Table 6.

Preoperative (A), operative (B), and postoperative (C) recommendation ([3,9,33,53]).

A. Preoperative recommendation

•Surgeons should check all scheduled elective programs and cancel, minimize, or postpone all non-urgent surgery •Surgeons must plan surgery according to the severity of the threat to the subject's life and health •In an emergency condition, cases should be located in the separated holding part and transferred to the operating room dedicated to COVID-19 patients •Transport operators should sanitize hands and wear personal protective equipment (PPE) before transfer and should minimize exposure with cases •Transfer routes of COVID-19 patients must be correctly managed and be as short as possible •The cases, wearing a surgical face mask, should be transported through a pre-defined short, direct path with minimum contact •Operators (i.e., surgeon, nurses, technicians, and anesthetist) need to be trained in the use of PPE •Operators should wash hand in a different moment, including before and after touching a patient or patient surroundings, after body fluid exposure, and before engaging in clean/aseptic processes (with water and soap or 2–3% hydrogen peroxide solution or gel) •If oxygen is required, it can be administered by face mask over the surgical mask •Any non-intubated cases should wear a surgical mask, disposable cap, gloves, and shoe covers during transport •Operators should treat COVID-19 cases with respect, dignity, and kindness •The on-call shift can decrease the number of times surgeons move between the hospital and home •On-call surgeons should manage the initial triage arrangements and postoperative care with remote support

B. Operative recommendation

Operating room •The operating room and entrance should be equipped with a negative pressure system •In the hospitals without negative pressure, the positive pressure and air conditioning must be turned off •A high frequency of air changes (25/hour) are proposed for the operating room •The COVID-dedicated operating room must be labeled “COVID-19 infectious surgery” on the door •The appropriate function of the laminar flow and the high-efficiency filter of the operating room must be ensured •Once the infected cases have entered, the operating room doors must be closed •All doors must be kept closed •Unnecessary equipment must be moved away from an infected patient •Minimal materials should be prepared for each operation •Single-use material should be preferred where possible •Use autonomous service (robots and transport system) for transfer of samples and test kits •Clinical documentation should put outside the operating room •Any activity that involves the pulmonary secretions, pharyngeal, nasal mucosal, and oral surfaces is recognized as a high risk to the operating room operators •The powered devices (e.g., microdebriders, saws, drills, and ultrasonic shears) must be considered higher risk •All electronic devices (hospital case sheets, mobile, laptop, and pagers) should be left outside the room •Anesthetic, ultrasound machine, and computers monitor surfaces should be covered with plastic wrap to simplify cleaning •All linen including pillowcases, crossbars, and sheets must only be touched while wearing PPE •Linen can be contaminated and should hence be handled and transported carefully •All essential material (e.g., scalpel blades, stitches, etc.) must be collected in a sterilizable steel basket •Operating room and adjacent areas must be cleaned, sterilized, and disinfected after each operation Staffs and patients •All surgery should be done in a rapid and effective manner •Reduce the total number of staff working in the operating room •Decrease medical students and apprentices in the operating room •Only operators that participate in direct care are permitted to enter the operating room •All staffs should enter the operating room timely •Staffs should not leave until the operation is finished, and once out they should not re-enter •Prepare everything needed for operation and reduce staffs transiting in and out the operating room •All staff in contact with the COVID-19 cases must wear PPE •Alcoholic hand hygiene solution must continuously be available •Double gloves are proposed to change the outer pair

C. Postoperative recommendation

•The operation room is recognized as an area with high risk of cross-infection and contamination •Clean surface and equipment, rinse and dry, and disinfect with 2–3% hydrogen peroxide or 2000–5000 mg/L sodium hypochlorite solution, or 70% alcohol •Grossly contaminated equipment should be cleaned and disinfected by 5000 g/L chlorine solution •The hospital stay must be reduced to the shortest during the coronavirus pandemic to increase the hospital capacity and reduce contamination and transmission risk •PPE must be carefully removed and disposed of in dedicated doffing areas •Patient transfer to and from the operating room must be as rapid as possible •Cases would be transferred while wearing a surgical mask •All areas where COVID-19 patients have been transferred must be carefully cleaned and disinfected •Recovery phase should occur in the operating room, and then the patient should be transferred to the ICU/general ward •Disposable materials should be discarded through IRHW (infectious-risk health waste) containers even if not used and should be decontaminated •All anesthesia materials should be disinfected promptly •For high-risk cases that have a cough with a fever after the operation, chest imaging and a PCR test should be done •For confirmed or suspected cases, appropriate oxygen therapy should be given after operation •The surgical team should pay attention to organ support treatment and nutritional therapy after surgery •There is a high risk of deep vein thrombosis (DVT) and secondary lung infections in confirmed or suspected cases •All waste in the operating room must be double-bagged and labeled “CORONAVIRUS” or “COVID-19” •Visitors of COVID-19 patients should be restricted, but if strictly essential, the number of visitors and the amount of time should be limited •Prepare perfect protocols about how to put on and remove PPE, and ensure hand hygiene