Table 1.

Analytical review of the included citations.

Author (Year)	Journal	Study	Purpose & focus	Findings/recommendations for laparoscopy under COVID-19
Al Balas, Al Balas, Al Balas (2020)10	The American Journal of Surgery	Overview	Surgery during the COVID-19 pandemic: laparoscopy or laparotomy?	Advocated careful attention during pneumoperitoneum creation and strict aerosol management even during the operation. Pneumoperitoneum pressure and CO2 ventilation should be as low as possible. Direct suction connected to a vacuum suction unit should be used for surgical smoke and pneumoperitoneum evacuation.
Altinbaş Tapisiz, Üstün (2020)11	Turkish Journal of Medical Sciences	Review	The concepts related to laparoscopic gynaecological surgery during COVID-19 pandemic in the light of current literature, are listed.	Minimally invasive approaches shorten the recovery and reduces the hospitalization period of the patients. All precautions should be considered, both protective equipment as well as recommendations about any type of surgery that may have include a risk of aerosolization.
Aminnejad, Salimi, Bastanhagh (2020)12	The Journal of Minimally Invasive Gynecology	Letter to the editor	Regarding “Understanding the “Scope” of the Problem: Why Laparoscopy is Considered Safe During the COVID-19 Pandemic"	No case of virus transmission through surgical plume or smoke has been confirmed yet, but no research has been conducted that refutes such a possibility. Yet, no space in the abdominopelvic cavity can be considered virus-free and importing a laparoscopic trocar to any point of this space carries the risk of spreading the virus throughout the operating theatre by gas insufflation. Laparoscopy can be performed with precautions to reduce the risk of virus transmission as much as possible.
Bogani, Raspagliesi, (2020)13	The Journal of Minimally Invasive Gynecology	Letter to Editor	Minimally Invasive Surgery at the Time of COVID-19: The OR Staff Needs Protection	The release of aerosol through the trocar valves might potentially expose the operating theatre staff to SARS-CoV-2. Pneumoperitoneum pressure and the power settings of electrosurgery should be as low as possible. Apply filters to reduce possible spread of the virus. Adequate personal protective equipment is necessary for all staff working in the operative theatre. Isobaric minimally invasive technique and robotic-assisted surgery might reduce the risk of infection in the operating theatre staff.
Chew, Tan, Ng, Ng (2020)14	Singapore Medical Journal	Commentary	Reconsidering elective surgery	In laparoscopic colorectal surgery: laparoscopy can lead to aerosolization of blood-borne viruses, although the applicability to SARS-CoV-2 remains unknown. In laparoscopic colorectal surgery, there may be risks of faecal spillage into the pneumoperitoneum due to bowel injury. There is no evidence to suggest a concurrent higher viral load in the pneumoperitoneum during laparoscopic surgery. For colorectal surgery specifically, transanal procedures may have to be approached with caution, especially in transanal minimally invasive surgery and transanal total mesorectal excision procedures.
Cohen, Liu, Abrao, Smart, Heniford (2020)15	The Journal of Minimally Invasive Gynecology	Perspe-ctives	Perspectives on Surgery in the Time of COVID-19: Safety First	Nonoperative treatment is advocated with surgery delay until recovered for COVID-19 positive patients, unless they have a life-threatening emergency. If surgery cannot be delayed for a patient who is COVID-19 positive, open surgery should be performed. Laparoscopy can be performed in a patient whose COVID-19 status is unknown if the entire operating theatre team has access to necessary personal protective equipment and extreme care should be taken to prevent release of pneumoperitoneum. If these measures are not in place, open surgery is the alternative. The use of laparoscopy should be reserved for the patient who is COVID-19 negative with full deployment of personal protective equipment
De Simone, Chouillard, Di Saverio et al. (2020)16	Annals of The Royal College of Surgeons of England	Systematic review	Reviewing the most current data on COVID-19 to provide essential suggestions on how to manage the acute abdomen during the pandemic.	In surgical patients with COVID-19, great care must be taken when carrying out a laparoscopic procedure as there is a hypothetical risk for occupational exposure and infection of the operating theatre staff. Having reviewed the available literature on COVID-19, authors concur that when considering the laparoscopic approach in an emergency, every effort should be made to limit the leakage of gas through advocated techniques for laparoscopy.
