Laparoscopic Surgery Practice in the Era of COVID-19: The Pakistani Perspective

INTRODUCTION

Since the start of the SARS-CoV-2 corona virus disease-19 (COVID-19) pandemic in 2019, the tally of patients suffering from the disease around the world has continuously increased with time. As of June 24th, 2022, the number of patients has risen to 547,492,681 globally, whereas 6,347,816 lives have been lost to this deadly pandemic.¹ Pakistan itself has seen 30,384 deaths as of June 24th, 2022, and with the first case of the much-feared sub-Omicron variant being reported recently, the pandemic is nowhere near its end.² Where COVID-19 has deteriorated the socioeconomic and political landscape of all the countries of the world, it has also changed the lives and practices of healthcare professionals (HCPs) for an indefinite amount of time.³

Due to the high risk of contracting the virus from patients, all HCPs are encouraged to always don personal protective equipment (PPE) and take safety precautions while handling patients suffering from COVID-19. The risk further increases with exposure to aerosol-generating procedures (e.g., endotracheal intubation, extubation, non-invasive ventilation, etc.) for at least 10 minutes at a distance of fewer than 2 meters from the patient.⁴ Although the gains of LS for patients are established, there have been concerns regarding additional prospects of COVID-19 spread owing to the creation of pneumoperitoneum, use of energy devices, and diathermy during laparoscopy.³ This has initiated an array of discussions from the use of energy devices and proper disposal of gases after insufflation to the use of filtration devices to curtail and limit the application of the laparoscopic approach during the COVID-19 pandemic.⁵ Laparoscopy is employed in scores of acute surgical undertakings; however, information at hand on the risks for HCPs performing LS on COVID-19 positive or suspected cases is limited.

Numerous renowned societies and professional organizations of minimally invasive surgeons have issued guidelines on the preventive measures and the technical, mechanical, and procedural modifications to be taken during a laparoscopic undertaking for the safety of HCPs and theater staff.⁶ This study aims to explore the practices of laparoscopic surgeons during this COVID-19 era to statistically evaluate their practices and awareness so that further steps can be recommended or devised on those grounds to improve the practices of laparoscopic surgeons in our local milieu amidst a rising fear of an increasing number of cases.

METERIALS AND METHODS

A cross-sectional, observational study was performed after IRB approval (IRB-1783/DUHS/Approval/2020) conducted from December 2020 to October 2021 via a purposive sampling technique. All surgeons performing laparoscopic surgeries in Pakistan were included in the study. Surgeons in training and those who had abandoned/stopped all types of operations during the COVID-19 pandemic were excluded from the study. Participants were requested through electronic communication channels, i.e., Surgical groups WhatsApp® and email groups, citing the link of the online semi-structured, pre-tested questionnaire by the investigators after consenting to participate in reading the online informed consent document. The identity of the participants and information retrieved from them was kept confidential.

Data was entered and analyzed by SPSS version 26. Frequency and percentages were calculated for qualitative data like gender, city of practice, academic association, and other responses while mean and standard deviation were calculated for quantitative data like age and years of practice. Stratification was done with reference to gender, teaching involvement, and specialties to control the effect modifier. The Chi-square test was put in application to appraise the impact of these on the outcome variables. The p-value < 0.05 was taken as significant.

RESULTS

A total of 168 surgeons involved in LS from different disciplines responded to the invitation and filled out the online questionnaire. The mean age of the surgeons was 48.72 ± 8.04 years 146 (86.9%) of them were married and the majority belonged to the Major cities of the country, i.e., Karachi, Lahore, Multan, Islamabad, and Rawalpindi (Table 1). Surgeons who participated had a mean practice experience of 12.12 ± 6.88 years (minimum 3 and maximum 31 years). Most of the respondents were general surgeons (GS) performing basic laparoscopic procedures, followed by minimal invasive surgeons (MIS) having advanced laparoscopic training, Obstetricians and Gynecologists (OB-GYN), and Urologists. About 41% were practicing in the city of Karachi and the rest were distributed in other cities of Pakistan (Table 1). Only 28% were academic surgeons involved in teaching. More than half of the respondents have neither been associated with any Laparoscopic surgical association nor have read any LS guidelines for laparoscopic surgery during the COVID-19 pandemic (Table 1).

