Table 2.
COVID-19 Surgical Patient’s Management Recommendations.
| Procedure and Recommendations |
|---|
| OT room |
| Dedicated OT room should be used |
| OT room should be adequately filtered and ventilated an integrated HEPA |
| High rate of air exchange >25 cycles/hour should be used |
| Negative pressure OT room should be preferred |
| Surgical equipment used for confirmed or suspected COVID-19 patients should be cleaned separately from other surgical equipment |
| Endoscopic procedures requiring additional insufflation of CO2 or room air should be avoided |
| Surgical aid such as OT trolley, laparoscopic trolley, anesthesia trolley, and gas cylinders should be used to avoid the increase in OT time |
| Surgeries should be performed with the minimum number of OT staff members |
| OT should be cleaned and sterilized post-surgery |
| Disposable materials (such as gloves or paper towel) should be used for cleaning |
| A minimum of 1 hour gap should be there between 2 surgical procedures |
| Consent discussion with patients to cover the risk of COVID-19 exposure and the potential consequences |
| Laparoscopy trocar cannula modifications |
| Incisions for ports should be very small to permit for the passage of ports but not for leakage around ports |
| Once placed port should not be used for evacuation of smoke or for desufflation without taking adequate precautions |
| Traditional trocars may be used with one-way valves within the proximal portion of the port |
| CO2 insufflation pressure should be minimum and an ultrafiltration (smoke evacuation system or filtration) should be used |
| All pneumoperitoneum should be safely evacuated via a filtration system before closure, trocar removal, specimen extraction, or conversion to open |
| Insufflator should be turned off only after the port that was used for inflation was closed to prevent gas going into the insufflator tubing |
| Smoke evacuators |
| Ultrasonic scalpels or electrical equipment used in MIS can produce huge amounts of surgical smoke |
| Standard electrostatic filters should be used in ventilation machines as these can filter bacterial and viral loads with great efficacy |
| Filters should be connected via standard tube to the trocar evacuation port which can evacuates the produced smoke and filter the possible viral load |
| Use of intelligent integrated flow systems is recommended for the maintenance of low intraabdominal pressure which ensures a self-maintained constant pneumoperitoneum |
| Integrated flow systems should be configured in a continuous smoke evacuation and filtration mode |
| HME filter with or without HEPA filter and under water seal sodium hypochlorite for lap evacuator under seal sodium hypochlorite can be used |
| Buffalo filters |
| Buffalo filter smoke evacuator tubing is connected to 2 HME filters and placed under the drape to provide air filtration. The use of multifilter system ensure maximum efficiency in filtering viral particles |
| Anesthesia modifications |
| Intubation during general anesthesia may result in general aerosolization, causing risk to anesthesia team as well as the OT person |
| During time of intubation or extubation barrier enclosures made up of plastic or acrylic as would decrease risk considerably |
| Preference should be given to regional anesthesia. Regional anesthesia offers benefits of preservation of respiratory function, avoidance of aerosolization, and hence viral transmission |
| Laminar airflow or air conditioner should be started after induction of anesthesia. Laminar airflow or air conditioner should be stopped 20 minute before the extubation |
| Reduce the Trendelenburg position time as much as possible. This minimizes the effect of pneumoperitoneum on lung function and circulation, in an effort to reduce pathogen susceptibility |
| Personal protections to surgeons |
| All elective surgical and endoscopic cases should be postponed at the current time, if not urgent |
| Surgeons must avoid contact with droplets and full body protection |
| Universal protection with PPE (appropriate gowns, N95/FFP2-3 masks, and face shields/goggles) are strongly recommended for surgeons |
| Surgery should be performed by the most qualified surgeon to minimize operative time |
| Donning of PPE should be done in the OT room and doffing should be done in wash area |
| MDT meetings should be virtual and restricted to core team members only |
| No 1 except the necessary staff should allowed inside OT while intubation and extubation |
| Senior oncologists (age >60 years) and those with co-morbidities should be abstain from surgery |
| Special care should be taken by the anesthetists or surgeons and endoscopists |
| All PPE should be removed outside the room |
| A proper OT exit pattern should be followed: Surgical team followed by patent after extubation followed by anesthesia team followed by cleaning and sterilization team |
| Cautery/diathermy low setting modifications |
| Electrocautery should be used in a lower power setting and should be escorted by suction |
| Charring of tissues should be avoided to minimize the creation of smoke |
| Energy devices should be minimally used. Cold hemostasis is the method of choice. Use more of clips and sutures |
| Long dissecting times should be avoided on the same spot using energy devices to reduce the surgical smoke |
| Energy devices used in lap minimal access surgery modifications |
| Energy device produce plume surgical smoke |
| With the use of energy device for 10 minute, the particle concentration of the smoke in laparoscopy surgery is higher than the open surgery |
| Sudden release of trocar valves, non-air tight exchange of instruments or even small abdominal extraction incisions can expose the team to the pneumoperitoneum aerosol |
| Negative pressure OT |
| Negative pressure inside the OT and alternatively frequent air change |
| It is important to perform surgeries at the lowest intra-abdominal pressure |
| Sodium hypochlorite smoke and gas under seal evaluators |
| Post-surgery the OT should be clean with peroxyacetic acid/0.5-1% sodium hypochlorite/gluraldehyde/benzalkonium chloride |
| Effective fumigation should be preferred |
Abbreviations: CO2 = carbon dioxide; HEPA = high-efficiency particulate air; HME = heat and moisture exchanger; MDT = multidisciplinary team; MIS = minimum invasive surgery; OT = operation theater; PPE = personal protection equipment.