key: cord-0830734-xzpkpdee
authors: Fader, Amanda N.; Huh, Warner K.; Kesterson, Joshua; Pothuri, Bhavana; Wethington, Stephanie; Wright, Jason D.; Bakkum-Gamez, Jamie N.; Soliman, Pamela; Sinno, Abdulrahman K.; Leitao, Mario; Martino, Martin; Karam, Amer; Rossi, Emma; Brown, Jubilee; Blank, Stephanie; Burke, William; Goff, Barbara; Yamada, S. Diane; Uppal, Shitanshu; Dowdy, Sean C.
title: Society of gynecologic oncology surgery considerations during when to operate, hesitate and reintegrate the COVID-19 pandemic
date: 2020-06-06
journal: Gynecol Oncol
DOI: 10.1016/j.ygyno.2020.06.001
sha: caff973cf306d95c8e982b475cbc6e6313d62576
doc_id: 830734
cord_uid: xzpkpdee

The COVID-19 pandemic has challenged our ability to provide timely surgical care for our patients. In response, the American College of Surgeons, U.S. Surgeon General, and other surgical professional specialties have recommended postponing elective surgical procedures and proceeding cautiously with cancer procedures that may require significant hospital resources and expose vulnerable patients to the virus. These challenges are particularly distressing for women with a gynecologic cancer diagnosis and their providers. Currently, circumstances vary greatly by region and by hospital, depending on COVID-19 prevalence, case mix, hospital type, and available resources. Therefore, COVID-19-related modifications to surgical practice guidelines must be individualized. Special consideration is necessary to evaluate the appropriateness of procedural interventions, recognizing the significant resources and personnel they require. Additionally, the pandemic may occur in waves, with patient demand for surgery ebbing and flowing accordingly. Hospitals, cancer centers and providers must prepare themselves to meet this demand. The purpose of this white paper is to highlight all phases of gynecologic cancer surgical care during the COVID-19 pandemic and to illustrate when it is best to operate, to pause, and re-integrate surgery. Triage and prioritization of surgical cases, preoperative COVID-19 testing, peri-operative safety principles, surgical training, and preparations for the post-COVID-19 peak and surgical re-integration are reviewed.

Equitable and accurate classification of surgical case urgency is critical during periods of resource constraint in order to preserve the availability of specialized staff, infrastructure and supplies.

In addition, hospitals are an important vector for disease spread during a pandemic, and utilization must therefore be strategic to ensure patient and staff safety (6) . While definitions will vary by institution, a diagnosis of cancer may not represent an urgent/emergent surgical indication. The ACS and CMS have categorized most gynecologic cancer cases as semi-urgent (8-9); however, the ACS further opines that if cancer cases are significantly delayed, this could result in significant patient harm. Clinicians with access to surgery should counsel patients about the risks of surgical delay versus in-hospital or communityacquired COVID-19 exposure in the perioperative setting. Furthermore, patients should be informed that surgical prioritization is determined based on 1) local/projected resources, 2) disease prevalence, 3) patient and tumor characteristics, and 4) expected outcomes from delays. Individual state mandates may actively prohibit elective and semi-urgent surgery during a pandemic, which can be contentious; consultation with institution legal representatives may be helpful in this setting.

Detailed surgical prioritization algorithms, such as the Medically-Necessary, Times-Sensitive (MeNTS) scoring system, consider patient co-morbidities and disease characteristics as well as additional factors based on available PPE, local COVID-19 prevalence, and the patient's need for blood products, length of hospital stay, and intensive care unit support (15) . The Elective Surgery Acuity Scale (ESAS) categorizes procedures into tiers based on medical necessity and urgency, procedure location (e.g., ambulatory care center, hospital), and the regional burden of COVID-19 to formulate a course of action (10). Whereas there is little controversy regarding the urgent/emergent and elective case categories, subtleties exist in the semi-urgent category. Most cancer-related procedures, including those for gynecologic cancers, are given a high priority, Tier 3 designation (second only to emergent and trauma).

Gynecologic oncologists have special expertise in the multi-modality management of gynecologic J o u r n a l P r e -p r o o f 6 malignancies and are uniquely qualified to identify cases that can be managed non-surgically, those for which a delay will not impact outcome, and those procedures that are truly urgent. Published literature regarding outcomes associated with gynecologic cancer surgical delays are retrospective, underpowered population-based or single institution analyses with inconsistent and inconclusive results (11, 12) .

