A. Maffioli

A.A. Bondurri

C. Guerci

F. Lazzarin

L. Ferrario

P. Danelli

English

AIR Universita degli studi di Milano

 1 
COVID-19: HOW CAN A DEPARTMENT OF GENERAL SURGERY SURVIVE TO A PANDEMIC?  
 
Claudio Guerci, MD1, Anna Maffioli, MD1, Andrea A. Bondurri, MD, PhD1, Luca Ferrario, MD1, 
Francesco Lazzarin, MD1, Piergiorgio Danelli, MD1. 
 
1Department of General Surgery, Department of Biomedical and Clinical Sciences "Luigi 
Sacco", "Luigi Sacco" University Hospital, Università degli Studi di Milano, 20157 Milan, Italy. 
 
Corresponding author: Claudio Guerci, via San Martino 4, 26017, Trescore Cremasco, 
Cremona, Italy. Telephone number: +39 3473898094. E-mail: guerci.clau@gmail.com / 
claudio.guerci@unimi.it  
 
 
 
Text of the paper 
The outbreak of coronavirus disease officially started on the 31st of December 2019, when 
the Wuhan Municipal Health Commission reported 27 cases of pneumonia of unknown 
etiology.  
Chinese scientists found the pathogen that causes this atypical pneumonia and named it 
“SARS-CoV-2” [1]. The disease caused by this novel coronavirus was called COVID-19 by the 
WHO on February the 11th 2020 [2]. 
Now, the outbreak of COVID-19 is a public health emergency of international concern, since 
more than 150 Countries have been quickly involved in the spread of this disease [3]. 
The SARS-CoV-2 is highly contagious and seems to have a predilection for middle-aged 
males, with a median age of 56 [4]. 
The infection could be characterized by a variety of symptoms: dry cough, fever, myalgia, 
asthenia, and dyspnea, but also vomit, diarrhea, abdominal pain, and anorexia. Besides, 
COVID-19 can bring to a severe infection of the inferior respiratory tract, with pneumonia, 
and acute distress respiratory syndrome (ARDS). Nevertheless, the majority of people 
experience an asymptomatic or little-symptomatic disease, according to the Chinese Centre 
for Disease Control and Prevention [5]. 
 2 
The first two Italian cases of COVID-19 were identified at Spallanzani Institute, on the 30th of 
January 2020: it was a couple of Chinese tourists coming from Wuhan. Then, other cases 
were identified and put under strict quarantine, but, with a relief of the authorities, all cases 
came from the Hubei Province.  
Then, on February the 20th, the first hospitalization for COVID-19 occurred in Italy. It was a 
case of a 38-old male from Codogno, Lombardy, with atypical pneumonia, which has had no 
contact with Chinese people nor traveled to Asia. 
The next day, 4 other people were urgently addressed to the infectious disease reference 
center Luigi Sacco Hospital, which was about to become one of the most important hubs for 
COVID-19 care. Most hospitals in Northern Italy have been reorganized. Most of them have 
special areas for COVID-19 patients. In Milan, some hospitals are working as hubs, to collect 
patients with the same disease.  
On the 23rd of February, the Italian Government issued a decree-law, in order to contain the 
infection. Extraordinary measures were taken during the next days, such as the closure of 
bars, restaurants, and museums in the regions involved by the virus’ spread. Even schools 
were closed in those areas. 
 
