Dear Editor,
We are grateful to Di Saverio et al.1 for their valuable contribution during the coronavirus disease 2019 (COVID-19) pandemic and for sharing their experience while providing a support for the current guidelines.
However, we find ourselves in disagreement with some of their statements. The mentioned article takes for granted the risk of viral spread through the surgical smoke and pneumoperitoneum and suggests avoiding the laparoscopic approach as much as possible.
While agreeing on the concept of the potential risks of surgical smoke for the theater staff, which have been widely demonstrated, we feel that our clinical decisions during this pandemic must be evidence based to the greatest extent.
On this particular topic, there is no published proof of the presence of COVID-19 in the surgical smoke, and the suspect is only indirect.2 The available evidence of the presence of active hepatitis B virus (HBV), human immunodeficiency virus (HIV), and human papillomavirus (HPV) viral particles in the surgical smoke is low level and may not apply directly to the COVID-19. At our knowledge, up until now, only one article demonstrated the presence of HBV in the surgical smoke in 10 of 11 HBV-positive patients undergoing laparoscopic or robotic surgery.3 Several articles demonstrated the presence of HPV in the laser plume,4 whereas the results of studies on HIV yielded contrasting results.5 Although there is evidence of patient-surgeon transmission of HPV through the laser smoke, the particular kind of surgery for HPV-related warts, where the surgeon usually stays very close to the surgical field and easily inhales the smoke, makes HPV a biased experimental model for viral transmission during laparoscopic surgery. Despite HIV and HBV being blood-borne viruses, laparoscopic surgery is being performed in HIV and HBV patients for many years, and no clear demonstration is available of viral transmission through the pneumoperitoneum or surgical smoke. On the contrary, COVID-19 has a special tropism for the upper and lower respiratory tract. Viral RNA has been found in stools and blood, but no infective virus has ever been demonstrated in the gastrointestinal tract and in the blood. Furthermore, it must be emphasized that smoke production and evacuation may be even more difficult during laparotomy than laparoscopy, for the absence of a unique smoke escape channel.
For these reasons, we do not believe that results from the available literature can be extrapolated to the COVID-19 pandemic as to justify the current too restrictive guidelines on laparoscopic surgery against the evident and well-known and evidence-based advantages of laparoscopy with respect to the open approach in many fields of surgery. We feel that replacing a grade of recommendation A (known benefits of laparoscopic surgery) with a grade D (avoid laparoscopy on the basis of perceived dangerous laparoscopic smoke) is not consistent with a modern healthcare system.
Last but not the least, we feel that the restrictions placed on the practice of laparoscopic surgery during the pandemic may not be consistent with ethics and professionalism because they reduce the level of care and abdicate to the already world widely accepted criterion standards in surgical care. While this can be acceptable in war scenarios with limited resources, they may not be totally acceptable in the current juncture where, despite undoubtedly facing a challenging pandemic, resources and expertise are widely available and access to the highest standard of care must be granted to everyone.
Giovanni D. Tebala, MD, MS, FRCS, FACS
Mariam Lami, MBBS, MRCS
Giles Bond-Smith, MBBS, MSc, FRCS(Ed)
Surgical Emergency Unit
John Radcliffe Hospital
Oxford University Hospitals NHS Trust
Headley Way, Headington
Oxford
United Kingdom
DISCLOSURE
The authors declare no conflicts of interest.
REFERENCES
- 1.Di Saverio S, Khan M, Pata F, Ietto G, De Simone B, Zani E, Carcano G. Laparoscopy at all costs? Not now during COVID-19 outbreak and not for acute care surgery and emergency colorectal surgery: a practical algorithm from a hub tertiary teaching hospital in northern Lombardy, Italy. J Trauma Acute Care Surg. 2020;88:715–718. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Mowbray NG, Ansell J, Horwood J, Cornish J, Rizkallah P, Parker A, Wall P, Spinelli A, Torkington J. Safe management of surgical smoke in the age of COVID-19. Br J Surg. 2020. doi: 10.1002/bjs.11679. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Kwak HD, Kim SH, Seo YS, Song KJ. Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery. Occup Environ Med. 2016;73(12):857–863. [DOI] [PubMed] [Google Scholar]
- 4.Neumann K, Cavalar M, Rody A, Friemert L, Beyer DA. Is surgical plume developing during routine LEEPs contaminated with high-risk HPV? A pilot series of experiments. Arch Gynecol Obstet. 2018;297(2):421–424. [DOI] [PubMed] [Google Scholar]
- 5.Baggish MS, Poiesz BJ, Joret D, Williamson P, Refai A. Presence of human immunodeficiency virus DNA in laser smoke. Lasers Surg Med. 1991;11:197–203. [DOI] [PubMed] [Google Scholar]