However, available data demonstrate that surgical delay of a few weeks is unlikely to impact overall outcomes for most women with newly-diagnosed gynecologic cancer. This, of course, will vary depending on the cancer stage, subtype, and interval between onset symptoms that and initial evaluation.

Recently, the Society of Gynecologic Oncology developed guidelines to assist surgeons in triaging cancer cases during the COVID-19 pandemic (13). Detailed recommendations are shown in Table   1 . Surgical treatment of aggressive cancers with a propensity for early metastases and symptom progression, especially those that can be managed in a minimally invasive/short stay manner, should be given the highest priority, along with potentially curative procedures for apparent early-stage cancers (13). Additionally, women with advanced-stage ovarian and uterine malignancies requiring interval cytoreductive surgery after neoadjuvant chemotherapy should be prioritized when possible; however, in heavily restricted surgical environments or regions with a high COVID-19 prevalence, primary and interval cytoreductive procedures should be postponed in lieu of chemotherapy to prevent viral exposure in immune-compromised patients and to conserve hospital resources and PPE. The ASCCP (American Society for Colposcopy and Cervical Pathology) has offered guidance on the management of preinvasive disease, stating that surgery for high grade dysplasia may be delayed up to three months and that cases performed for lower grade disease may be delayed for 6-12 months (14) . In contrast, individuals with suspected invasive disease should be evaluated within one month. To mitigate community spread of the COVID-19 virus, the Centers for Disease Control (CDC) supports social distancing, stay-at-home orders, frequent hand hygiene, and restrictions on nonessential business (16). While social distancing (both within and outside of healthcare settings) is critical to lessen the impact of COVID-19, this measure has created barriers for patients which span the full spectrum of medical care. This includes access to routine cancer screening, laboratory testing, imaging and ambulatory consultations. As many centers have developed policies to limit visitors accompanying patients to the hospital, this also impacts the patient experience in critical moments. For instance, a patient may undergo a major surgical procedure or receive difficult news from a masked provider without a loved one or care giver present for support and help with decision making. Utilization of virtual technologies may help mitigate these barriers.

In addition, a patient with gynecologic cancer who requires surgery should enhance social distancing measures to decrease the risk of asymptomatic infection at the time of surgery. Options include consistent use of a face mask outside the home, and limitation/elimination of visitors for at least two weeks prior to the procedure and two to four weeks postoperatively given the immunosuppressive nature of surgery. Face masks may provide source control (protecting others from the mask wearer's respiratory secretions) and protection (shielding the wearer from others' secretions), but not all masks fulfill both roles (16-20). Table 2 describes the qualitative differences and applications of several mask types.

The CDC additionally recommends that health care workers wear a face mask at all times in the workplace in addition to meticulous hand hygiene and interpersonal distancing of more than six feet (18). Eye protection is critical for providers caring for patients who are not able to wear a mask. N95 respirators/eye protection or Powered Air-Purifying Respirators (PAPRs) are also recommended in the J o u r n a l P r e -p r o o f 8 care of suspected or known COVID-19-positive patients. N95 respirators are designed to achieve a close facial fit and efficient filtration of at least 95% of airborne particles 0.3 microns and greater (19) (20) (21) (22) (23) (24) . For those who fail fit testing, the CDC has issued caution regarding the use of Powered Air-Purifying Respirators (PAPRs) in the operating room because the exhalation valve may contaminate the sterile surgical field with the wearer's exhaled, unfiltered air (24) . If N95 stock is limited, other options include respirator re-use, reprocessing or extended use. When extended use is necessary, providers should be aware of the potential for decreased efficacy over time and the risk of self-inoculation during respirator handling.

Access to timely and reliable testing for the presence of active virus has been a major challenge during this pandemic due to limited testing capacity, reagents, and supplies. The CDC, commercial entities, and many medical institutions have rapidly developed PCR-based tests for nasopharyngeal or oropharyngeal secretions (25-30). Clinical screening for COVID-19 consists of queries regarding the presence of viral symptoms or potential contact with high risk individuals, including those in quarantine with active COVID-19 or a CDC-defined close contact (3)t. All patients should be clinically screened at multiple points (pre-visit phone screen, immediately prior to surgery, at entry into the institution, etc.) and any positive screen should be further evaluated.