Since February the 21st, everything has changed in Luigi Sacco Hospital. 
All ambulances called by 112 (European emergency Number) coming from the territory were 
prevented to head to Sacco Hospital, to which only transfers of critical patients from other 
hospitals were accepted. Despite this measure and the Government discouragement, more 
and more people appeared to the hospital emergency room. 
A reorganization of the hospital complex structure was immediately required, in order to 
contain the infection’s spread and to prevent each department from being invaded by the 
 3 
virus. This enormous task required to use existing teams and resources efficiently, to build a 
solid and effective structure. 
As almost 10% of COVID-19 patients required intensive care, the regular Intensive Care Unit 
was closed on the 21st of February and a wider dedicated ICU was established near the 
Infectious Disease Department Building. 
Since then, the emergency room has been almost completely dedicated to handling infective 
patients, and the most of unsuspected patients who required urgent medical or surgical 
treatment have been hijacked to other hospitals. Thanks to this measure, between the 22nd 
of February and the 20th of March, only 9 urgent interventions concerning general surgery 
have been performed at Sacco Hospital. 
For Surgical and Operating Room Department, some special considerations need to be done. 
First, the number of anesthesiologists available for the Operatory Room has steeply 
decreased, because of their efforts to manage the state of emergency. Second, the ICU 
would not be available for delicate and complicated surgical patients. Third, the nursing staff 
was involved: the number of cases has grown to such an extent that aid staff has been 
recruited and dispatched from other departments to the Infectious Disease Unit. 
Consequently, all patients admitted to the surgical department who did not require urgent 
treatment were discharged; some unsuspected patients have been transferred from the 
Infectious Disease to the Surgical Department in order to free beds for the COVID 
emergency; all scheduled surgery has been suspended. Therefore, between the 22nd of 
February and the 1st of March, the operating room was almost paralyzed, and no elective 
surgery has been performed.  
On the 1st of March, the number of Italian cases of COVID-19 was about 1700, and the trend 
seemed to be at a rapid increase. As a consequence, the Italian Government implemented 
 4 
and extended the emergency measures to Lombardy and other 14 Provinces. On the 4th of 
March, these rules would be extended to the whole National territory. From the 10th of 
March on, Italian people have been forced to stay home, unless it’s urgent, or necessary [6]. 
On the 11th of March, the WHO declared COVID-19 a pandemic [7]. 
To deal with this emergency, and to try to maintain “a clean surgical service” for urgent and 
oncological patients, in contrast to other realities [8], the General Surgery Unit had to 
reorganize spaces and personnel. Because of the transfer of the nursing staff, the number of 
beds assigned to surgery has been halved (from 40 to 20). Also, to cope with the number of 
infected people, the Week Surgery Course was closed and dedicated to the management of 
highly suspect patients waiting for laboratory tests or mild confirmed cases waiting for 
admission. But it was not enough. 
The more patients arrived, the more doctors and nurses were required. Therefore, on the 9th 
of March, an urgent department meeting was held, and plenty of surgeons pleaded ready to 
help. 
As a consequence, the next day, a third of general surgeons received detailed instructions on 
what to do and how to behave in handling COVID-19 patients. Courses on dressing and 
undressing procedures as well as on respiratory failure treatment mainly focused on the 
application of continuous positive airway pressure were held. Since then, those surgeons 
were employed in the emergency department and in the management of highly suspect 
patients waiting for laboratory tests or mild confirmed cases waiting for admission. As an 
example of adapting to cope with adversities, they were all excluded from surgical activities 
and prevented from having contacts with the other surgeons. 
In this respect, dedicated pathways were arranged to separate “clean” areas, included 
courses, stairs, elevators, changing rooms, and showers from those defined “contaminated”. 
 5 
Having said that, the Operating Room remained a “clean” area with dedicated staff, and no 
COVID-19 outpatient or inpatient of Sacco Hospital needed an urgent surgical operation until 
now. Anyway, if necessary, an OR located at the end of the operative complex, with a 
separate entrance, is available for all suspected or confirmed cases. The same operating 
room and anesthesia machines would only be used for COVID-19 cases for the duration of 
the epidemic. A separate pathway and elevator are prepared in case of COVID-19 surgical 
urgency, and a surgical dedicated staff is on call, if needed.  
Furthermore, for oncological patients who need general or abdominal surgery, the Unit of 
General Surgery of Sacco Hospital joined an agreement written and issued by a group of 
experts established by Lombardy Region Authorities. These criteria define the requirements 
for oncological patients and list them on an urgent basis. Therefore, patients are divided into 
three groups, which should undergo surgical procedure within two weeks, two months, or 
delayed after two months respectively. The aim is to allow oncological patients to have 
access to elective surgery, as well as to give adequate treatment to patients who need post-
operative ICU, working in another secure and clean hub. Previously, other Authorities and 
Hospitals have already made such plans for some critical patients [9].  
As regards the general surgery ward, all patients are screened before admission with home 
screening and evaluation by phone call, to identify fever or respiratory symptoms, and, at 
admission, with blood tests and lung X-rays. To avoid nosocomial transmission of the virus, 
the members of the medical and nursing staff always use personal protective equipment 
(PPE). Besides, the visitor policy was updated: all patients may have only one visitor at a time 
and each visitor should wear a surgical mask during the entire stay. Concerning clinic, office 
visits were suspended, and all hospital appointments were delayed, except for the 
emergency ones, to make resources available for most severe cases. 
 6 
As a result of these measures, between the 2nd and the 20th of March, 20 elective surgical 
operations in oncological patients have been safely performed, and no patient in the general 
surgery ward resulted SARS-CoV-2 positive nor had respiratory symptoms, nor positive X-ray. 
Besides, other 19 oncological patients have been listed to undergo surgical operations within 
the next two weeks. 
In conclusion, although Sacco Hospital is an infectious disease center, no infected patients 
have been identified in the General Surgery Unit and no patient developed COVID-19 after 
surgery. Until now, surgeons could be professionally and ethically proud of their work, 
because they are demonstrating good coping skills in this situation, despite the few 
resources available.  
Anyway, we could say we have learned this lesson: two months ago, the epidemic broke out 
in Wuhan seemed to be very far and we felt safe, in our continent. We should have 
considered that, in a globalized world, any epidemic could easily spread with a simple flight. 
If we could go back in time, we should have implemented these recommendations in 
advance. 
Moreover, it would have been useful to immediately identify reference hubs sorted by 
pathology, in order to maintain “clean” areas and hospitals. 
Another thing we think should not be underestimated is the possible psychological distress 
that doctors can experience during coronavirus emergency. Healthcare professionals 
involved could undergo a Critical Incident Stress Syndrome, with emotional reactions which 
could even compromise private and social life. For this reason, Sacco Hospital have arranged 
a psychosocial support for healthcare personnel. This has turned to be a very important 
measure we suggest implementing, to get totally ready. 
 7 
The recommendations described in this article are based on current clinical practice and 
previous experiences reported during the current outbreak [10]. 
Key point box 
What we do need to survive 
1. Self-protection --> Personal protective equipment  
2. Designing --> Separate wards, different pathways 
3. Strategy --> Planning surgical activity on a urgent basis 
4. Resilience --> Adapting to cope 
5. Institution --> Psychosocial support 
 
 
Conflicts of interest 
The authors declare no conflict of interest. 
 
 
Disclosure of funding  
 
No funding received for this work. 
 
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n/a(n/a).  
 
 
 
 


COVID-19: How can a department of general surgery survive in a pandemic?

https://air.unimi.it/retrieve/handle/2434/731929/1464033/COVID-19%20reviewed.pdf

COVID-19: How can a department of general surgery survive in a pandemic?

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