key: cord-1043546-rt6x7vkp
authors: Al-Jabir, Ahmed; Kerwan, Ahmed; Nicola, Maria; Alsafi, Zaid; Khan, Mehdi; Sohrabi, Catrin; O’Neill, Niamh; Iosifidis, Christos; Griffin, Michelle; Mathew, Ginimol; Agha, Riaz
title: Impact of the Coronavirus (COVID-19) pandemic on surgical practice - Part 1 (Review Article)
date: 2020-05-12
journal: Int J Surg
DOI: 10.1016/j.ijsu.2020.05.022
sha: eec4d85db2455f1bd983ddffad86bb8d3ef3eda8
doc_id: 1043546
cord_uid: rt6x7vkp

The Coronavirus (COVID-19) pandemic has resulted in over 2.3 million confirmed cases and over 160,000 deaths. The impact of COVID-19 on surgical practice is widespread ranging from workforce and staffing issues, procedural prioritisation, viral transmission risk intraoperatively, changes to perioperative practice and ways of working alongside the impact on surgical education and training. Whilst there has been a growing literature base describing the early clinical course of COVID-19 and on aspects of critical care related to treating these patients, there has been a dearth of evidence on how this pandemic will affect surgical practice. This paper seeks to review the current evidence and offers recommendations for changes to surgical practice to minimise the effect of the COVID-19 pandemic.

Following a number of cases of pneumonia of unknown origin in Hubei Province in China, Severe Acute Respiratory Syndrome Coronavirus-type 2 (SARS-CoV-2) was identified as the RNA virus causing 'Coronavirus Disease 2019' . This virus rapidly spread throughout the world and was recently declared a pandemic by the World Health Organisation (WHO) on 11th March 2020 [1] [2] [3] [4] , impacting many sectors as well as leading to global socio-economic implications [5] .

The impact of COVID-19 on surgical practice is widespread ranging from workforce and staffing issues, procedural prioritisation, viral transmission risk intraoperatively as well as on surgical education ( Figure 1 ).

Whilst there has been a growing literature base describing the early clinical course of COVID-19 [7] and on aspects of critical care related to treating these patients, there has been a dearth of evidence on how this pandemic will affect surgical practice.

Both Brindle et al. [8] and the COVIDSurg Collaborative [9] have identified key areas where practice should be altered during the COVID-19 pandemic for safe global surgical care. These include:

1. Preparing a surgical pandemic response plan for this rapidly evolving situation to include postponing elective operations, repurposing operating rooms (OR) as critical care areas and operative workflow 2. Develop a clear team-based plan for providing an essential emergency surgical service during the pandemic 3. Staff education on personal protective equipment (PPE) and COVID-19 management to deliver surgery safely during the pandemic 4. Recognising and managing COVID-19 infections whilst decreasing exposure of health care staff 5. Develop a dedicated COVID-19 operating space as part of a wider hospital response This paper seeks to review the current evidence and offers recommendations for practice in the implementation of these areas.

There are different considerations for each speciality with regards to the prioritisation of surgical services and delivery of surgical practice. These have been outlined in part 2.

The critical care bed capacity in the United Kingdom (UK) compares poorly with other countries in Europe. For example, a comparison between the UK and Germany shows a difference in Intensive Care Unit (ICU) bed numbers of 7.5 versus 31.8 per 100,000 population, respectively [10] . Moreover, predictions made by the Imperial College COVID- 19 Response Team indicate a critical care bed demand of more than 30 times the UK capacity [11] .

Consequently, the UK National Health Service (NHS) hospitals have been reconfigured in order to provide more space for critically-ill patients in anticipation of greater surges of COVID-19 cases. To date, 33,000 hospital beds have been freed up and 1,200 ventilators have been provided by the private sector. Elective and other routine operations have been cancelled or postponed, allowing access to the operating rooms (OR) and the recovery rooms to be used as critical care units [12, 13] with a potential model being set up by a commercial team, COVIDvent [14] .

Considering the large numbers of anticipated critically ill patients, pressure has also been put on increasing the number of appropriately trained medical staff to care for these patients. Guidelines have been published by the NHS with recommendations on staffing frameworks for critical care of patients and on the deployment of medical staff to meet the critical care capacity surge [15] .

