Strategies for perioperative management of general surgery in the post-COVID-19 era: experiences and recommendations from frontline surgeons in Wuhan

Editor

SARS-CoV-2 has caused an ongoing pandemic of COVID-19, and brought a worldwide crisis to society and economy¹. With lockdown being lifted in Wuhan in April, our hospital has thus far effectively cleared a huge backlog of operations accumulated during COVID-19 pandemic. Given over 20 per cent mortality rate associated with COVID-19 infection during perioperative periods², surgeons still need to adapt standard procedures against COVID-19. Here, we introduce strategies for perioperative management based on our experiences in the post-COVID-19 pandemic era.

Strategies for preoperative management. The prioritization of surgical interventions should be rationalized to effectively manage a large volume of patients with different conditions. For these patients, preoperative assessment should be focused on detection of COVID-19 infection, stage of disease, and operation types (emergent, elective, or selective). Patients who need emergent surgery should be prioritized as the first. The second level priority is given to cancer patients whose elective surgery has been delayed beyond recommended optimal waiting windows. The third level priority is rendered to patients who have advanced cancer and / or a high risk of metastasis and recurrence. Patients who need surgery but are asymptomatic or at the early stage of illness with a low risk of rapid deterioration can be prioritized as the fourth level. The fifth level priority should be placed for patients who need selective surgery, such as inguinal hernia repairs and hemorrhoidectomy. Of note, the above operation prioritization should be carefully determined with necessary multi-disciplinary consultation. Additionally, during the time period of preoperative preparation, viral nucleic acid testing and serologic antibody testing are mandated to be performed for patients every seven days.

Strategies for intraoperative management. Surgeons should wear appropriate personal protective equipment (PPE) according to relevant regulations. For endotracheal intubation that is considered as an aerosolizing procedure with high infection risk, the top level of PPE is necessary with as less staff involved as possible. For laparoscopic or robotic surgeries, the release of positive pressure pneumoperitoneum gas from trocars might transmit aerosolized viral particles. It is recommended to keep low insufflation pressure, use closed suction to remove generated gas / smoke within abdominal cavity, and consider open surgery for high-risk patients³.

Strategies for postoperative management. Since immunocompromised and elderly patients are at a high risk of COVID-19 infection⁴, postoperative protection of patients should be strictly implemented. Moreover, it is important to actively prevent and effectively treat postoperative complications in order to shorten hospitalization time towards accommodating the large volume of pandemic-delayed medical demands. Patients suspected of nosocomial SARS-CoV-2 infection should be isolated and receive clinical tests and CT scanning as early as possible. With the help of advanced technology, autonomous robots can be applied to deliver drugs, clean and patrol wards for reducing close contact and risk of nosocomial infection.

In summary, we hope that our experience can help peers in perioperative management of general surgery, and ensure medical safety in the post-COVID-19 pandemic era.

Contributions

Conception and design: Z. Wang, L. Wang, G. Wang, J. Zhang, X. Lu.

Drafting: L. Wang, X. Lu, Z. Wang.

Revising critically: Z. Wang, L. Wang, X. Lu, J. Zhang, G. Wang.

Final approval: L. Wang, X. Lu, Z. Wang, J. Zhang, G. Wang.