During the coronavirus disease 2019 (COVID-19) pandemic, the mandatory use of personal protective equipment (PPE) has resulted in a significant reduction in the infection rate among health care workers (HCWs). However, there are some ongoing concerns about the negative impact of using PPE for prolonged periods. This study examined the impact of wearing PPE on surgeons’ performance and decision making during the COVID-19 pandemic. In this cross-sectional study, an anonymous online questionnaire was created and disseminated to surgeons all over the Eastern Province of Saudi Arabia. The questionnaire included the demographic data, the local hospital policies, the non-technical skills (e.g., communication, vision, and comfort) and the technical skills, and the process of decision making. From June 2020 to August 2020, 162 surgeons participated in this questionnaire. Of them, 80.2% were aged from 26 to 45 years, 70.4% have received a special training for PPE, and 59.3% of participants have operated on COVID-19 confirmed cases. A negative impact of wearing PPE was reported on their overall comfort, vision, and communication skills (92.6%, 95.1%, and 82.8%, respectively). The technical skills and decision making were not significantly affected (60.5% and 72.8%, respectively). More preference for conservative approach, damage control procedures, and/or open approach was reported. Despite its benefits, PPE is associated with a significant negative impact on the non-technical skills (including vision, communication, and comfort) as well as a non-significant negative impact on technical skills and decision making of surgeons. Extra efforts should be directed to improve PPE, especially during lengthy pandemics.

Rare co-existance of disease or pathology Background:Colonic varices are rare entity that often results from portal vein hypertension and hepatic cirrhosis. In the absence of underlying pathology, they are termed "idiopathic colonic varices". They are usually an incidental finding; however, they can present with varying degrees of lower gastrointestinal bleeding. There is only one reported case in the literature of colonic varices with a concomitant colonic tumor; our patient is the second one with such a presentation. We report a case of this rare combination with the outcomes of the elected surgical management and review the literature. Case Report:A 24-year-old male was referred to our hospital with a 1-month history of colicky abdominal pain. His family history is remarkable of 2 relatives with colonic varices. A computed tomography scan of the abdomen and pelvis showed a hepatic flexure colonic mass. Colonoscopy revealed pancolonic varices. Biopsy from the lesion revealed adenocarcinoma. Options were discussed with the patient to undergo only a right hemicolectomy for his cancer or a total colectomy to include the colonic segment involved with varices, and he elected the first option, with no complications upon 1 year follow up. Conclusions:Idiopathic pan-colonic varices are rare pathology. Their presence with colonic tumor presents a dilemma as to whether a subtotal/total colectomy is needed on the premise that a limited resection may carry the risk of subsequent bleeding. In the literature, the only similar case to ours had brisk postoperative bleeding, while ours did not experience such a complication.

Key Clinical Message This case is the first published associated liver partition and portal vein ligation for staged hepatectomy procedure done successfully in Saudi Arabia, with excellent hypertrophic response to the liver remnant. This is a milestone in liver resection techniques in the country and the region.