ELSA recommendations for minimally invasive surgery during a community spread pandemic: a centered approach in Asia from widespread to recovery phases

Abstract

Background The COVID-19 pandemic has resulted in significant changes to surgical practice across the worlds. Some countries are seeing a tailing down of cases, while others are still having persistent and sustained community spread. These evolving disease patterns call for a customized and dynamic approach to the selection, screening, planning, and for the conduct of surgery for these patients. Methods The current literature and various international society guidelines were reviewed and a set of recommendations were drafted. These were circulated to the Governors of the Endoscopic and Laparoscopic Surgeons of Asia (ELSA) for expert comments and discussion. The results of these were compiled and are presented in this paper. Results The recommendations include guidance for selection and screening of patients in times of active community spread, limited community spread, during times of sporadic cases or recovery and the transition between phases. Personal protective equipment requirements are also reviewed for each phase as minimum requirements. Capability management for the re-opening of services is also discussed. The choice between open and laparoscopic surgery is patient based, and the relative advantages of laparoscopic surgery with regard to complications, and respiratory recovery after major surgery has to be weighed against the lack of safety data for laparoscopic surgery in COVID-19 positive patients. We provide recommendations on the operating room set up and conduct of general surgery. If laparoscopic surgery is to be performed, we describe circuit modifications to assist in reducing plume generation and aerosolization. Conclusion The COVID-19 pandemic requires every surgical unit to have clear guidelines to ensure both patient and staff safety. These guidelines may assist in providing guidance to units developing their own protocols. A judicious approach must be adopted as surgical units look to re-open services as the pandemic evolves.Publisher's Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

EAES Recommendations for Recovery Plan in Minimally Invasive Surgery Amid COVID-19 Pandemic

“…Preliminary guidelines recommended against performing laparoscopic surgery to avoid putative risks of SARS-CoV2 transmission via aerosolization due to pneumoperitoneum but were later revised recommending laparoscopic surgery under restrictions [15]. Several subsequent guidelines did not recommend against laparoscopic surgery; however, they advised strict precautions such as closed circuit smoke evacuation and the use of filtering system and personal protective equipment (PPE) [16][17][18][19]. The role of MIS has been argued to be more favourable in SARS-CoV-2 positive patients, as the potential benefits of MIS might exceed the risk of pneumoperitoneum on cardiovascular and respiratory systems [20].…”

Rapid Scoping Review of Laparoscopic Surgery Guidelines During the COVID-19 Pandemic and Appraisal Using a Simple Quality Appraisal Tool “EMERGE”

“…A summary of all guidelines with the origin of their country, academic association, type of study, type of evidence, and recommendations based on various surgical/technical parameters are shown in Table 2 [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24].…”

Laparoscopic Surgery in COVID-19 Era—Safety and Ethical Issues

“…However, this favors the aerosolization of the particles in the surgical smoke. For this reason, the recommendations during the COVID-19 pandemic are to use negative pressure or if not possible, at least to stop the positive pressure [6][7][8][9][10][11]54,55]. Spacing interventions with a 30 min to 1-h interval, depending on the ventilation possibilities, is also necessary to limit the possibility of contamination.…”

“…All surgical societies (SAGES, EAES, AMASI, IAGES) [6][7][8][9][10][11] have adopted a set of measures to minimize the emission of aerosols during the intervention, consisting in reduced pressure of the pneumoperitoneum, tight incisions to prevent leakage at the trocar orifices, minimum use of energy devices and use of cold hemostasis whenever possible, integrated insufflation devices comprising smoke evacuation and filtration mode, HEPA or ULPA type and valve type valves to prevent gas loss when changing the instrument. Hand-assisted surgery and specimen removal are associated with significant leakage of CO 2 , as a consequence, they must be performed after desufflation.…”