Elective and non-urgent surgery cancellations mean that surgeons can play a key role and contribute to the critical care of these patients. Specifically, surgeons can carry out line insertions and proning of patients while ensuring safety of the airway and management of infusions and lines [15] . Other healthcare staff with OR experience such as nurses and allied healthcare workers can provide critical care nursing [16] .

The Royal College of Surgeons (RCSEng) has set a number of priorities for adapting the surgical workforce [17] . It is of primary importance to maintain other non-COVID emergency surgery pathways with competent surgical staff and virtual support with teleconferencing from specialists for the generic surgeon and virtual outpatient clinics to minimise exposure. Secondary priority is to protect and preserve the surgical workforce with the appropriate use of PPE, alongside adequate rest and psychological support where necessary. A lower importance has been set for fulfilling alternate surgical and non-surgical roles. The adapting roles of individual surgeons can be divided into current practice, "on the edge" practice, and "beyond the edge" practice ( Figure 2 ).

For the surgical staff who need to work beyond their competencies, the RCSEng has recommended that their extended scope of practice should depend on the specific local needs identified. The recommendations emphasise the need for appropriate training, support and collaboration with appropriately trained colleagues to allow best possible patient care. The same recommendations apply for retired surgeons and trainees who temporarily return to practice [18] .

A strategy to minimise the risk of acquiring COVID-19 infection while managing the critical care of patients is to reorganise the surgical team into two groups. One that is active within hospitals, and one that works remotely in isolation, both groups alternating with each other at 2-week intervals. This will ensure that any symptoms are identified within the incubation period of COVID-19 [19] .

An alternative strategy is to consolidate the surgical teams in each day into two teams working long (e.g. 12 hour) shifts using each available operating room in turn (rather than to complete the whole day's list in a single OR) to allow maximum time for deep cleaning of each OR and minimise the amount of staff in a department who could be potentially exposed [20] .

During the COVID-19 pandemic elective operating services will be greatly restricted, with the exception of cancer cases requiring surgical management. Stratification of patients into groups is crucial in order to prioritise the workload and offer the best available treatment under the circumstances while simultaneously preserving resources to enable the battle against the deadly virus. NHS England recommends patients be classified into priorities 1-3 based on clinical need [21] :

Priority 1 patients should be further divided into 1a and 1b. 1a being patients requiring an emergency operation within 24 hours in order to preserve life; and 1b to include patients with acute conditions secondary to their underlying issue which may cause irreversible harm if not operated on urgently i.e. within 72 hours. Situations included in the 1b classification may include gastrointestinal obstructions, bleeding or spinal cord compression among others.

Priority 2 patients should include patients aimed to be operated on within 4 weeks with the intention of cure and prevention of progression of the disease to an inoperable stage. These patients should be stratified based on clinical urgency, expected complications secondary and the specific growth rate of the specific cancer. The NHS also recommends that complications be controlled utilising interventional radiological or gastroenterological procedures (e.g. stents) in cases where operative intervention has been postponed.

Priority 3 patients are classified as those whose operations can be deferred for 10-12 weeks without negative consequences.

The American College of Surgeons also stresses the importance of cancer care coordination. It recommends the establishment of triage criteria based on prevalence of the disease in the area as well as the availability of non-surgical alternatives [22] .

The College has classified the cancer workload into 3 phases based on hospital COVID-19 status (Table 1) .

During the COVID-19 pandemic, face-to-face outpatient appointments should be avoided where possible. This is because it increases the risk of infection for both the patient as well as the medical professional conducting the clinic. Where face to face appointments are still essential, the recommendation is to follow a one-patient one-room policy to minimise risk of infection. However, telephone and video appointments are preferred where possible. Virtual Clinics have run successfully for many years [23] [24] [25] , but during the COVID-19 pandemic regulations have been eased to allow greater usage [26] .

There are a number of methods in use in the UK such as NHS Attend Anywhere as well as those conforming to USA HIPAA regulations such as Zoom, Microsoft Teams and Doxy. However where this is not available, it is also acceptable to use video conferencing tools such as Skype, WhatsApp, Viber and Apple FaceTime [27] .

