This article is freely available via Open Access. Click on the Publisher URL to access it via the publisher's site.published version, accepted version (12 month embargo), submitted versio

Smart, Neil J.

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published version, accepted version (12 month embargo), submitted versionThis article is freely available via Open Access. Click on the Publisher URL to access it via the publisher's site

Royal Devon and Exeter Research Repository

  Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website.  Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.  PerspectivesPerspectives on Surgery in the Time of COVID-19: Safety FirstPrimum non nocere: First, do no harm. This is a profes-sional and ethical imperative with which we as physiciansare very familiar. Can we expand this principle to includethe patient and the healthcare team? As minimally inva-sive surgeons and ambassadors, the authors could neverhave imagined penning a document that argues the meritsof traditional open surgery. We are all ardent supporters ofminimally invasive techniques and the myriad benefitsthey afford. However, we now find ourselves in themidst of a global crisis from the coronavirus disease2019 (COVID-19) pandemic; a time when the word“unprecedented” has taken on new meaning. Since earlyMarch, it has been reported that more than 3300 healthcareworkers in China were infected with COVID-19, whereasin Italy, upward of 20% of healthcare workers have beeninfected with news reports of more than 50 deaths amongphysicians [1].Significant and realistic concerns have been raisedregarding the risk of severe acute respiratory syndromecoronavirus (SARS-CoV)−2 (the virus responsible forCOVID-19 disease) dissemination during minimally inva-sive surgery owing to pneumoperitoneum-associated aero-solization of particles and the presence of the virus in bloodand stool [2]. It is important to recognize that our under-standing of viral aerosolization by electrosurgical or ultra-sonic tools comes from work with other viral diseases, suchas hepatitis B [3]. Particles in surgical smoke have beendemonstrated to contain a variety of toxic and virulentmaterials thought to be potentially capable of infectingthose who inhale them, with case reports of doctors con-tracting a rare papillomavirus when surgical smoke expo-sure was suspected to be the source [4]. The plausibility ofaerosol and fomite transmission of SARS-CoV-2 has beenestablished, with similar findings to that of SARS-CoV-1(the virus responsible for a multinational disease outbreakin 2002−2003), which was associated with nosocomialtransmission and superspreading events [5]. There havebeen particular concerns raised about laparoscopic surgerybecause of the higher concentrations of particulate matterthat occur compared with open surgery, which may be dueThe authors declare that they have no conflict of interest.1553-4650/$ — see front matter © 2020 AAGL. All rights reserved.https://doi.org/10.1016/j.jmig.2020.04.003to the electrosurgical devices employed, the low gas motil-ity of pneumoperitoneum, and gas expulsion through portsor trocars [4].Regarding COVID-19 specifically, we emphasize thatthere are no data on surgical exposures translating into adefinitive risk to the operating room team. With a dearth ofscientific evidence to guide us, the healthcare community isleft with 2 solutions. The first involves continuing on withnormal practice unless it becomes clear that these practicesare definitively harmful. Proponents of maintaining the sta-tus quo will no doubt highlight the fact that the scientificcommunity is too early in our understanding of COVID-19to have proven a causal link between surgical exposuresand infection of healthcare workers. Surgeons may arguethat there is no evidence specific to laparoscopic plume con-taining SARS-CoV-2 resulting in infection. The rebuttal tothis stance is that neither is there evidence of safety. Theauthors suggest championing an alternative solutionwhereby we as a medical community become proactiverather than reactive, adopting a conservative yet balancedplan to protect both the patient and the healthcare team.When faced with a biologically plausible concern that couldinfer serious harm, we are obligated to act with an abun-dance of caution, examining and questioning our standardpractices.Certainly, it is uncomfortable to consider changing prac-tice in the absence of definitive evidence, but let us considerwhether it will be possible to obtain such evidence eithernow or in the foreseeable future. The necessary studies onthis subject would require lengthy follow-up, be difficult toconduct, and expose a vast number of staff to potential riskin the process. Equipoise concerns may preclude such worktaking place in the in vivo setting. Reliable information onthis subject is not likely forthcoming anytime soon, and yetwe are required to act now to alter practice if we wish toavoid exposure risks. We must bear in mind that theabsence of data is not data in and of itself, or taken anotherway, just because surgical exposures have not been provento be harmful, does not mean that it is safe to proceed withusual practice. The reality is that decision making andguideline