About 87% of surgeons were of the opinion that LS carries the additional risk of COVID-19 transmission while a little more than half agreed to have changed practice approaches during the COVID era. A total of 23 (13.7%) were only testing suspected patients for COVID before operating and the majority resorted to RT-PCR nasopharyngeal swabs for preoperative COVID screening. The choice of PPEs was also variable amongst surgeons with only a minority donning the N95 or respirator masks, eye protection, and coverall suits even during the peak of the pandemic. The availability of anesthesia gas scavenging systems (AGSS), negative pressure in the operating room (OR), smoke evacuation systems, and high-efficiency particulate air (HEPA) or ultra-low particulate air (ULPA) filter systems for laparoscopic surgeons were very limited. Only 30 (17.9%) practiced the recommendation of doing LS with lower intra-abdominal pressure than usual, i.e., <12 mm Hg. Minimizing the Trendelenburg position and avoiding the use of energy devices was also an uncommon practice, though, more than half (56%) of surgeons exercised exsufflating the pneumoperitoneum with vacuum suction before removing the ports for converting to open surgery or closure (Table 2).

Females (61.3%) and teaching surgeons (60.7%) were more statistically believing in additional risk of COVID transmission during LS while male surgeons (81%) and teaching surgeons (92.9%) were mandatorily doing preoperative COVID testing compared to female and non-academic surgeons with the difference reaching statistical significance (p-values < 0.05). The differences in practices with respect to gender and academic teaching affiliation are detailed in Table 3, whereas apart from preoperative COVID testing and working in HEPA/ULPA filter-installed ORs the rest were statistically similar between teaching versus non-teaching surgeons, but most of the questionnaire responses differed widely amongst gender groups as evident by the p-values.

Table 4 details the comparison of practices with respect to the specialties of participants, the Pearson Chi-square test for p-value showed that the practices were widely variable saving only two acts, i.e., use of the smoke evacuation system during LS and reducing the Trendelenburg tilt intentionally, which was not enacted routinely by all the subspecialties statistically (p-value > 0.05).

DISCUSSION

The SARS-CoV-2 pandemic has brought attention to a neglected matter in recent times, that of aerosols and plume exposure-related risks to health during laparoscopy. Laparoscopy brings about the generation of aerosols as it requires the establishment and efficient pneumoperitoneum maintenance through CO₂ insufflation. A study found that after 10 minutes of laparoscopic dissection by ultrasound or electrosurgery, in comparison to dissection in open surgery, there was an elevation of the concentration of particles measuring 0.3–0.5 μm.⁷ Also, there is a possible increased threat of transmission to HCPs in surgical theaters by laparoscopy due to gas leakage of the pneumoperitoneum which may hold suspended viruses in soaring concentration.⁵ However, in the literature, only a small number of reports have related to this feared risk of transmission of viruses to the surgical team via inhalation from patients undergoing LS. Our findings revealed that only 51.8% of surgeons believed that LS carries an increased risk of COVID-19 transmission, out of which 61.3% were females and only 49.6% were males. About 55.8% of the surgeons admitted to having brought changes to their practices during the COVID-19 era.

DesCoteaux et al. demonstrated that the cautery smoke produced in the course of laparoscopic interventions has breathable aerosols and cell-size fragments.⁸ It has very tiny particles (5%), diffused in water vapor (95%), that are not only able to go across the surgical masks but also inoculate the conjunctival layer in the eye.^8–10 Long before the COVID-19 pandemic, these understandings resulted in the proposal of advanced protective measures in the operating room (OR) like respirator masks, FFP2 or higher, sealing wrap goggles, and air filtration devices, though the implementation remained lacking largely.^9,11 The concentration of aerosolized particles lessens with the lowering of insufflation pressures and minimizing the duration and power of energy devices. The process of intubation, OR air pressure, intra-abdominal pressure, desufflater, smoke evacuation, and tissue extraction are some of the potential routes for viral contamination in the OR during LS, the most potent of which is intubation and extubation.¹²