Di Marzo, Cardi (2020)17	The Journal of Minimally Invasive Gynecology	Commentary	Regarding “Understanding the “Scope” of the Problem: Why Laparoscopy is Considered Safe During the COVID-19 Pandemic"	High efficiency particulate arrestance filters are extremely effective in capturing a very high proportion, up to 100%, of nanoparticulate contaminants, ranging in size from 0.1 to 0.001 micron (diffusion regime) because they do not fly straight, collide with other fast-moving molecules, move around in random pathways and hit the filter fibres remaining stuck in them. The intersecting regime has just a small dip in efficiency that affects the particles of around 0.3 μm, defined as most penetrating particle size (MPPS). Typical HEPA filter varies from 0.2 to 0.3 micron depending on flow rate. Lowering the flow speed will result in making a simple HEPA perform as an ultra-low particulate arrestance (ULPA) filter.
Di Saverio, Marzo Khan, Pata et al. (2020)18	Journal of Trauma and Acute Care Surgery	Expert opinion	Laparoscopy at all costs? Not now during COVID-19?	The use Non Operative Management strategies should be encouraged whenever possible and safe, even with established outpatient management and follow up for sub-acute, uncomplicated and/or mild abdominal conditions (e.g. Acute, non-severe cholecystitis, uncomplicated or maximum Hinchey 1a diverticulitis, uncomplicated appendicitis) by telephone or remote follow up if the patient is suitable for oral intake (food and antibiotics) and reliable is assessing remotely their response to treatment. The recommended use of filtration devices, smoke evacuation device connected to trocars, use of self-sealing trocars connected to negative pressure suction. Authors feel safer performing open surgery as much as possible mentioning that open surgery can be less time-consuming during the pandemic. Exploratory laparotomy can be performed without any use of cautery to avoid smoke production. Hot gallbladders are initially managed conservatively with antibiotics and/or percutaneous cholecystostomy drainage. Preoperative imaging should be implemented in all patients with lower abdominal pain to avoid diagnostic laparoscopies and negative appendicectomies. Perforated appendicitis needs urgent surgery by open surgery in all COVID positive or suspected patients.
Di Saverio, Pata, Gall et al. (2020)19	Colorectal Disease	Advise and guidance	Coronavirus pandemic and Colorectal surgery: practical advice based on the Italian experience	The conservative management of COVID-19-positive patients with diseases of surgical interest should be as conservative as possible. Only life-threatening colorectal emergencies should be treated (i.e., intestinal perforation, obstruction, and bleeding). The use of laparoscopy in confirmed COVID-19 positive patient needing colorectal surgery must be carefully considered. It is advisable to use trocars with self-sealing type Hasson and to make the incision as small as practicable. Connect the trocar trephine to negative pressure suction with water seal. The insufflator must be turned off and the pneumoperitoneum must be emptied by negative pressure connected to a water seal before releasing the pneumoperitoneum. In COVID-19 positive emergency cases, authors adopted a selective use of laparoscopy when the appropriate equipment is available and safely used. Recommendations for operating theatre settings and use of laparoscopy have been described.
Francis, Dort, Cho (2020)20	Surgical Endoscopy	Guidelines	SAGES and EAES recom-mendations for minimally invasive surgery during COVID-19 pandemic	Although specific evidence to COVID-19 and the risk for aerosol transmission during laparoscopy is lacking, every effort must be made to minimize this potential risk through following recommendations.
Kimmig, Verheijen, Rudnickin SERGS Council (2020)21	Journal of Gynecologic Oncology	Position Statement	A statement of the Society of European Robotic Gynecological Surgery (SERGS)	Robot-assisted surgery (RAS) reduces hospital stay for patients who need complex-oncological-surgery, which allow making room for COVID-19 patients. RAS reduces not only contamination with body fluids and surgical gasses of the surgical area, but also the number of directly exposed medical staff when compared to open surgery. Surgical precautions under COVID-19 circumstances must be taken, with the addition of prevention of gas leakage. Evidently, if precautions cannot all be taken, e.g., by lack of equipment, consider if open surgery would be safer or whether indeed surgery would be feasible at all under the circumstances.
Mallick, Odejinmi, Clark (2020)22	Facts, Views & Vision in Obgyn	Opinion article	Recommendations for laparoscopic surgery in suspected or confirmed COVID-19	Non-surgical treatments are utilised if possible, to reduce the risk of horizontal transmission of SARS-CoV-2 virus to health care workers (HCW), and reduce the need for hospital admission, provided they are a safe alternative. COVID negative patients can proceed with the standard laparoscopy and routine surgical infection control procedures. The laparoscopy is undertaken by the most experienced surgeon for safe laparoscopy performed in the shortest time possible. Recommendations to protect operating staff during laparoscopy have been mentioned. Gynaecological operations that carry a risk of bowel involvement, however small should be performed by laparotomy. Total laparoscopic hysterectomy in malignancies, can continue to be undertaken in the pandemic.
