the spread due to open surgery. Filtration devices can be extremely affordable and for sure don't impact on hospital economy [4] . Some work still needs to be done in prevention of leaks while exchanging instruments through cannulas, as it's most probable that single use trocars offer a better way to prevent leaks due to the internal double rubber seals, but this requires specific investigation. 2. It's true that a recent meta-analysis of RCTs demonstrated few advantages of laparoscopy compared to open surgery in the treatment of perforated peptic ulcers, but still some advantages were observed, such as reduced rate of wound infection, being most of the other metrics subjective. Laparoscopy for perforated peptic ulcers does not require any dissection, so any particular aerosolization can be expected. 3. Laparoscopic cholecystectomy for acute cholecystitis has a higher incidence of conversion and complications, compared to elective cholecystectomy, but still nobody doubts that the laparoscopic route should be preferred for the evident benefits for the Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. patient. Selection of patients requiring undelayable surgery is mandatory, but then, it seems reasonable to still prefer the laparoscopic route, also considering that the hypothesis of no use of electrocauterization without relevant blood loss might be true for a midline laparotomy, but not in case of a subcostal incision such as for open cholecystectomy. 4. Complete imaging workup is mandatory and not due to the current situation, to minimize diagnostic laparoscopies and negative appendectomies, not so common anymore. Moreover, a perforated appendectomy is difficult to perform through a Mc Burney access. It's definitely more cautious to use a midline or pararectal incision, which would then require a large access. Considering also the limited use of electrocautery, it seems quite illogic to renounce the clear advantages of laparoscopy compared to laparotomy. (ESGE) guidelines for malignant obstruction of the colon [5] palliation was a clear indication for stenting, being the risk of perforation, even delayed, almost negligible. This would avoid emergent surgery, and consequent stoma formation, in a rate between 80 and 90% of individuals. Thanks to the results of the ESCO trial and of the CREST study (UEGW2019, Barcelona, Spain) we know that no oncologic issue is raised by the use of metal stents in malignant colonic obstruction. Therefore, stenting seems a better option compared to emergent surgery, not only for the better advantages mainly in terms of lower complications and lower need of both temporary and permanent stomas, but also, in times of viral infection, as it may help in delaying a general anesthesia which may be fatal in asymptomatic carriers of the virus [3] . Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. Laparoscopy at all costs? Not now during COVID-19 and not for acute care surgery and emergency colorectal surgery: a practical algorithm from a Hub Tertiary teaching hospital in Northern Lombardy Antibiotic Treatment and Appendectomy for Uncomplicated Acute Appendicitis in Adults and Children: A Systematic Review and Meta-analysis Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection A Low Cost, Safe and Effective Method for Smoke Evacuation in Laparoscopic Surgery for Suspected Coronavirus Patients Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) Guideline -Update 2020