Table 2.

Recommendations for the safe use of laparoscopy during the pandemic.

Preoperative considerations during covid-19 pandemic
Settings of surgical theatre: Two teams: One inside and one outside the theatre a)Team outside: anaesthetic nurse/operating department practitioners, scrub nurse, health care workers (HCW). b)Team in: anaesthetic nurse/operating department practitioners, scrub nurse, health care workers, anaesthetist, surgical team.
Entrance order to operating theatre: 1Scrub nurse/health care workers 2Anaesthetist/anaesthetic nurse 3Patient (accompanied by the Surgical Ward staff to help transfer the patient directly to the room on the surgical bed, through marked COVID path). 4Surgical team, once inside the operating theatre, require second sterile gown and second pair of gloves.
Other precautions: •Staff in operating theatre should be reduced, and their temperature needs to be measured before starting the surgery. •Staff should perform their clinical tasks wearing hats, gloves, and disposable surgical masks. •Use personal protective equipment (PPE) including fit-tested disposable N95 respirator, goggles, face shield, gowns, double-layered gloves, and protective footwear. •Staff complete personal hand hygiene before and after contact with patients and after removing gloves. •Limit the presence of staff during intubation and induction of anesthesia. Anesthetists should oxygenate patients with 100% O2 followed by rapid sequence induction and intubation to avoid manual ventilation and decrease aerosolization. •PPE should be removed with care followed by handwashing. Use high-quality Heat and Moisture Exchange Filter between the facemask and breathing circuit. •Anesthetic equipment is used by one person only and the anesthesia machine is disinfected after use.

Intraoperative considerations during covid-19 pandemic
•If the laparoscopy is indicated, it should be performed by an experienced surgeon. •Avoid movement or changing of HCWs during laparoscopy. •Check all instruments and the proper functioning of the suction system. •Minimise the amount of Trendelenburg. •Closed technique can be advisable for obtaining pneumoperitoneum. Incisions for ports must be as small as possible to avoid leakage around ports. •Close the taps of the trocars before insertion and during the operation. Use balloon trocars and create suitable holes for the intro-duction of leak-free trocars. •Make a minimum number of incisions, minimum size of incisions, and minimum exchange of the instruments. •If a patient is having COVID-19 or is suspected, the operation is performed in a negative pressure environment; keep pressure difference between the operating room below - 4.7 Pa. •CO2 insufflation pressure must be kept to a minimum and an ultrafiltration (smoke evacuation system or filtration) should be used, if available. Set the intraabdominal pressure as low as possible (10–11 mmHg). •Minimize the use of energy devices, lower the electrocautery power settings; avoid using ultrasonic devices and avoid prolonged desiccation. •Consider using vacuum suction devices, a closed-circuit smoke evacuation device with a HEPA filter or a ULPA filter if possible. •Make sure that the taps of the trocars are closed all the time unless evacuation is achieved. •Any specimen to be removed should also be done at this time of the operation with the abdomen desufflated. •Fully aspirate the pneumoperitoneum before removing the last trocar through a smoke evacuator device or direct suction. •After all other ports are removed, ports larger than 5 mm can be closed by a J needle rather than using an Endoclose device, which would increase the risk of gas leaking from the abdomen. •Ventilate the operating room. •Manage waste appropriately during and after laparoscopy.
Postoperative considerations during covid-19 pandemic
Exit from operating theatre: 1The department of destination is alerted and prepares the bed; OUTSIDE staff physically goes to take the bed in the ward and brings it to the Operating Block; INSIDE staff take the bed inside the operating room, and transfer the patient from the table to the bed. 2When leaving the theatre, the staff undresses in the filter area, then following a dedicated path. 3Take off the theatre gown with great care so as not to spread the virus and to remove the face mask as the last procedure and immediately put on a clean one. 4The team should go to the nearest changing room to the theatre, take a whole-body shower and to change scrubs.
Exit order: 1Surgical team 2Scrub nurse 3Anaesthetist + Anaesthetic Nurse without changing wear, they take the patient to the ward of destination following the COVID dedicated path (which is fully sanitized after completion of surgery) together with the OUTSIDE HCW and Nurse who precede them and act as “forerunners” opening the doors, pushing for the lift and making sure that the path is isolated. 4INSIDE HCW sanitizes the operating room, then exit and change their scrubs following the same rules as above
Other precautions: •Specimens are labeled as 2019-nCoV and handled as infectious specimens in the pathology department. •Daily assessment of HCWs' and patients' body temperature and respiratory symptoms. •Any patient with new-onset fever or cough is isolated and investigated to rule out COVID. Any suspected or confirmed COVID patient should be isolated in a single room with a negative pressure, with oxygen supply and nebulization. •If suspected COVID-19, all staff should be isolated and quarantined for observation until the patient is cleared. If the diagnosis of COVID-19 is confirmed, the staff involved in the surgery should be isolated for 14 days after the surgery.