Morris, Nickles Fader, Milad, Dionisi (2020)23	The Journal of Minimally Invasive Gynecology	Overview	Why Laparoscopy is Considered Safe During the COVID-19 Pandemic	Performing laparoscopy with lower intraabdominal CO2 pressures and minimizing the use of energy limit the production of surgical plume and pneumoperitoneum. The use of a smoke evacuation/filtration system controls release and filtration of the surgical plume. Gas and plume evacuation and filtration is achieved with the use of ultralow particulate air filter (ULPA) rated to screen particles of 0.1 micron in diameter (e.g., the ConMed Airseal or Stryker Pneumoseal). High efficiency air filters (HEPA) filters particles of 0.3 micron in diameter. N95 masks filter out at least 95% of 0.3-micron particles. Laparoscopy can almost entirely contain the surgical plume in the abdominal cavity; therefore, avoid release of the pneumoperitoneum. The abdominal cavity should be actively desufflated through a filtration system or with a simple piece of tubing attached to a suction. Use of a containment bag for tissue extraction can limit loss of pneumoperitoneum.
Novara, Giannarini, De Nunzio, Porpiglia, Ficarra (2020)24	European Urology	Overview	Risk of SARS-CoV-2 Diffusion when Performing Minimally Invasive Surgery During the COVID-19 Pandemic	Special care must be taken intraoperatively to reduce smoke formation (e.g., lowering electrocautery power settings, using bipolar electrocautery, electrocautery or ultrasonic scalpels sparingly to reduce surgical smoke). This is crucial when removing trocars at the end of a procedure, when making a skin incision for specimen retrieval, and in the conversion to open surgery. Generous use of suction to remove smoke and aerosol should be advocated. Care must be taken to limit smoke dispersal or spillage from trocars (e.g., lowering the pneumoperitoneum pressure). It can be beneficial to use pressure-barrier insufflator systems to maintain a forced-gas pressure barrier at the proximal end of the trocar.
Pawar, Pokharkar, Gori et al. (2020)25	Journal of Laparo-endoscopic & Advanced Surgical Techniques	Case presenta-tion	Is there evidence for viral transmission through surgical smoke in laparoscopy? .	A case of 28 years old female patient with carcinoma rectum had near total intestinal obstruction. She was operated on utilizing laparoscopic anterior resection. Safe gas evacuation was performed using the air seal (CONMED, Utica, NY) and high-efficiency particulate air (HEPA) filter. Precautions using N95 masks and personal protective equipment (PPE) is advised. Air filtration products like aerosol, HEPA filters are of great aid in safe evacuation of gases. Authors have done 12 laparoscopic colorectal cancer procedures using airseal and a HEPA filter since March 30, 2020. They believe that using laparoscopy even if there is risk, will be very minimal if all precautions are taken.
Schwarz, Tuech (2020)26	British Journal of Surgery	Correspondence	Is the use of laparoscopy in a COVID-19 epidemic free of risk?	If the laparoscopy is indicated, it is recommended: to check all instruments and the proper functioning of the suction system, to use balloon trocars and create suitable holes for the introduction of leak-free trocars; not to create a leak in the presence of smoke obstructing the surgical field, but to extract the smoke by the vacuum suction device; and to aspirate the entire pneumoperitoneum before removing the trocars. Laparoscopy should be performed by an experienced surgeon. In case of doubt or lack of experience in laparoscopy, a laparotomy should be performed. The authors stated that there is a theoretical risk that should be weighed against the benefit of laparoscopy.
Tuech, et al. (2020)27	Journal of Visceral Surgery	Original article	What strategy for digestive and oncological surgery is good during the Covid-19?	Elective surgery for benign disorders should be postponed. For patients who are or may be infected by Covid-19 and who require emergency surgery, consider protection of HCWs. Laparoscopy is preferred if the patient's cardiorespiratory status is stable. Emergency surgery is the priority and elective surgery should be postponed. In cancer surgery, there is an added risk due to the pandemic that must be balanced against the risk incurred by deferring surgery. For each type of cancer: colon, pancreas, oesogastric, and hepatocellular carcinoma; authors stated morbidity and mortality rates and compared with the oncological risk incurred by deferring surgery and/or the tumour doubling time.
