Point of View of the Dutch Society for Gynaecological Endoscopy on Surgery during the Coronavirus 2019 Crisis

To the Editor:

We are still in the middle of the coronavirus disease (COVID-19) pandemic with almost 2 million confirmed cases and 123 000 deaths worldwide [1,2]. As a result, a second crisis has become visible: a reservoir of delayed elective surgeries and the consequences of postponed treatment of less urgent complaints. Currently, in the Netherlands, elective gynecologic surgery has been put on hold because anesthesiologists and operating room personnel are needed in intensive care units, limiting available resources. As acute surgery is still being performed, the debate regarding safe procedures and prevention of unnecessary risks is a hot topic. Despite numerous international safety statements and 2 Dutch guidelines [3,4], a discussion is ongoing regarding the following 2 important questions: “How can we accurately screen for COVID-19 before surgery, and is this even needed?” and “What are the contamination agents during surgery, and what precautions should be taken to protect healthcare providers (HCPs)?” [3,5, 6, 7, 8, 9, 10]

Though based on limited evidence [11,12], the guidelines suggest performing polymerase chain reaction tests and computed tomography scans for asymptomatic patients, preferably 48 hours before surgery. We fear that the suggested preference for computed tomography scan–testing with significantly higher sensitivity [11,13,14] might become a bottleneck in the future for preoperative screening owing to limited capacity [15,16].

The second question concerns the contaminating agents. These can be divided into 3 groups: proven contagious; possible presence of RNA; and undefined but possibly not contagious. The first group, comprising droplets and aerosols produced during the surgical procedures, especially during intubation and extubation 17, 18, 19, is taken care of by using additional protective measures. The second group, for example, surgical smoke, blood, and removed tissue [20,21], is surrounded by multi-interpretable arguments and ambiguous considerations such as excessive protection and the threat of lack of resources or unnecessary costs. And, finally, the unknown instances, for example, carbon dioxide from the pneumoperitoneum during laparoscopy.

The Dutch Society for Gynaecological Endoscopy supports the international and national statements, and recommends the following guidelines for surgery on a patient who has tested positive for COVID-19:

• •Elective surgery should be delayed for a period of 2 weeks or performed after repeated testing for COVID-19 is negative.
• •Personal protective equipment for the surgeon during (laparoscopic) surgery must include eye protection, a waterproof gown, and a surgical mask that conforms to at least the type IIR standards.
• •There is no reason to perform a laparotomy when laparoscopy is normally the procedure of first choice.
• •There is no moratorium on vaginal or hysteroscopic surgeries, which can be performed using normal protective methods.
• •To decrease the contamination risk for HCPs during laparoscopy, we advise low-pressure operating rooms during intubation and extubation, if possible; balloon trocars that minimize gas leakage; active evacuation of surgical smoke and carbon dioxide in a closed circuit; removal of tissue after desufflating the abdomen; and allowing the operating room air to be sufficiently refreshed before attending new surgery [3].

With the availability of national guidelines and support from international societies, we sincerely hope that we can find the means to perform safe surgery and protect patients and HCPs.

On behalf of the Dutch Society of Gynaecological Surgery.