Conor et al. [26] suggest that the stages of setting up a telemedicine clinic are: 1. Identifying patients who are suitable for a telemedicine clinic 2. Informing patients and giving instructions on access. A locally modified patient information sheet is recommended, such as the sheet set up in Norwich and Norfolk University Hospitals in the UK [28] 3. Choosing an appropriate platform 4. Documentation and coding for appropriate remuneration [29] As many clinicians are uncomfortable with the use of telemedicine clinics, some recommendations for setting up a service are outlined in Table 2 .

The COVID-19 outbreak has also necessitated global surgical workforce repurposing and reconfiguration [36] . Alongside hospitals being advised to urgently discharge all medically fit patients, authority institutions such as NHS England have instructed the suspension of all non-urgent elective surgeries for at least 3 months [37] . Similar measures have been invoked in other affected countries. These measures are intended to maximise critical care capacity, in order to mitigate the anticipated sharp increase of cases [38] . In England, this is predicted to increase capacity of general and acute beds from 100,000 to 130,000 [12] . Indeed, modelling by the Imperial College COVID-19 Response Team has predicted an 8-fold overwhelmed critical care system notwithstanding the most drastic protective measures (i.e. case isolation, home quarantine, and social distancing of over 70s) [11] . Thus, the UK government is taking further measures to increase capacity such as acquiring up to 8,000 beds from independent hospitals and building multiple field hospitals capable of housing up to 4,000 beds each [39, 40] .

The first surgical priority of healthcare systems is the maintenance of emergency capabilities, including major trauma [12] . As staffing deficiencies are likely due to the self-isolation of clinicians, the protection and preservation of the surgical workforce is critical for upholding the provision of emergency services. The considerations for optimal protection of the surgeon can be compartmentalised into five domains: (1) the use of PPE, (2) pre-operative risks such as during intubation, (3) specific operative risk issues, (4) post-operative risks, and (5) keeping others safe.

There are four identified modes of transmission for the COVID-19 virus: contact, droplet, airborne, and faeco-oral [18] . Thus, advisory bodies such as the United States of America (USA) Centres for Disease Control (CDC) and Public Health England (PHE) have recommended the utilisation of PPE for all procedures involving a patient with confirmed or suspected COVID-19 infection [41] . For procedures involving an aerosol-generating procedure (e.g. intubation and extubation) a higher level of protection such as N95 respirators are advised with a paramount emphasis on fit testing ( Figure 3 ) [42] . This is supported by a number of studies suggesting a relationship between viral dose and severity of disease [43] . The specific method of discarding disposable equipment should be in accordance with local policy, followed by hand hygiene [44] . In order to minimise human error, the CDC has advised a trained observer, with the sole responsibility of ensuring adherence to correct procedure, to supervise the donning process. This involves verbally walking through the procedural checklist, concluded by visual confirmation and official documentation.

The risk of COVID-19 transmission through aerolisation and droplets are important considerations for surgical personnel. This was highlighted during the 2003 SARS-CoV outbreak which resulted in a preponderance of frontline healthcare workers demonstrating significantly increased risk of contraction and thus illness and death [45] . Additionally, the COVID-19 outbreak also has reported cases emerging in the medical staff population with 29% of nosocomial infections in the Wuhan University Central South Hospital being in staff [46] . Procedures which are believed to generate aerosol include: bronchoscopy, endotracheal intubation, tracheostomy procedures, cardiopulmonary resuscitation, and diagnostic sputum induction [47, 48] . Surgical personnel are at an increased risk when conducting procedures which involve the aspiration of body fluids [49] and this is highlighted in the algorithm developed by Forrester et al [50] for institutional protection of surgical staff.

The UK Royal Surgical Colleges advise that any patients for prioritised planned surgery must have been asymptomatic for 7 days, self-isolated for 14 days and then have a negative swab within 48 hours prior to planned admission as well as to be assessed for COVID-19 ( Figure 4) . Furthermore, where the patient is likely to require level 2 or 3 critical care post cancer surgery (High Dependency Unit or ICU), they should be assessed with a CT chest [51] . Any patients presenting to hospital requiring urgent or emergency surgery should be assessed for COVID-19 using history, RT-PCR COVID-19 testing and chest x-ray. Any patient receiving an emergency abdominal CT scan for acute pain, should also receive a High resolution CT chest (unless a previous scan performed in the past 24 hours) at the same time to exclude COVID-19.