Diagnostic testing involves identification of SARS-CoV-2 specific genes (nucleocapsid or envelope) using RT-PCR, with most results expected within 12-48 hours. Real-time RT-PCR allows for results to be visualized while the PCR reaction is still cycling, reducing assay time to <3 hours. Under the FDA's Emergency Use Authorization, commercial entities such as Cepheid (Sunnyvale, CA) and Abbott (Abbott Park, IL) developed rapid testing platforms that can provide a result in as little as 10-45 minutes (26) . However, poor availability of reagents has limited testing capacity.

J o u r n a l P r e -p r o o f 9 Theoretically, RT-PCR assays for SARS-CoV-2 should be highly sensitive in detecting the presence of viral RNA. However, the limit of detection differs among the various respiratory tract sources (25). A recent literature review and pooled analysis of previously published studies on RT-PCR performance from nasopharyngeal specimens by time since symptom onset or SARS-CoV-2 exposure demonstrated that the false negative rate ranged from 20-100% depending on test time point [31] . Care must be taken in interpreting RT-PCR tests for SARS-CoV-2 infection, particularly early in the course of infection, when using these results as a basis for removing precautions intended to prevent onward transmission .SARS-C0V-2 RT-PCR tests appear to be 100% specific (29, 30) .

Routine preoperative COVID testing is recommended due to the high prevalence of asymptomatic cases. Recognizing that morbidity and mortality from postoperative COVID-19 pneumonia is a concern [8, 9], surgery should be delayed in patients with a positive test until asymptomatic for >14 days, with some centers also recommending subsequent documentation of negative RT-PCR testing before proceeding to the operating room. A single negative test cannot reliably exclude COVID-19 and N95 masks should be worn, when available, during aerosol generating procedures. Table 3 demonstrates preoperative testing strategies at six U.S. academic institutions. If a patient declines preoperative SARS-CoV-2 testing, she should be informed that this may result in delay of surgery unless truly emergent. In emergent or urgent surgical settings, surgery should be performed presuming the patient is positive if testing results are unavailable.

Published reports from China during the viral outbreak examined the role of screening computed tomography (CT). One study demonstrated that 19% of COVID-19 pneumonias occurred in asymptomatic patients (33) (34) (35) , suggesting that preoperative chest CT may be valuable as an additional preoperative test, especially in those at highest risks. However, generalizability of these results is limited by methodologic flaws (36) . In settings where RT-PCR testing is not available, and in areas of high prevalence, chest CT may be the only option for preoperative testing. At this time, the CDC recommends J o u r n a l P r e -p r o o f 10 using chest CT only if it will change management. The American College of Radiology recommends that it not be performed as a screening tests for COVID-19 and rather be reserved for diagnostic purposes among symptomatic patients (37) . As preoperative SARS-CoV-2 testing improves, CT imaging may become less relevant for COVID-19 screening purposes.

From an infection transmission standpoint, the most hazardous aspect of surgery in a COVID-19 positive/unknown patient is endotracheal intubation and extubation (38) . Aerosol-generating procedures (AGPs) are described as "…procedures performed on patients [that] are more likely to generate higher concentrations of infectious respiratory aerosols than coughing, sneezing, talking, or breathing" (38) (39) . Enhanced safety measures appear to reduce the risk of exposure. The essential theme of AGP safety protocols is "Safe -Accurate -Swift" management in order to minimize potential aerosolization of respiratory droplet particles (40) . The following recommendations allow for timely and safe intubation/extubation process for all operating room personnel (41):

1. Only necessary personnel (i.e., anesthesia providers) should be in the operating room (OR) during the intubation/extubation process. Other surgical team members may relocate outside of the OR, and timing of re-entry is based upon the type of PPE they are wearing and the air exchange rate of the room (42). If an OR has a typical 15 air changes per hour, 99% of the airborne pathogens will be removed from the room within 18 minutes, at which point staff can safely re-enter wearing a surgical mask and eye protection. Alternatively, surgeon and OR staff may wear a N95 respirator with a face shield or goggles if they are unable to relocate outside of OR and will remain near an unmasked patient (20) (21) (22) (23) (24) .

J o u r n a l P r e -p r o o f 11 2. Rapid sequence intubation and video laryngoscopy reduce the risk of aerosolization and promote accuracy and increased distance between the person performing intubation and the patient.

3. All surgeons should wear the usual cap, gowns, footwear protection and double gloves. N95 masks (when available) and eye protection are recommended for AGPs; surgical mask with eye protection can be used for non-AGPs (43) .

