key: cord-1031839-q7m6vffq
authors: Koh, Cherry E.; Brown, Killian G.; Fisher, Oliver; Steffens, Daniel; Yeo, David; McBride, Kate E.
title: Sense and sensibility through confusing surgical practices during COVID‐19 pandemic
date: 2020-07-02
journal: ANZ J Surg
DOI: 10.1111/ans.16126
sha: ad966ffb297c8fa48de6870588dcf02ee9eec0a9
doc_id: 1031839
cord_uid: q7m6vffq

nan

The coronavirus disease 2019 (COVID-19) pandemic has presented unprecedented challenges. For surgeons, the reality is that many of us will have little to do with COVID-19. COVID-19 is largely a medical disease where patient treatment is led predominantly by physicians. Whilst the secondary impact on surgery and surgical training has been profound, most surgeons will have little role in the direct treatment of COVID-19 patients. Nonetheless, how we practice surgery has also been called to question, including the safety of minimally invasive surgery, appropriate personal protective equipment (PPE) use and the push for non-surgical or outpatient-based management of simple surgical emergencies such as acute appendicitis, abscesses or diverticulitis.

Perhaps, one of the most contentious issues from a surgical standpoint is the threat that minimally invasive procedures pose to the surgical team. Minimally invasive procedures are considered aerosol generating and, as such, the Royal College of Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons both released statements cautioning against minimally invasive procedures during the COVID-19 pandemic. 1 Some have even gone as far as advocating for open surgery over minimally invasive procedures. While there is no smoke without fire, it is also important that we understand how this came about. The plausibility of viral transmission through laparoscopic plume is based on several different pieces of evidence tenuously strung together. A study of 205 patients with COVID-19 which collected serial samples from different sites confirmed that the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (the virus responsible for COVID-19) can be detected in serum in 1-2% of patients. 2 The presence of SARS-CoV-2 within serum necessarily means that the virus can be systemically disseminated and may therefore be present within peritoneal fluid, albeit, probably at fairly low rates. This may in turn account for the conflicting evidence about whether the SARS-CoV-2 can be isolated from peritoneal fluid, although one must also be cognizant that both these studies are case reports. 3, 4 The next step in aerosolization is whether viable viral particles can be aerosolized through the use of energy device. In the absence of data for SARS-CoV-2, one can only extrapolate from other viruses such as the hepatitis B virus or human immunodeficiency virus. 5, 6 Aerosolization of both these viruses is possible, but this does not translate to infectivity as both these viruses are blood-borne diseases rather than air-borne illnesses. As for the SARS-CoV-2, what is known is that it can remain viable for extended periods of time suspended in very small airborne droplets, droplets much smaller than usual nasopharyngeal droplets. 7, 8 However, little is known about aerosolization of SARS-Co-V-2 in vivo and even if this is possible, there certainly has not been evidence of increased surgical transmission through the SARS or Middle East respiratory syndrome epidemics, both of which are caused by coronaviruses and there is no reason to suspect that this would be any different with SARS-CoV-2. There is no doubt that evidence will continue to accumulate as the global experience with COVID-19 builds but the data are needed right now to guide practice. Without any certainty in these uncertain times, fear drives our decision-making. Considering the benefits of laparoscopic surgery in terms of post-operative length of stay and functional recovery, especially at a time when hospital beds are a highly valued resource that needs to be utilized judiciously, it would seem drastic to abandon these proven benefits in exchange for the theoretical risk of aerosol transmission. Notwithstanding this, absence of evidence does not mean absence of risk and it is important that we, as surgeons, take the necessary precautions to minimize any risk to ourselves and, importantly, our colleagues in the operating theatre. To minimize the risk of surgical plume from minimally invasive procedures, measures have been put in place including the use of the Airseal system (Conmed corporation, Utica, NY, USA) and filtration devices that are able to filter particles larger than 0.1 μm (SARS-CoV-2 virion measures about 0.12 μm). Time will tell if these measures were necessary and whether these additional costs are justified but these may be a small price to pay when the corollary could be a surgical workforce at risk or reverting to open procedures.