In order to minimise the risk of transmission, the CDC advises removal of nonessential surgeons and personnel from the operating room during aerosol generating procedures [53] . For example, when dealing with a confirmed or suspected COVID-19 case, non-essential personnel should wait outside the OR whilst anaesthesia induction and intubation are completed. Additionally, even essential staff should be screened for temperature before entry into the OR [54] . For quick and safe induction of anaesthesia during Caesarean section, Chen et al. [55] used 5 minutes of preoxygenation with 100% oxygen, rapid inhalation of sevoflurane (8% in 100% oxygen) concurrent with cricoid pressure followed by 2-3 minutes of ventilation and intravenous 2% lidocaine (1-1.5 mg/kg), remifentanil (1-2 mg/kg) and succinylcholine (1-2 mg/kg).

Ergonomics are also crucial to infection control. Amongst other evidence-based perioperative guidelines, Dexter et al [20] suggesting double gloving during induction and placing alcohol or chlorhexidine hand rub on the IV pole to the left of the anaesthetist and a wire basket lined with a zip closure plastic blag to the IV pole on their right as a designated dirty area to place contaminated instruments such as laryngoscopes. Moreover, they suggest using nasal povidone iodine and oral chlorhexidine decolonisation [56] .

It is also recommended that a COVID-19 modified version of the WHO Safe Surgery checklist should be used ( Figure 5 ) as well as intubation checklists of which there is a multitude [57, 58] . Furthermore, the designation of dedicated PPE donning and doffing areas can reduce cross-contamination and many editable templates are available for local modification [59, 60] .

Furthermore, one recommendation is to produce pre-prepared bags of equipment ( Figure 6 ) to avoid contaminating general equipment stores [59] . These can include intubation sets (such as laryngoscopes and airway devices), intravenous access sets, transportation monitoring sets (such as blood pressure and ECG equipment) and regularly used drug sets (such as muscle relaxants and sedatives).

Finally, Wong et al. [59] also wrapped all 'high-touch' equipment such as monitors, nursing station and anaesthetic workstation to avoid repeated contamination).

Furthemore, changes can be made to the OR ventilation system to minimise risk. Advancements in computational fluid dynamics have enabled evaluation of OR ventilation design and monitoring procedures [63] and this in turn has established several principles relating to the design of ORs. Firstly, ventilation applies a dilution effect which minimises the concentration of contaminants, including viruses and thus it is recommended that in patients with COVID-19, the OR is set to have a high frequency of air flow changes (≥25 per hour) to maximise this effect on reduction of viral load [59] . Secondly, contaminant diffusion is further minimised by introducing low-velocity airflow directed towards the exhaust outlets. Moreover, personnel in adjacent areas will benefit from negative pressurisation in ORs as this functions as a filtration barrier and so negative pressurisation ORs is now an official recommendation of the CDC.

There are a number of measures that must be undertaken to protect essential members of the operating team during an operation.

Surgical teams managing the early wave of infection in China produced comprehensive guides to the intraoperative management of surgical patients including the recommendation that if electrocautery is used, to use on the lowest power setting with a smoke evacuator to minimise the exposure to surgical smoke and any potential aerosolised virus particles [54, 64] . Furthermore, surgical practitioners should pay extra attention to any needlestick injuries or damage to PPE during the procedure.

PHE [65] have also suggested using well-known protocols for infectious patients undergoing surgical procedures and modifying for those suspect of suffering from COVID-19 to include:

• Placing a surgical mask on the patient during transfer to and from the OR • The patient being anaesthetised and recovered in the OR rather than an anaesthetic room. This should also be undertaken by staff wearing FFP3 respirators and full gowns if this will involve aerosol-generating procedures (AGPs) such as intubation • Single-use instruments wherever possible • Surgical instruments to be decontaminated in the normal method • Staff to be reduced to only the minimum required with no unnecessary visitors • To place all operations on patients with confirmed or suspected COVID-19 at the end of the list where possible

