key: cord-1054836-bxfumwpd authors: Dalli, Jeffrey; Faraz Khan, Mohammad; Nolan, Kevin; Cahill, Ronan A title: Gas Leaks Through Laparoscopic Energy Devices and Robotic Instrumentation‐Video Vignette date: 2020-07-21 journal: Colorectal Dis DOI: 10.1111/codi.15278 sha: c9a4844a5efde4fd00f5ac1e1ebb3da5d32e03a4 doc_id: 1054836 cord_uid: bxfumwpd The COVID‐19 pandemic has focused surgeons and healthcare systems on the aerosolization hazards of minimally invasive surgery and its devices. Energy and articulating laparoscopic and robotic instruments contain hollow spaces in their shafts and handles to allow cabling transmit electrical energy to the instrument tip and tissue. While much attention has been placed on the management of smoke that occurs during cautery by instrument activation, it may be less obvious that such instruments may act as chimney flues for intraperitoneal gas to flow unfiltered directly into the operating room environment. This gas will contain smoke but also simply the carbon dioxide (CO(2)) used to distend the abdominal cavity and any associated aerosolised cells and virions. This article is protected by copyright. All rights reserved The COVID-19 pandemic has focused surgeons and healthcare systems on the aerosolization hazards of minimally invasive surgery and its devices. 1, 2 Energy and articulating laparoscopic and robotic instruments contain hollow spaces in their shafts and handles to allow cabling transmit electrical energy to the instrument tip and tissue. While much attention has been placed on the management of smoke that occurs during cautery by instrument activation 3, 4 , it may be less obvious that such instruments may act as chimney flues for intraperitoneal gas to flow unfiltered directly into the operating room environment. This gas will contain smoke but also simply the carbon dioxide (CO 2 ) used to distend the abdominal cavity and any associated aerosolised cells and virions. The associated video demonstrates this in both bench and clinical scenarios. High-speed schlieren imaging in a high-fidelity surgical model (porcine cadaver) shows how CO 2 is directly channelled to the exterior via the instrument shaft of a Liagsure device (Medtronic) and also a robotic instrument (Da Vinci, Intuitive)(CO 2 is optically distinct from room air by its density and so is dynamically detectable by this assessment modality). Clinically, a specific thermographic camera (the FLIR GF 343, FLIR Systems Ltd) confirms this mechanism of CO2 effluvium during actual operations for these instruments by its sensitive visualisation of CO2 gas via its specific near-infrared absorption characteristic. In addition, it shows a greater tendency for the gas to move around the operating room versus the laboratory due likely to the impact of in-theatre airflow around the operative field (a combination of positive pressure room ventilation and additional factors such as surgical movement and patient temperature). This confers the potential for pollutants and pathogens in microdroplets and vapour in the gas to contaminate the operating room team. Interestingly, hook diathermy instrumentation and a harmonic scalpel device did not carry gas through their instrument shafts but did still cause gas leaks at the level of the trocar. While smoke evacuation will reduce smoke within the peritoneal cavity, unfiltered gas and smoke can escape still via instruments accesses 5 and trocars 6 during minimally invasive surgery. This information reinforces the rationale for personal protective equipment 7 alongside adherence to guidance regarding smoke management and trocar etiquette. While it also suggests a benefit in risk mitigation for more simple solid instrumentation like hook diathermy, it emphasises that surgeons need really understand the construction as well as performance of their instruments to make sure they provide due duty of care for their patients and operating room teams. This article is protected by copyright. All rights reserved SAGES and EAES recommendations for minimally invasive surgery during COVID-19 pandemic Solving the problems of gas leakage at laparoscopy Are Surgical Teams at Risk During the COVID-19 Pandemic? Safe management of surgical smoke in the age of COVID-19 Online ahead of print Carbon dioxide gas leaks during transanal minimally invasive surgery Online ahead of print Gas Aerosol Jetstreams from Trocars during Laparoscopic Surgery-A Video Vignette Online ahead of print The authors grateful acknowledge the following equipment loans-high speed Phantom camera for Schlieren Imaging by Bell Labs and the FLIR GF 343 from Mr Steve Beynon, Flir Systems Ltd supplied with thermographic training by Mr David Doyle, Butler Technologies, Ireland.