Surgical smoke produced by the thermal destruction of tissue with electrosurgical devices or lasers may harbor aerosolized toxic or carcinogenic chemicals, live or dead cellular material, and potential bacterial and viral particles (43) (44) (45) (46) (47) (48) . The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) created a statement cautioning the potential for aerosolization of SARS-CoV-2 during minimally invasive surgery (MIS). (46) . The concern was derived from prior research demonstrating that laparoscopy can lead to aerosolization of blood borne viral RNA particles. Preliminary research has identified very small quantities of COVID-19 viral RNA in the blood stream or stool of COVID-19 positive patients: however, to date, there has been no scientific evidence to suggest that 1) viral RNA particles are infectious, or 2) that viral respiratory pathogens spread to OR personnel via abdominal exposure (47-48). In fact, a Joint Statement of six U.S. gynecologic professional societies lead by the AAGL (and with the Society of Gynecologic Oncology as a co-signatory), states that "there is no available evidence from the COVID-19 pandemic, or from prior global influenza epidemics, to suggest that respiratory viruses are transmitted through an abdominal route from patients to health care providers in the OR" (49) .

Open surgery should not be considered safer than MIS (43) . In fact, filtration of aerosolized particles may be more effectively controlled in MIS procedures provided that the pneumoperitoneum is not released suddenly (47-48). For these reasons, SAGES later issued an updated announcement, stating J o u r n a l P r e -p r o o f that "there is no evidence to indicate that there is aerosolization of COVID-19 during laparoscopy, nor that it would be isolated to minimally invasive procedures" (45).

While viral aerosolization and transmission of COVID-19 during abdominal surgery remains theoretical, several techniques may mitigate risk (48) (49) . In open surgery, the National Institute for Table 4 .

In the perioperative setting, optimization of best practices and targeted modification of care processes are options to minimize exposure risks and resource utilization (50) . For example, video visits (preoperative and postoperative) and limiting unnecessary preoperative testing decrease potential patient exposure to COVID-19. Utilization of absorbable skin sutures rather than staples will reduce early post-operative visits, and vaginal cuff checks may be delayed in asymptomatic patients. Additionally, J o u r n a l P r e -p r o o f implementation of enhanced recovery and same day discharge pathways can minimize length of hospital stay, as can preoperative assessment of social determinants of health to avoid discharge delays due factors such as inadequate habitation or transportation. Measures should also be taken to reduce the risk of delirium, which may be exacerbated given restrictions on inpatient visitors and companions.

Strategies to reduce post-operative complications and readmissions should be enhanced, not abandoned during this time, and include surgical site infection bundles (50) , venous thromboembolic prevention protocols, and restrictive blood transfusion protocols.

The COVID-19 pandemic provides an opportunity to explore novel care models within institutional, state and regulatory billing and licensing guidelines, such as inpatient virtual rounds (51) .

Previous experience is limited in scope, but virtual rounds have been used in multidisciplinary radiology rounds and as a mechanism to include family members in treatment planning and postoperative rounding, with no change in patient satisfaction compared to face-to-face rounding (51) (52) (53) . In addition, with the onset of the COVID-19 pandemic, CMS has modified billing restrictions and permitted synchronous audio-video connection for consults and inpatient rounding (53) . Virtual technologies facilitate conservation of PPE, reduce the potential for patient and provider exposure, and allow ongoing clinical education for house staff and midlevel providers.

In one example of virtual rounding developed at The Johns Hopkins Hospital, a single health care provider dresses in appropriate PPE conducts bedside rounds with the patient, and projects this clinical interaction to the remainder of the team at offsite locations using a Health Insurance Portability and Accountability Act compliant, institution-approved audio-visual platform (i.e., an iPad) mounted on a stand. During each inpatient interaction, the in-person provider introduces the patient to all team members present on the audio-visual platform, confirms patient consent and conducts the bedside visit.

In order to maintain remote team member engagement and education, each member is assigned different tasks, such as writing the progress note, entering orders, updating the service sign out list, J o u r n a l P r e -p r o o f 15 providing constructive feedback to the in-person provider regarding the clinical interaction and identifying case-based learning points for team discussion. The process requires accurate documentation of the attending attestation regarding the visit method and her/his role in the patient interaction (with billing determined ideally based on clinical decision making and time spent with the patient). Notably, it is acceptable for the attending to bill for the encounter even if present virtually as long as CMS guidelines are followed and an institution-approved, synchronous two-way video platform is utilized. The use of virtual visits for inpatient consults may be performed with a similar platform/approach.