There is a theoretical risk of transmission of SARS-CoV-2 during laparoscopy as it is an aerosol generating procedure and that other viruses have been detected in surgical smoke [67, 68] . Additionally, it has been suggested by Tao et al. [69] that laparoscopy should be avoided due to artificial pneumoperitoneum potentially cause patients with reduced lung volume, increased airway pressure, CO 2 retention, and decreased lung compliance, which is not conducive to postoperative functional lung functional recovery however it is possible to mitigate the risk from laparoscopy [70] . Zheng et al. [71] report their experiences of minimally invasive surgery in China and Italy and recommend using minimally-feasible insufflation pressures and liberal intraperitoneal suction usage as well as to minimise use of the Trendelenburg position to further minimise the risk of pulmonary complications of the pneumoperitoneum.

Furthermore, the Royal Surgical Colleges of Great Britain advise that laparoscopy should only be performed in select cases where it can be clinically justified considering the risk of viral transmission to surgical staff [52] .

The Society of American Gastrointestinal and Endoscopic Surgeons recommend that incisions be made as small as possible to minimise leakage, that insufflation pressures are kept to a minimum and that smoke evacuation systems should be utilised [72] , and that CO2 insufflation must be turned off and vented through a filter before the removal of specimens, trocars or port closure [73, 74] . Considerations are similar during endoscopic procedures for the use of 'clean' ORs and filtration devices as well as for only to be performed where urgent. Additionally, in endourological surgeries, irrigation fluid should be collected in a closed system.

Patients should be recovered in the OR both to minimise potential viral spread as part of an alteration of the usual patient flow, both to minimise risk of spread as well due to the repurposing of the usual surgical recovery area (Figure 7 ). Patients should also be given a single dose of 5-HT3 antagonist (such as ondansetron or metoclopramide) to minimise postoperative nausea and vomiting which could lead to further spread [75] .

Surgical specimens must be labelled as suspected COVID-19 and sealed in the OR in addition to all body fluids, disposable equipment, tubing, gowns and PPE should be double-bagged, labelled with a sign designating as from an OR with confirmed/suspected COVID-19 patient and disposed of according to local infectious waste guidelines.

Following this, the OR must be disinfected according to local protocols which may include the disinfection of high-touch surfaces such as the operating table and anaesthetic machine with a minimum of 75% alcohol of chlorine-based disinfectant. Furthermore, other surfaces in the OR are to be thoroughly cleaned after each operation with a neutral detergent followed by a chlorine-based solution with a minimum strength of no less than 1000ppm of chlorine. This is especially important as without proper decontamination, the virus can survive on surfaces for a long time [76] . Conventionally ventilated ORs are not to be used for 20 minutes postprocedure, or 5 minutes if ultraclean ventilation is used [65, 75] . This is due to the fact that 1 ventilation system air exchange is thought to reduce viral load by 63% and after 5 air changes, less than 1% of airborne contaminant remains [65] .

Furthermore, personnel involved in the transportation of confirmed or suspected COVID patients should be minimised to essentials as well as the provision of a dedicated route for the transfer of suspected COVID-19 patients. Then, all members of the transportation team should wear different PPE to what was donned during the procedure as well as for the patient to wear a respirator or surgical mask during transfer, according to local protocols.

Patients should be monitored carefully in the post-operative phase as there are indications that previously undiagnosed COVID-19 may complicate post-operative recovery [77] . Postoperative pulmonary complications are not uncommon and it is important to consider COVID-19 as part of the differential diagnoses alongside aspiration pneumonia or pulmonary emboli and to perform the appropriate diagnostic workup.

Additionally, it is common in many surgical systems for patients after major surgery to be electively admitted to critical care routinely to monitor for post-operative complications. Typically, these patients have short lengths of stay, with one large study showing median length of stay of 0.9 days (IQR 0.8-1.5) and low mortality [78] and there is some evidence that additional critical care support may be harmful or futile [79] . With severe strain on the capacity of critical care units, it would be prudent to carefully rationalise elective planned ICU admissions and whether it is required. 

Many workers on the frontline share their places of residence (e.g. family or individuals residing within the same flat or apartment) thus there exists an understandable anxiety about passing the infection on. Exact policies regarding postoperative actions for personnel involved in the surgical procedure differs from hospital to hospital. However, it is generally advisable to seal your clothes in a bag upon arriving at the hospital and having a shower before putting them back on to go home.