Vigneswaran Prachand, Posner, Matthews,Hussain (2020)28	Journal of Gastro-intestinal Surgery	Review article	What Is the Appropriate Use of Laparoscopy over Open Procedures in the Current COVID-19 Climate?	Laparoscopy should be performed with the precautions as it still may be of benefit to the patients. Authors recommended avoiding traditional practices and creating a closed circuit for insufflation with the use of some sort of smoke evacuator device to avoid any release of pneumoperitoneum into the room. Desufflation at the end of the operation should be done through a smoke evacuator device or direct suction. Thereafter, care should be taken to evacuate the abdomen under direct vision for as long as possible and placing the tip of the trocar on suction away from bowel, either resting above the liver or turned up toward the abdominal wall. Any specimen to be removed should be done with the abdomen desufflated. All precautions should be taken whenever possible to minimize the risk of transmission regardless of known COVID-19 status. Based on this review of the current scientific knowledge, no scientific evidence was found to support the use of open surgery over laparoscopy or robotic surgery to reduce viral transmission of COVID-19; however, there is still much to discover about the viral transmission.
Veziant, Bourdel, Slim (2020)29	Journal of Visceral Surgery	Review	Risks of viral contamination in healthcare professionals during laparoscopy in the COVID-19 pandemic,	The risk of contamination of HCWs may be greater in laparoscopy than in laparotomy if gas leakage occurs or exsufflation is poorly controlled. No contamination of HCWs by SARS-CoV-2 during a laparoscopy is reported. Personal protection equipment (PPE) for HCWs: surgeon, assistant, scrub nurse or circulating nurse are less exposed than anaesthetist and anaesthetist's nurse, who are directly in contact with patient's upper airways, the main source of contamination. Every member of the HCW team must have according to WHO guidelines, PPE with long-sleeved fluid protection gowns, lined gloves, goggles and masks. The risk of contamination of HCWs is highest during the insertion of trocars, extraction of the excised tissues and removal of trocars at the end of the operation. Recommendation in the use of laparoscopy included preferring the ‘closed’ technique for obtaining pneumoperitoneum. Prefer intracorporeal bowel anastomosis and extract excised tissue after complete emptying of the pneumoperitoneum. No literature suggests that laparoscopy should be replaced by laparotomy during the Covid-19 epidemic.
ALSGBI https://www.alsgbi.org/2020/04/22/laparoscopy-in-the-covid-19-environment-alsgbi-position-statement/ [30]	Internet	ALSGBI Position Statement	Association of laparoscopic surgeons of Great Britain and Ireland (ALSGBI) position statement regarding the use of laparoscopic surgery during COVID-19	Benefits of laparoscopy include less hospital stay and increased bed availability, decreased complications and faster recovery and less contamination compared to open surgery. Recommendations: Elective laparoscopic procedures should be performed in clean area. Laparoscopic surgery should be performed by experienced surgeon to minimize operation time and potential of aerosolization Use of closed-circuit smoke evacuation/Ultra low particulate air filtration system. Lowest insufflation pressure (12 mmhg). Minimal use of energy device. Routine closed evacuation of gas at the end of procedure. Initiation of elective surgery should include careful case selection, starting with a younger patient group (under 70 years), with fewer comorbidities (ASA <2), aiming for day case/reduced hospital stay as standard practice. The risks and consequences of COVID-19 infection should form part of the informed consent process. ALSGBI support the use of laparoscopy in cases where there are clear benefits to the patient and where the hospital and theatre resources allow this as a safe option for the patient and staff.
IGSG https://www. rcseng.ac.uk/coronavirus/joint-guidance-for-surgeons-v2/6 April (update) [31]	Internet	Intercollegiate guidance on COVID-19	Updated Intercollegiate General Surgery Guidance on COVID-19	Disadvantages of laparoscopy: Laparoscopy generally should not be used as it is considered to carry some risks of aerosol-type formation and infection and considerable caution is advised. Consider laparoscopy only in selected individual cases where clinical benefit to the patient substantially exceeds the risk of potential viral transmission to surgical and theatre teams in that particular situation. Where non-operative management is possible and reasonable (such as for early appendicitis and acute cholecystitis) this should be implemented. Appropriate nonoperative treatment of appendicitis and open appendicectomy offer alternatives.