World Now that much of the U.S. and several countries worldwide have reached the peak or plateau of COVID-19 infections, it is time to begin the challenge of more fully re-integrating surgery and cancer care. Several future scenarios have been predicted by epidemiologists, which differ according to how often and how severely SARS-CoV-2 afflicts the population (54) . It is postulated that the current pandemic may only represent the first of several waves of SARS-CoV-2 infection, and that resurgent outbreaks may occur in late 2020 or early 2021.

Many hospitals have used COVID-19 prediction models in order to estimate the future burden of disease in their catchment area. This information is critical to determine if clinical volume (i.e., surgery, outpatient visits) should be scaled back or allowed to recover to pre-pandemic levels. Predictions from these models are heavily influenced by a variety of assumptions and have the greatest accuracy over a 2-3-week period. Most models utilize a SEIR epidemiology approach based on individuals in a population J o u r n a l P r e -p r o o f 16 who are susceptible, exposed, infected, and recovered (55) (56) . The population analyzed differs between models, with some focusing on rates at the state level, others at the county level, and many institutions have created their own models focusing on their referral region. Companies such as Google and Apple are using cell phone location data to track compliance with social distancing over time, and provide near real-time predictive value in these models. Other important considerations for assessing the status of disease include the availability of testing, the proportion of the population with a positive test, and the associated mortality rate. Modeling is also increasingly used to estimate PPE burn rates, the availability of critical pharmaceutical supplies, total available beds, ICU beds, and ventilators.

Despite the current uncertainties, we know that 1) health care systems cannot remain in a crisis state in perpetuity, either infrastructurally or financially, 2) we need to be prepared to endure COVID-19 over a longer time frame, even though it is challenging to think about long-term health care system strategies at this time, and 3) a sound path forward will most likely involve developing a series of shorter term contingency plans that hospital administrators/physicians develop in conjunction with epidemiologists, public health and government officials, payors, and industry partners. Recognizing that novel therapies and vaccines for COVID-19 are unlikely to be developed in 2020, we must come to terms with the fact that gynecologic oncology surgical practice may be forever changed and that safely navigating COVID-19 will be a reality for some time to come. While many medical specialty societies have issued guidance in how to triage cases for delay during this pandemic, there is scant guidance on how to start resuming surgical practice (57) . For health care systems, this decision will be dictated in large part by state governors, health departments and/or institutional policies, based on regional COVID-19 prevalence/burden on health care systems. Declining COVID-19 infection rates and lower rates of COVID-19 hospitalization over a 14-day period of time are important criterion to begin non-urgent cases. The availability of abundant PPE supplies, blood products, operating rooms, intensive care unit beds, and adequate staff will also impact when and how J o u r n a l P r e -p r o o f delayed cases will resume. Physician and institutional readiness to resume elective and semi-urgent surgeries will also vary by geographic location. The virus will continue to have a disproportionate adverse impact on U.S. gynecologic oncology survivors of Black race, Hispanic ethnicity, and those of low socioeconomic backgrounds (65). Hospital systems and cancer centers are encouraged to consider novel strategies to study and optimize surgical and cancer care in these vulnerable populations. Finally, access to adequate SARS-CoV-2 RT-PCR, as well as antibody testing for patients and health care workers and operationalizing testing and contact tracing on a national scale are also critical (54) (55) .

On April 17, 2020, The ACS, in conjunction with other societies, developed a joint statement outlining a roadmap for surgery reintegration after the COVID-19 pandemic (57). In the same manner that patients with non-urgent conditions were triaged for surgical delay, the development of processes to systematically and objectively prioritize these delayed cases are needed. Departmental leadership and/or institutional, multi-specialty surgical review committees should make recommendations to proceed with surgery as resources become available (57) . The review committees will help to fairly allocate resources among the different surgical services and quickly resolve any disputed cases. It is also recommended that institutions consider a phased approach to surgical reintegration to allow for a gradual ramp up period, so that the health care system is not stressed and to prevent worsening COVID-19 infection rates. Logistics and (possibly permanent) infrastructural changes are important to consider, such as how surgical and ambulatory waiting rooms will be designed to optimize social distancing, and if visitor policies will be forever modified.