Although hospitals and healthcare institutions may offer accommodation to workers who live with vulnerable individuals (e.g. the elderly and immunocompromised), this is not a feasible option for all. Alongside the previous measures mentioned (i.e. hand hygiene, changing clothes) workers must be aware that they are exposed more frequently to other possibly contaminated surfaces (e.g. ATM, petrol pumps) compared to persons in self-isolation. It is thus important to have a heightened sense of caution regarding hygiene methods. (e.g. frequency of hand hygiene, wiping phones, minimising non-essential travel). Furthermore, the absolute reduction of physical contact with family and friends should be considered.

If healthcare workers are at all concerned about possible exposure to SARS-CoV-2, they should contact their occupational health service as well as to begin to log their temperature or any symptoms [81, 82] Impact on Surgical education and training

The pandemic is expected to cause an unprecedented disruption to the provision of surgical education. Undoubtedly undergraduate medical education and the training of surgical residents will suffer with the suspension of normal training rotations as highlighted in the UK, Singapore and many other countries [83, 84] . The Association of Surgeons in Training and the 15 surgical speciality associations in the UK have specifically warned of a profound impact to surgical training. On 13th March 2020, the Royal College of Surgeons of Edinburgh announced that all examinations, courses, and other educational events would be postponed until further notice [85] . This was a move swiftly seconded internationally across many healthcare institutions [86] [87] [88] .

Many surgical educational conferences have also been cancelled or delayed, decreasing the number of learning opportunities for surgical trainees. The deceleration of training is expected to increase the capacity of emergency and critical care units by enabling the redeployment of trainees and attendings to clinical areas not usually occupying their daily practice or grade [89] . In the USA, hospitals have been enrolling surgical residents into critical care nursing workshops enabling them to support key allies [90] . There has been a strong emphasis on deployed trainees receiving appropriate induction and supervision before they begin unfamiliar roles, ensuring safe practise [18] . For those surgical trainees in academic surgical training, a huge emphasis is on ensuring an easy and safe transition to clinical surgical service delivery.

This experience has borne out in Italy where urological residents have adapted and used smart learning technologies to replace traditional training methods [91] . These include a pre-recorded video library featuring taught classes and expert tips and tricks, live webinars with expert commentary and discussion of clinical cases, social media journal clubs, and 'virtual' rounds.

The four governing surgical bodies of the UK have assured their trainees that COVID-19 will be taken into consideration during the Annual Review of Competency Progression (ARCP), where their yearly progress is reviewed [92] . For surgical trainees requiring revalidation before September 2020, extensions have been granted. As an alternative option, funding for online and distance learning during COVID-19 as described above is being considered. The Health Education England will need to discuss strategies for the smooth transition of surgeons to return to their surgical training for times past the pandemic [93] [94] [95] .

The American Board of Medical Specialities has also developed similar guidelines for recertification as well as the American Board of Surgery modifying certification requirements such as not including self-isolation into the 6 weeks of allowed leave, reducing minimum case-logs by 10% as well as recognising time spent treating COVID-19 patients as part of training time requirements [96, 97] .

Surgical research, both laboratory and clinically based, has been suspended to the COVID-19 pandemic with many surgeons in academia being re-deployed to the clinical setting to help treat patients with COVID-19 [98] . Moreover, many clinical and scientific conferences have been cancelled which are valuable sources of scientific communication, with some transferring to a virtual model instead [99] . However, many academic institutions have realigned their research goals to tackle COVID-19 and surgeons are no exception [100] .

The University of Birmingham and the National Institute for Health Research (NIHR) Global Surgery Unit are using real world collaborative international data as part of a project called CovidSurg with the RCSEng encouraging members to contribute to it [101] . This international, multicentre, pan-speciality will determine multiple endpoints, including 30 day mortality in patients with COVID-19, the impact on safety in cancer surgery patients and impact of delayed pathways, as well as on the surgical workforce and on emergency surgical services [102] .

