Guidance for Endoscopic Surgery during COVID-19 | 6 April 2020

SASREG guideline for endoscopic surgery during the COVID-19 pandemic.

Further to the revised SASREG guidance on fertility care and surgery in the era of COVID-19 released on 24 March 2019, this document aims to address certain safety concerns when performing laparoscopic and hysteroscopic surgery during this pandemic.

This is an evolving situation and this guidance will be reviewed as the local prevalence of the disease and availability of resources and testing changes.

Elective Surgery

It is the position of SASREG that elective and non-urgent surgical procedures be postponed during the current phase of the COVID-19 pandemic. This reduces the number of people visiting health care facilities thus reducing contact,  risk of transmission and protecting healthcare professionals. It also aims to preserve critical healthcare resources including personal protective equipment (PPE), nursing staff, hospital beds and ventilators that need to be allocated to the management of a potential health care crises.

During this period, the medical therapy of benign gynaecological conditions that would otherwise require surgery should be optimised. In doing so surgery can be delayed with minimal impact on the patients quality of life. Procedures for suspected or known gynaecological malignancy should not be delayed during this period. When this or certain gynaecological emergencies require surgery, the considerations in this document are applicable.

If possible any surgery on a COVID-19 positive patient should be delayed until their infection has fully resolved.

Rational use of full Personal Protective Equipment (including N95 mask)

SASREG promotes the rational use of full PPE during this pandemic. To this end, we only recommend the use of full PPE when performing surgery on persons under investigation (PUIs) or patients confirmed with COVID-19. Currently, universal pre-operative PCR testing is not feasible, and patients should be screened according to the case definitions as published and updated by the NICD. Details and procedures regarding the use of PPE would be specific to your institution and consultation with the infectious diseases specialist on the COVID Outbreak Response Team for your hospital is advised on a case by case basis.

Choice of Laparoscopy vs Laparotomy

Concerns have been raised about the potential aerosolization of viral particles via the pneumoperitoneum required during laparoscopy. The SARS-CoV-2 virus is primarily a respiratory pathogen, and although viral RNA has been detected in blood, reports of infectious virus in these extrapulmonary sources have not been published (CDC and European CDC). The presence of viral particles in surgical smoke has previously been demonstrated in relation to other viruses (HPV) and steps should be taken to mitigate any potential risk of viral transmission, thus the recommendations in the rest of this document. Laparoscopy however still holds numerous advantages over open surgery, especially during this pandemic. The obvious advantage being shorter hospital stay, limiting potential transmission of the virus and reducing the burden on healthcare resources and bed utilisation as mentioned above. Laparotomy is associated with increased respiratory morbidity, a factor that could be especially relevant when considering surgery in PUIs or patients having COVID-19.

General considerations related to surgery during the pandemic

  • Anaesthesia – SARS-CoV-2 is a respiratory virus and general anaesthesia, with endotracheal intubation and extubation, is an aerosol-generating procedure (AGP) with increased risk of viral transmission to the anaesthetic team.
  • Aerosolization of viral particles may occur with the use of electrosurgical or ultrasonic devices causing a surgical plume.
  • Aerosol exposure to the healthcare team occurs during intended or unintended release of CO2 during and at the end of the procedure.
  • During this pandemic, and as the prevalence of infection increases, we recommend standard personal protection equipment (theatre attire with surgical mask and goggles or visor) for all surgical procedures even in low-risk patients.

Recommendations during laparoscopic surgery

  • During laparoscopy try to minimize CO2
  • Close the taps of ports, before inserting them.
  • Attach CO2 filter to one of the ports for smoke evacuation or use a closed smoke evacuation system.
  • Alternatively use the laparoscopic suction to remove surgical plume and to deflate the pneumoperitoneum – DO NOT deflate into the room!
  • Minimise introduction and removal of instruments through ports.
  • Before specimen retrieval, deflate with the suction device before removal and reinsert port before insufflating again.
  • Use lower intra-abdominal pressures (10-12 mmHg).
  • Check seals in reusable trocars or use disposable trocars.
  • Minimise blood and fluid droplet spray.
  • At the end of the procedure turn CO2 off, deflate with the suction device or via the CO2 filter, before removal of the ports.

Considerations during hysteroscopy

  • The risk is unknown, but the theoretical risk is low.
  • Hysteroscopy is not considered an aerosol-generating procedure.
  • Current evidence indicates that SARS-CoV-2 is NOT present in vaginal secretions.
  • Although electrosurgery during hysteroscopy produces some smoke, this mostly remains confined to the uterine cavity and is released through contained outflow suction.
  • Where available hysteroscopic tissue removal systems have an advantage due to the absence of surgical smoke
  • Suction device must be connected to the outflow sheath.
  • Standard droplet precaution is recommended for personal protection.
  • Conscious sedation or spinal anaesthesia preferred
  • As far as possible hysteroscopy should be performed in an outpatient theatre to limit potential transmission of SARS-CoV-2 and relieve the pressure on hospital resources during the pandemic.

SASREG Endoscopy Sub-Committee: Dr Gerhard Hanekom, Dr Yusuf Dasoo, Dr Abri de Bruin, Dr Igno Siebert and Dr Sulaiman Heylen.


References:

  • AAGL 2020. Joint Statement on Minimally Invasive Gynecologic Surgery During the COVID-19 Pandemic. Retrieved from https://www.aagl.org/news.
  • ESGE 2020. ESGE Recommendations on Gynaecological Endoscopic Surgery during COVID-19 Outbreak. Retrieved from https://esge.org.
  • ASRM 2020. A Message from the SRS and ASRM Regarding Surgery During the COVID-19 Pandemic. Retrieved from https://www.asrm.org/news-and-publications.
  • NICD 2020. Coronavirus disease 2019 (COVID-19) – Technical Resources and Guidelines. Retrieved from https://www.nicd.ac.za/diseases-a-z-index/covid-19/covid-19-resources/
  • Brown J. Surgical Decision Making in the Era of COVID-19: A New Set of Rules, The Journal of Minimally Invasive Gynecology (2020).
  • Cohen SL, Liu G, Abrao M, et al. Perspectives on Surgery in the time of COVID-19: Safety First, The Journal of Minimally Invasive Gynecology (2020).
  • Morris SN, Fader NA, Milad MP, et al. Understanding the “Scope” of the Problem: Why Laparoscopy is Considered Safe During the COVID-19 Pandemic, The Journal of Minimally Invasive Gynecology (2020).
  • Qiu L,  Liu X,  Xiao M, et al. SARS-CoV-2 is not detectable in the vaginal fluid of women with severe COVID-19 infection. Clinical Infectious Diseases (2020).
  • Zheng MH, Boni L, Fingerhut A. Minimally Invasive Surgery and the Novel Coronavirus Outbreak: Lessons Learned in China and Italy. Annals of Surgery (2020).