Procedures performed for gynecologic cancer, precancerous or risk reducing indications are likely to be prioritized, especially those performed minimally invasively and for curative or preventative intent. For the foreseeable future, most, if not all, patients having an AGP will require preoperative J o u r n a l P r e -p r o o f 18 COVID-19 testing and every surgical procedure will require appropriate safety measures. Additionally, as we continue to recognize the impact of viral infection on postoperative recovery (58, 59) we must broaden our differential diagnosis of postoperative fever, continue to study and optimize outcomes, and contribute to COVID-19 clinical trials. It may also be necessary to extend surgical block time into evenings and weekends to facilitate access to surgery.

Finally, it cannot be emphasized enough that this phase of increased clinical demand and intense financial pressure on health care providers will have a tremendous toll on physical and psychological well-being. Even at baseline, gynecologic oncologists face considerable professional trauma, stress and burnout (60). During the COVID-19 pandemic, they have had to grapple with almost impossible ethical situations associated with delays in surgery and cancer care. Additionally, it is well established that health care workers serving in prior infectious outbreaks have experienced long-term psychological and occupational effects including burnout, psychological distress, and posttraumatic stress (61). Our hospital systems must take heed and consider including generous wellness allowances for their staff to mitigate this potential stress.

The challenges to gynecologic cancer surgical care brought on by the COVID-19 pandemic--and specifically related to the questions of when to operate, hesitate and when and how to reintegrate--are difficult, but far from insurmountable. Gynecologic oncology surgeons have been an extremely valuable resource during the COVID-19 pandemic, and should be supported strongly by their health care systems as they focus on the needs of their oncology patients and continue to rapidly adapt their surgical and cancer care paradigms to address a fast moving public health problem. Procedures performed for cancer J o u r n a l P r e -p r o o f indications will be prioritized in the coming months, but surgical restrictions are likely to continue to some degree as institutions adapt their infrastructures and health care missions to optimize care for populations in a post-COVID world. As surgeries gradually ramp up again in the post-pandemic period, optimizing surgical manpower, supporting operative personnel, and using hospital resources equitably and responsibly, will be paramount.

Dr. Warner Huh reports personal fees from LICOR, outside the submitted work and Expert Witness:

Skadden (on behalf of Intuitive Surgical).

Dr. Bhavana Pothuri reports grants, personal fees and non-financial support outside the submitted work;

institutional PI for industry sponsored trials from Tesaro/GSK, AstraZeneca, Merck, Genentech/ Roche, and Clovis Oncology. Compensated advisory boards include Tesaro/GSK, AstraZeneca, and Eisai.

Dr. Mario Leitao reports personal fees from JnJ/Ethicon, outside the submitted work and Dr. Leitao is an ad hoc speaker for Intuitive Surgical, Inc.

Dr. Joshua Kesterson reports personal fees from GSK/Tesaro, personal fees from Clovis Oncology, outside the submitted work.

Dr. Jason Wright reports grants from Merck, personal fees from Clovis Oncology, outside the submitted work.

Dr. Amer Karam reports personal fees from Clovis Oncology, personal fees from GSK, personal fees from Astra Zeneca, personal fees from UpToDate, outside the submitted work.

Dr. S. Diane Yamada reports other from LEAP Therapeutics, outside the submitted work.

All other authors have nothing to disclose.

Drs. Amanda Fader and Sean Dowdy conceived of the manuscript and developed its sections. They wrote large parts of the manuscript, edited and approved the final submission.  A preselected route should be identified without stopping in an anesthetic bay, preoperative care unit, or any place other than the COVID-dedicated operating room.

 All transporting personnel should don appropriate PPE, and should doff that PPE (I,e., gowns and glove) and perform robust hand hygiene once they arrive to the operating room and have transferred the patient to the operating table.

 New, sterile PPE should be used for the procedure, with N95 masks and eye protection recommended throughout the case. Intraoperative gowns/gloves should be doffed and new PPE donned for transport of the patient at the completion of the procedure. Detailed recommendations regarding appropriate operating room protocol and PPE selection are available on the American College of Surgeons website (44) .

 Consider leaving the stretcher that the patient was transported on in the operating room during the case to avoid contamination in an adjacent hallway. Discard stretcher bed linens in biohazard containment bags once the patient is moved to the operating room table and apply fresh linens on the same stretcher prior to transport at the procedure's end.