It would be fair to say that in 2020, the majority of simple surgical emergencies are managed laparoscopically (acute appendicitis, cholecystitis or ectopic pregnancy or just to name a few). Most trainees would have had limited exposure to its open counterpart, let alone in an emergency where planes are likely to be obscured and bleeding is more likely. While the push for open procedures may now increase their exposure, it may also reduce their operative experience further in this climate where there is less tolerance for trainees to 'have a go' because of the need for expediency and the call for a consultant-led service to minimize adverse outcomes.

Considering the recommendations by the Royal College of Surgeons and the Society of American Gastrointestinal and Endoscopic Surgeons, one has to applaud the Royal Australasian College of Surgeons (RACS) and General Surgeons Australia for not endorsing the same recommendations on minimally invasive procedures. Internationally, there has also been a number of concerns about the 'blanket ban' on minimally invasive procedures. 6 The regional differences in recommendations despite the same evidence pool can be disconcerting and confusing but one must also take into consideration the influence of the COVID-19 caseload in each region on recommendations. For the large number of cases in London, where the caseload has overwhelmed the health system's ability to provide care, any recommendations put forth will be primarily aimed at preserving the workforce and minimizing any further risk to patients and the healthcare worker. In this context, it is understandable that any recommendations are likely to be conservative. For Australia and New Zealand, certainly at the time of writing, it will be appropriate to offer minimally invasive procedures provided the necessary precautionary measures are in place.

Anyone looking at online resources available through the RACS COVID-19 website would have seen the large number of guidelines that have become available over the past 6 weeks. 9 A typical general surgeon in 2020 is not only a subscribing member of RACS, but usually also of a number of other subspecialty governing bodies such as Colorectal Surgical Society of Australia and New Zealand or Gastroenterological Society of Australia. Most surgeons will also be accredited at a number of public or private hospitals, all of which would have issued local recommendations in terms of PPE use or local changes to surgical practice. Keeping pace with each of these has been mind boggling if not impossible. This is particularly true for PPE practices where the differences can be vast between institutions, even when the institutions are simply across a shared walkway. The authors have also witnessed rapidly changing PPE practices within the same institutions seemingly unrelated to changing caseload or recommendations which simply confirms the lack of consensus on what constitutes the 'best' practice. While some have adopted the attitude of protecting the surgical workforce with universal precautions, others have had a more pragmatic approach based on risk assessment. The former adds considerable time to patient turnover and has generated further controversies about adequacy of PPE supplies while the latter has been deemed inadequate because of possible asymptomatic communitybased transmission. These differences in recommendations and practices are difficult to reconcile and has generated considerable anxiety in our early experience with COVID-19.

Most surgeons have been very accommodating and understand that there is insufficient evidence to guide best practice, but we have also witnessed anger at local administration because of perceived inadequate staff protection. As the pandemic evolves, guidelines and recommendations need to evolve correspondingly to reflect the changing landscape. The surgical community will also be better served with a set of unified practice guidelines rather than disparate and conflicting recommendations. To minimize further confusion, a comprehensive but sufficiently brief set of guidelines produced through a collaborative and consultative approach with broad engagement of all relevant craft groups and governing bodies, led by our college, is the probably best way forward.

COVID-19 aerosolisation during laparoscopic surgery. Risks and recommendations for clinicians

Detection of SARS-CoV-2 in different types of clinical specimens

COVID-19 is not detected in peritoneal fluid: a case of laparoscopic appendicectomy for acute appendicitis in a COVID-19 infected patient

SARS-CoV-2 is present in peritoneal fluid in COVID-19 patients

Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery

Human immunodeficiency virus-1 (HIV-1) in the vapors of surgical power instruments

Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1

Understanding the "scope" of the problem: why laparoscopy is considered safe during the COVID-19 pandemic

Royal Australasian College of Surgeons. Useful guidelines