The United States are scaling back the work of many of the basic science based laboratories to prioritise work on the COVID-19 pandemic and thus with many surgical researchers being away from their laboratories, many researchers have been forced to postpone and abandon experiments, leading to severe implications for the pace of scientific discoveries [100, 103] Recovery of surgical services

The postponement of non-urgent surgical services will inevitably lead to a significant backlog. This has a significant impact, both on the capacity of the surgical system as well as at a personal level, causing extreme stress and anxiety for patients. One study showed that 30% of patients who had operations cancelled during winter pressures complained of extreme stress and frustration as well as 59% reporting moderate or severe concern about a deterioration in their condition [104] , in addition to the impact on a patient's family as well.

The Royal College of Ophthalmology have outlined a framework for resumption of normal services to include: a preliminary period of gradual resumption of operations whilst maintaining a surge capacity in case of further COVID-19 peaks (Recovery phase 1 -'interim period') and a longer period (Recovery Phase 2 -'the new normal') during the next 12-18 months [105] . They stressed the need to consider repeated cycles of 'switching on and off' peak COVID-19 demand as well as the need for adoption of clear patient pathways during looser social distancing measures. Furthermore, the importance of not returning to 'business as usual' and the benefits of embedding the transformative ways of working developed during the pandemic such as increased efficiency, regional workload sharing, and digital outpatient services

Additionally, the Royal College of Surgeons of England have developed 9 key elements to the short-term recovery of surgical services [106] • Key considerations before resuming elective services This is a fast-moving pandemic with the academic literature base growing exponentially on a daily basis. This paper is a comprehensive general overview of the most current guidelines issued by speciality bodies and learned societies as of date of publication. However, these guidelines are responsive to emerging research and subject to change.

Additionally, whilst surgical services vary widely across the world in response to local and regional variation in budgetary restraints, healthcare system configurations and patient demographics, this leads to differing and often contradictory guidelines issued by different bodies. This paper does not seek to offer specialised local guidelines, but instead points of principle that are generally applicable, with room for local variation.

While COVID-19 continues to make its presence felt in healthcare all over the world, surgeons will no doubt adapt to non-surgical roles in the crucial fight against the COVID-19 pandemic. Finally, it is imperative that in this time of crisis, as Yong et al. [107] remind us:

Provenance and peer review Not commissioned, externally peer-reviewed Aim: Surgery to be prioritised for patients whose survival will be affected if they don't receive an operation within 3 months.

Hospital status:

• A large number of COVID-19 patients • Hospital in rapidly escalating phase of COVID-19 spread • Few ICU beds available • Operating room resources limited Aim: • Surgery to be prioritised for patients whose survival will be affected if they don't receive an operation within the next few days

Hospital status: 1. Overwhelming number of COVID-19 patients 2. Maximum ICU capacity reached 3. Operating room supplies depleted Aim:

• Surgery to be prioritised for patients whose survival will be affected if they don't receive an operation within a few hours. • Background -Set up a solid colour background behind you such as a Green Screen or a collapsible backdrop • Lighting -Ensure you are well-lit with light facing you. This can be achieved by a lamp with a diffuse lampshade or a ring light • Screens -If possible, have two screens so you can take and read notes on one screen and talk to the patient on another Load any documents or imaging prior to starting the consultation to avoid disruption Set up a 'Virtual Background' such as an image of the hospital or of your usual clinic room. This provides the patient with continuity and reassurance as well privacy for your surroundings.

• Ask the patient if they can hear or see you • Reassure the patient that a video consultation is like a face-to-face one and that it is confidential and secure • Confirm their name and date of birth • Confirm where the patient is, are they private and if there is anyone else in the room During the consultation:

• Look at the screen, it is not required to look at the camera only • If you look away from the screen or are quiet, reassure the patient: 'If I've gone quiet, it's because I'm writing' • If there are technical difficulties, ask the patient the last information they heard clearly and resume • If exchanging safety-critical information (i.e medication dosages), ask them to repeat it to confirm After the consultation: • Summarise the main points of the consultation using the text function, if available, as well for the patient to refer back to. • If the patient has no more questions, say 'Goodbye' and end the call Complete documentation in the normal way and record that the consultation was performed over a virtual platform

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Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons in Ireland, Updated General Surgery Guidance on COVID-19

Protecting Surgical Teams During the COVID-19 Outbreak: A Narrative Review and Clinical Considerations

Safety and efficacy of different anesthetic regimens for parturients with COVID-19 undergoing Cesarean delivery: a case series of 17 patients, Can

