PALES Position Statement on Laparoscopic Surgery in COVID-19 Pandemic

In the context of COVID-19, community transmission poses a threat against safety of everyone especially doctors in the frontline. 

 

A lot of discussions have been generated in the past week. As surgeons of PALES, it is our responsibility to inform, educate and raise the level of awareness to prevent, control and eliminate transmission of infection during this crisis especially in Covid-19 hot zones. 

 

Solid data on spread of coronavirus during aerosol generating procedures is still unfounded. However, in laparoscopy, generation of artificial pneumoeperitoneum and surgical smoke produced by the use of energy devices become risks for aerosol exposure 1, 2, 3, 4,5 particularly when there are leaks in trocar sites and during evacuation of pneumoperitoneum. Therefore, Covid-19 positive, suspect or asymptomatic, the most important aspect to consider at this point in time is for each surgeon to wear standard surgical personal protective equipment (PPE) which includes a face shield / goggles, N95 mask/ PAPR if available, double gloves, water proof surgical gown & booties and mitigate all aspects of risks from exposure while looking after patients especially during surgery. 5, 6, 7 

 

We have gathered resources 4,8 - 20 available and reviewed various recommendations pertaining to and involving the use of laparoscopy during COVID-19 and the effects of microparticles generated from surgical smoke. We hope that this set of recommendations for our local setting will help you prepare your team well during this crisis and beyond. 

PHASE 1

1)    Cancel all elective procedures

2)    Intentional Postponement of non-emergent, urgent procedures

3)    When in doubt, treat all cases as COVID-19 positive unless proven otherwise

4)    Create COVID-19 ORs and workspace separate from NON-Covid-19 OR

5)    Designate COVID-19 surgical team & Non- COVID-19 teams with no crossing of rooms & staff

6)    Organize Work flow

7)    Simulate Work flow in laparoscopy with the goal of eliminating risk for the team providing care for the patient

PHASE 2

Pre-op

1)    Create a team to Assess and triage* cases for surgery

2)    Screen every patient comprehensively, including a CT chest even in asymptomatic for ALL cases especially in non-emergent, Urgent cases such as cancer

3)    Discuss the risk on COVID-19 infection with patient

Intra-op

1)    Need for a negative pressure room for established COVID-19 PCR positive patients, those with Covid lung on CT, highly suspicious patients based on PSMID interim guideline 20

2)    Standard or enhanced PPE is imperative for every member of the surgical team taking care of the COVID-19 positive and suspect patient. These include Goggles, Face Shield, PAPR, Hazmat suits, double gloves, shoe covers. Proper Donning must be observed, with a Donning Quality officer.

3)    Special attention to maintain integrity of PPE at all times.

4)    During the procedure, Prevention and elimination of aerosol transmission is most crucial. The following principles apply:

•    Limit laparoscopic procedure to the most proficient surgeon

•    Make appropriately sized incision for trocar sites to avoid gas leak

•    Keep pneumoperitoneum intraabdominal pressure as low as possible without compromising the surgical field. (8-10mm Hg, not to exceed 12mmHg)

•    Minimize trendelenburg position ( increases

•    Set electrosurgical power settings to a minimum.

•    Keep instruments blood free.

•    Minimize changing of instruments

•    Use suction liberally to reduce surgical smoke.

•    DO NOT open trocar valves to evacuate surgical smoke or gas during the procedure

•    Consider using an outside filter device attached to a vacuum suction unit if which may be attached to one of the trocars

•    Establish strict protocols to maintain pneumoperitoneum avoiding gas leaks that may aerosolise the virus including small port site incisions,

•    Completely evacuate pneumoperitoneum through a filter device into a vacuum suction unit prior to specimen extraction and trocar removal before closure or during conversion.

Post-op

1)    Follow strictly doffing procedures with the Doffing Quality officer and check for breaks

2)    Post operative room and equipment decontamination and disinfection management should follow and comply with standards from accredited societies and DOH.

3)    Devices used for COVID-19 positive or suspects should be segregated, labeled and undergo separate disinfection

4)    Clinical waste materials should be properly labelled and disposed.

CONCLUSION

It is strongly recommended to apply laparoscopy only in selected cases where COVID-19 is absolutely ruled out and in selected patients where benefit of laparoscopy significantly outweighs the risk of potential aerosolization of virus causing COVID-19 transmission and contamination.  

If laparoscopy is the preferred approach of benefit, mitigation of aerosol transmission from pneumoperitoneum evacuation and surgical smoke by a filter is imperative. 

Safety of the entire surgical team in the OR should not be compromised. 

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