 Ideal characteristics of a COVID-dedicated operating suite include negative pressure, the presence of an ante room, and designated nurses and safety officers/health care personnel in attendance to oversee the case from transport in and out of the operating room and from procedure start to finish. 

Clinical features of patients infected with 2019 novel coronavirus in Wuhan

Director-General's remarks at the media briefing on 2019-nCoV on 11

Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72314 Cases From the Chinese Center for Disease Control and Prevention

Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection

Baseline Characteristics and Outcomes of 1591

Patients Infected With SARS-CoV-2 Admitted to ICUs of the Lombardy Region

Giuntli RL 2 nd . Survival implications of time to surgical treatment of endometrial cancers

Time to surgery and risk of cancer progression in patients with gynecologic cancers o the lower genital track

Interim Guidelines for Timing of Diagnostic and Treatment Procedures for Patients with Abnormal Cervical Screening Tests

Medically-Necessary, Time-Sensitive Procedures: A Scoring System to Ethically and Efficiently Manage Resource Scarcity and Provider Risk During the COVID-19 Pandemic

Potential Utilities of Mask-Wearing and Instant Hand Hygiene for Fighting SARS-CoV-2

Effectiveness of Surgical and Cotton Masks in Blocking SARS-CoV-2: A Controlled Comparison in 4 Patients

Sobsey: Coronavirus survival on healthcare personal protective equipment

United States Food and Drug Adminiatration

United States Food and Drug Adminiatration

Covid-19 in Critically Ill Patients in the Seattle Region -Case Series

Respiratory Viruses Branch, Division of Viral Diseases Real-Time RT-PCR Panel for Detection 2019-Novel Coronavirus

Detection of 2019 novel coronavirus (2019-nCoV) by real-time RT-PCR

Triplex real-time RT-PCR for severe acute respiratory syndrome coronavirus 2. Emerg Infect Dis

Variation in False-Negative Rate of Reverse Transcriptase Polyemerase Chain Reaction-Based SARS CoV-2 Tests by Time Since Exposure

COVID-19 in the perioperative period of lung resection: a brief report from a single thoracic surgery department in Wuhan

Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection

Radiological findings from 81 patients with COVID-19 pneumonia in Wuhan, China: a descriptive study. The Lancet Infectious Diseases

Sensitivity of chest CT for COVID-19: comparison to RT-PCR

Chest computed tomography for detection of coronavirus disease 2019 (COVID-19): Don't rush the science

ACR Recommendations for the use of ct Radiography and Computed Tomography (CT) for Suspected COVID-19 Infection

Statements/Recommendations-for-Chest-Radiography-and-CT-for-Suspected-COVID19-Infection

COVID-19 infection prevention and control in healthcare settings: questions and answers

COVID-19 and Risks Posted to Personnel During Endotracheal Intubation

A Consensus guidelines for managing the airway in patients with COVID-19: Guidelines from the Difficult Airway Society, the Association of Anesthetists the Intensive Care Society, the Faculty of Intensive Care Medicine and the Royal College of anesthetists

The Use of Personal Protective Equipment by Anesthesia Professionals during the COVID-19 Pandemic

Understanding the "Scope" of the Problem: Why Laparoscopy is Considered Safe During the COVID-19 Pandemic

COVID-19: Considerations for Optimum Surgeon Protection Before, During, and After Operation

Minimally invasive surgery and the novel coronavirus outbreak: lessons learned from Italy

Annals of Surgery. 2020

Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery

Joint Statement on Minimally Invasive Gynecology during the COVID-19 Pandemic

Outcomes Associated with a Five-Poiont Surgical. Site Infection Prevention Bundle in Women Undergoing Surgery for Ovarian Cancer

Virtual rounding via videoconference-enabled smartphones: a case for multifacility rounds. Oral Surg, Oral Med, Oral Path

Virtual rounds: Observational study of a new service connecting family members remotely to inpatient rounds

Postoperative Robotic Telerounding: A Multicenter Randomized Assessment of Patient Outcomes and Satisfaction

Three potential futures for Covid-19: recurring small outbreaks, a monster wave

Statistical inference in a stochastic epidemic SEIR model with control intervention: Ebola as a case study

When will the battle against novel coronavirus end in Wuhan: A SEIR modeling analysis

Roadmap for Resuming Elective Surgery after COVID19 Pandemic

ACS Create a Surgical Review Committee for COVID-19-Related Surgical Triage Decision Making