Laparoscopy safety in the setting of COVID-19

Addressing the potential for CO2 to aerosolize the virus during laparoscopy

For laparoscopic surgery, it is essential to maintain an artificial pneumoperitoneum. This may increase the risk of aerosolized viral particle exposure for the operating team as seen with HPV and HIV.[1] Low temperature smoke created during laparoscopic surgery cannot effectively deactivate the cellular components of the virus. It has been suggested that surgical smoke exposure may be connected to cases of physicians who contracted a rare papillomavirus. The cause may be low gas mobility in the pneumoperitoneum, causing the aerosol to concentrate in the abdominal cavity. One study demonstrated that the particle concentration of smoke after use of electrical or ultrasonic equipment for 10 minutes was significantly higher than in traditional open surgery.[1][2][3] Given these findings, reasonable concern exists as to the potential for the coronavirus to be aerosolized by CO2 during laparoscopy. Though no data currently exists that demonstrates aerosolized COVID-19 release during laparoscopic/abdominal surgery, it is reasonable to adopt a conservative approach to protect healthcare workers from possible SARS-CoV-2 transmission. Current literature recommends delaying elective surgery. The need for emergent, necessary laparoscopic surgery remains a real one and requires guidelines for safe practice moving forward.

Although it is unknown if aerosolized coronavirus is released during laparoscopy, the sources referenced for this summary document unanimously advise that coronavirus should be assumed to have similar properties to the aforementioned viruses for precautionary purposes.[1][2][3] Thus, elements of laparoscopic surgery such as sudden release of trocar valves, non-air-tight exchange of instruments and small abdominal extraction incisions can expose the O.R. team to pneumoperitoneum aerosol. For laparoscopy, use of devices to filter released CO2 is recommended.[3] In addition, The Chinese Journal of Gastroenterology states that laparoscopy with an auxiliary incision can reduce operation time and exposure.[2]

Laparoscopy procedure recommendations:

Live virus has been isolated from blood and feces. One case report documented that an 81 year old patient with acute enterocolitis secondary to SARS-CoV-2 infection had positive RT-PCR stool studies up to hospital day 15.[4] A report from The Chinese Journal of Gastroenterology recommends (of note, Google Translate was utilized for this text and a “?” below indicates possible grammatical error)[2]:

1) Detailed inspection of all equipment for normal function
2) Check Trocar hole for air leaks, select appropriate hole size and suitable Trocar
3) Trocar hole is connected to negative pressure suction of water seal and connected to central negative pressure device (NOT an independent device)
4) Can be operated with constant pressure insufflator (empties aerosol with virus into abdominal cavity) – of note, The Annals of Surgery recommendations listed below recommend against using a two-way insufflator
5) Assist incision and laparotomy? Gas in the abdominal cavity should be evacuated as much as possible to prevent residual gas from being ejected during auxiliary ? incision
6) Distinguish post-op abdominal infection fever from COVID-19 fever

A Review from The Annals of Surgery has compiled a set of recommendations based on experience in Shanghai and Milan1:

1) “General protection: all surgery patients must complete preoperative health screening, whether they are symptomatic or not. As operating staffs might become infected, and therefore 2020 Wolters Kluwer Health, Inc. All rights reserved. reduced in number, all medical personnel have to comply with the tertiary protection regulations (8,9).
2) Prevention and management of aerosol dispersal: During operations, instruments should be kept clean of blood and other body fluids. Careful establishment of pneumoperitoneum, hemostasis and cleaning at trocar sites or incisions to prevent any gush of body fluid caused by air leakage or uncontained laparotomy incisions. Liberal use of suction devices to remove smoke and aerosol during operations, and especially, before converting from laparoscopy to open surgery or any extra-peritoneal maneuver. Avoid using two-way pneumoperitoneum insufflators to prevent pathogens colonization of circulating aerosol in pneumoperitoneum circuit or the insufflator
3) Management of artificial pneumoperitoneum: keep intraoperative pneumoperitoneum pressure and CO2 ventilation at the lowest possible levels without compromising the surgical field exposure. Reduce the Trendelenburg position time as much as possible. This minimizes the effect of pneumoperitoneum on lung function and circulation, in an effort to reduce pathogen susceptibility.
4) Operation techniques: The power settings of electrocautery should be as low as possible. Avoid long dissecting times on the same spot by electrocautery or ultrasonic scalpels to reduce the surgical smoke. Special attention is warranted to avoid sharp injury or damage of protective equipment, in particular gloves and body protection.
5) Postoperative operating room and equipment management: all protocols involving postoperative cleaning and disinfection should comply with governmental and learned society instructions (1,8,9). Devices used on infection-suspected or proven patients should undergo separate disinfection followed by proper labeling. It is mandatory to specifically label and dispose clinical wastes separately.
6) Ideally hospitals should be immediately divided into two main categories: dedicated hubs for positive COVID-19 patients (with limited surgical staff and ORs, for those infected patients requiring surgery) and other both for emergency surgery and urgent oncological procedures in negative COVID 19 patients. Health authorities should allow surgical teams to move from one hospital to another.
7) Teaching and future recommendations: Strengthen the awareness on the hazards caused by surgical smoke and the management of intraoperative aerosol. Strict protocols must be established for the creation and maintenance of laparoscopic pneumoperitoneum to reduce the occupation hazard caused by aerosol exposure.
8) Operating staff protection: efforts must be made to raise awareness of the occupation protection on operating staffs, including surgeons, anesthetists, and nurses and all possible 2020 Wolters Kluwer Health, Inc. All rights reserved. transiting persons in the OR. Correct two-way protective apparel (goggles, visor, mask, and body protective garb) should be routine. When engaging a suspected or diagnosed patient, tertiary dress code should be applied according to the protocols which also include strengthening OR ventilation and installing air purification equipment.
9) Preoperative health screening: In order to effectively battle against the possibility of prolonged 2019-nCOV outbreak, it is imperative to establish new standards of practice for admitting patients in the future. This should range from preoperative health screening to final differential diagnosis, including epidemiology investigation and adequate imaging.”

Gaps in knowledge

It is unknown if active COVID-19 particles are present in the peritoneal gas during laparoscopy.