The Use of Povidone Iodine Nasal Spray and Mouthwash During the Current COVID-19 Pandemic May Reduce Cross Infection and Protect Healthcare Workers

Intubation Checklist for suspected or confirmed COVID-19 Patient

Anaesthetic 'COVID Sequence Induction' CSI)

Preparing for a COVID-19 pandemic: a review of operating room outbreak response measures in a large tertiary hospital in Singapore, Can

COVID-19 preparedness within the surgical, obstetric, and anaesthetic ecosystem in sub-Saharan Africa

Ventilation performance in operating theatres against airborne infection: review of research activities and practical guidance

Management strategies and recommendations for new-type coronavirus pneumonia patients in emergency surgery

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infection-prevention-and-control/reducing-the-risk-of-transmission-of-covid-19-in-thehospital-setting

What we do when a COVID-19 patient needs an operation: operating room preparation and guidance, Can

Preliminary study of electrocautery smoke particles produced in vitro and during laparoscopic procedures

Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery

General Surgery Branch of Hubei Medical Association, General Surgery Branch of Wuhan Medical Association

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

Minimally Invasive Surgery and the Novel Coronavirus Outbreak: Lessons Learned in China and Italy

Can Efficient Smoke Evacuation Limit Aerosolization of Bacteria?

SAGES, SAGES and EAES Recommendations Regarding Surgical Response to COVID-19 Crisis

SAGES, Resources for Smoke & Gas Evacuation During Open, Laparoscopic, and Endoscopic Procedures

Chinese Society of Anesthesiology Expert Consensus on Anesthetic Management of Cardiac Surgical Patients With Suspected or Confirmed Coronavirus Disease

Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1

COVID-19 Outbreak and Surgical Practice: Unexpected Fatality in Perioperative Period

Outcomes of intensive care unit admissions after elective cancer surgery

Elective ICU admission after major surgery: can too much support be futile?

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

Coronavirus (COVID-19) Self-monitoring sheet

North Carolina Department of Health and Human Services, 2019-nCoV Symptom Selfmonitoring log

Stepping Forward: Urologists' Efforts During the COVID-19 Outbreak in Singapore

The Coronavirus Pandemic: Adaptations in Medical Education

Statement on COVID-19 and its effect on surgical training

MRCP(UK) and other exams cancelled -new advice on trainee progression in 2020

Final-year medical students graduate early to fight Covid-19, The Guardian

Association of American Medical Colleges, Coronavirus (COVID-19) and The MCAT Exam

Association of Surgeons in Training, ASiT and The 15 Speciality Associations Joint Letter to Surgical Trainees on COVID-19: The implications for surgical trainees in the delivery of care and training

Surgeons-in-training learn important skills to back up key allies during the coronavirus pandemic -nurses

European Society of Residents in Urology (ESRU) of European Association of Urology (EAU), Slowdown of urology residents' learning curve during COVID-19 emergency

Northern Ireland Medical and Dental Training Agency, Health Education and Improvement Wales, Letter and ARCP update from the four Statutory Education Bodies to all trainees

COVID-19 Study Leave Update

COVID-19 Letter to all medical trainees

Guidance on managing revalidation arrangements for doctors in postgraduate training during the GMC's 6-month deferral of revalidation recommendations

American Board of Medical Specialities, ABMS and ACGME Joint Principles: Physician Training During the COVID-2019 Pandemic

American Board of Surgery, Modifications to Training Requirements -COVID-19 Update

American College of Surgeons, COVID-19 and Surgery

Traditional and Virtual Congress Meetings During the COVID-19 Pandemic and the Post-COVID-19 Era: Is it Time to Change the Paradigm?

US research labs closing down for everything but coronavirus

Outcomes of Surgery in COVID-19 Infection: International Cohort Study (CovidSurg)

Coronavirus pandemic forces some research labs to shut down

Winter cancellations of elective surgical procedures in the UK: a questionnaire survey of patients on the economic and psychological impact

Reopening and redeveloping ophthalmology services during Covid recovery -Interim guidance

Recovery of surgical services during and after COVID-19

Surgical treatment for esophageal cancer during the outbreak of COVID-19, Chin