development in this arena will be based on thelimited available data and the information inferred fromother viruses and similar epidemics.Cohen et al. 793Taking the aforementioned discussion into account, wepropose the following management algorithm. In patientswho are COVID-19 positive, unless they have a life-threat-ening emergency that requires surgery, we advocate fornonoperative treatment and delay of surgery until recov-ered. If surgery cannot be delayed for a patient who isCOVID-19 positive, a laparotomic operation should be per-formed. In patients with unknown COVID-19 status, preop-erative testing is ideal when available, although it isimportant to also consider the test’s sensitivity/specificityand underlying degree of suspicion on the basis of symp-toms and local disease prevalence. Laparoscopy can be per-formed in a patient whose COVID-19 status is unknown ifthe entire operating room team has access to necessary per-sonal protective equipment and extreme care is taken toprevent release of pneumoperitoneum into the operatingtheater. If these measures are not in place, an open opera-tion is the alternative. The many advantages of laparoscopyare well-known, and it is important to stress that there willbe cases and patients for whom the risks of a laparotomyfar outweigh the risks of laparoscopy, even when takinginto account utilitarian concerns for the healthcare teamregarding potential exposure issues. Outside of these uniquesituations, however, the use of laparoscopy should bereserved for the patient who is COVID-19 negative; or inthe absence of testing, in patients who are symptom- andexposure-screened negative with full deployment of per-sonal protective equipment (Supplemental Fig. 1).We must also keep an open mind to alternatives to tradi-tional minimally invasive surgery, which may be appropri-ate in most cases during this pandemic. With thesuspension of nonessential procedures, many of the emer-gent benign gynecologic cases that we will be approachingin patients who are COVID-19 positive or unknown status(such as ovarian torsion or ectopic pregnancy) could beaccomplished through minilaparotomy with little to no useof electrosurgery and same day discharge. This approachcould prove to optimize benefits to both the patient and thehealthcare team. In addition, regional anesthesia is feasiblewith this technique, which could allow for further limitationof healthcare team exposures related to the aerosol-generat-ing procedures of intubation and extubation. Whether oper-ating using minimally invasive or open techniques,effective mechanisms exist for the removal of smoke andparticulate matter that can significantly reduce the surgicalteam exposure. Whenever possible, electrosurgical/ultra-sonic device use should be coupled with a smoke evacua-tion/filtration system.It is our fervent hope that as more data comes to light,the arguments made in this piece may no longer beapplicable. With more accurate, rapid, and available testingfor COVID-19, including serum tests of markers of acuteinfection and immunity, the decision making will becomemore streamlined. In addition, if future evidence demon-strates a lack of infectivity of the aerosolized, blood, orfluid-borne viral particles, then the aforementioned discus-sions may become moot. Until such time, however, let usnot allow blind allegiance to 1 approach be the primary fac-tor determining surgical route. The best outcomes for allcan be achieved when individual patient and local circum-stances are considered, along with surgical experience andjudgment.Sarah L. Cohen, MD, MPH,a,* Grace Liu, MD, MSc,bMauricio Abrao, MD,cNeil Smart, MBBS (Hons), PhD, FRCSEd,dTodd Heniford, MDeaDivision of Gynecology, Mayo Clinic, Rochester,MinnesotabUniversity of Toronto, Toronto, CanadacUniversity of S~ao Paulo, S~ao Paulo, BrazildRoyal Devon and Exeter NHS Trust, Exeter,United KingdomeDepartment of Surgery, Carolinas Medical Center,Charlotte, North Carolina*Corresponding author: Sarah Cohen, Division ofGynecology, Mayo Clinic, 200 First Street SW,Rochester MN 55905.E-mail: scohen20@partners.orgSupplementary materialsSupplementary material associated with this article canbe found in the online version at https://doi.org/10.1016/j.jmig.2020.04.003.References1. The Lancet. COVID-19: protecting health-care workers. Lancet.2020;395:922.2. Zhang W, Du RH, Li B, et al. Molecular and serological investigationof 2019-nCoV infected patients: implication of multiple sheddingroutes. Emerg Microbes Infect. 2020;9:386–389.3. Kwak HD, Kim SH, Seo YS, Song KJ. Detecting hepatitis B virus insurgical smoke emitted during laparoscopic surgery. Occup EnvironMed. 2016;73:857–863.4. Zheng MH, Boni L, Fingerhut A. Minimally invasive surgery and thenovel coronavirus outbreak: lessons learned in China and Italy. AnnSurg. 2020 Mar 26. [Epub ahead of print].5. van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and surfacestability of SARS-CoV-2 as compared with SARS-CoV-1. N Engl JMed. 2020 Mar 17. [Epub ahead of print].

Perspectives on Surgery in the Time of COVID-19: Safety First

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Perspectives on Surgery in the Time of COVID-19: Safety First

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