RT-PCR for COVID-19 is strongly recommended for testing of surgical patients before operative interventions; however, 10–30% false-negative rate precludes guaranteeing non-infectivity.¹³ For this reason, wearing complete PPE, limiting elective hospitalizations, and spacing surgeries with keeping 30 minutes 1 hour between them is recommended.^5,13–15 The International Endoscopic Surgery Societies have been propounding the risk of aerosolization of particles in advocacy to avoid laparoscopic approach in COVID-19-positive and suspected patients, which has led to preventive measures being defined more coherently with time. These include appropriate PPE, proper room filtration, ventilation, and installation of smoke evacuation–filtration system.^5,14 Wong et al. stressed on using certified N95 respirators, face shields or eye goggles in addition to routine protective gadgets.¹⁶ Owing to the possibility of transmission even with N95 masks, employing a powered air purifying respirator (PAPR) during procedures involving the generation of aerosols when operating on COVID-positive or suspected-positive cases is strongly recommended. Repici and colleagues advocated advanced measures and novel equipment for protection in endoscopic undertakings.¹⁷ The Zhejiang University School of Medicine’s Handbook of COVID-19 Prevention and Treatment gives an account of vital findings and essence from the initial waves advising level III protection during all kinds of surgeries, ORs with negative pressure systems with some other precautionary measures.¹⁸ All aforementioned studies place special emphasis on the significance of protecting HCPs with apt PPE, be they examining or operating upon the patients. According to our findings, only 12.5% of surgeons wore N95 masks during surgeries, while 61.3% wore surgical masks which don’t provide sufficient protection. Notable, 52.6% of male surgeons used surgical masks, 24.8% KN95, 15.3% N95, and a full face respirator were worn by 7.3%, in contrast, all-female surgeons (100%) chose to wear surgical masks. Furthermore, only 17.3% of all surgeons wore eye protection (21.2% males and 0% females) and only 6% wore protective cover all suits (32.3% females and 0% males). Even though these findings are statistically significant, they point towards a much larger lack of adherence to existing guidelines for protection against COVID-19 transmission.

A negative pressure OR environment prevents air from escaping the OR, making it the perfect tool for preventing virus transmission.¹⁶ Operating in a negative pressure system installed ORs was among the common and strong recommendations of both the American Society of Gastrointestinal Endoscopy and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).^19,20 Wax and Christian also concurred with this and included it in their set of practical recommendations.²¹ A review of the preparedness of OR measures and responses in COVID-19 from anesthetists of Singapore General Hospital entailed their efforts of making dedicated ORs with committed ventilation systems and HEPA filters for COVID-19 suspected and diseased patients. Maintaining a single entry and exit route through the scrubbing lobby and implementing locked-OR doors protocol during surgical interventions were part of a plan to reduce transmission by controlling traffic and airflow.¹⁶ However, unfortunately, only 8.3% of surgeons in our study reported working in negative-pressure ORs despite the existence of formal guidelines, hence highlighting an infrastructural weakness in healthcare systems that needs to be given focused attention in order to minimize transmission of SARS-CoV-2.

Previous researchers have demonstrated the toxic potential of surgical smoke alongside several other plausible risks during operative interventions.¹⁰ This is especially relevant when laser aerosolizes contaminated tissue rich in infectious living and dead agents. The expected debris produced from different types of energy devices commonly employed in open and minimally invasive abdominal operations namely Ultrasonic scalpel, laser ablation, and electrocautery are 0.35–6.5 microns, 0.3 microns, and less than 0.1 microns respectively.²² Even though the exact potential of coronavirus to aerosolize in the abdomen is not known, abstaining from electrosurgical dissection and certain energy devices, e.g., ultrasonic scalpel, may reduce the danger of viral emission by reducing particle aerosolization. Moreover, surgical smoke filtration systems have proven to be beneficial in protecting against the infectious potential of SARS-Cov-2. Given that the virus size ranges from 0.070 to 0.075 μm, the recommended filters are HEPA, with an efficiency of 99.97% in removing particles > 0.03 μm diameter or ULPA filters, which can filter particles > 0.05 μm size. All surgical societies (SAGES, EAES, AMASI, IAGES) have adopted a set of measures to minimize the emission of aerosols during the intervention, consisting of the 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, and integrated insufflation devices comprising smoke evacuation and filtration mode (HEPA/ULPA).^6,23–26 According to our data, only 5.3% of surgeons reported having used smoke evacuation systems during laparoscopic surgeries, only 7.1% reported having used HEPA or ULPA filters, and only 11.9% had avoided the use of energy devices. Unfortunately, discrepancies also existed between the practices of male and female surgeons as evident by the fact that 29% of female surgeons reported using smoke evacuation systems against an alarming 0% of male surgeons. Furthermore, 38.7% of female surgeons reported using HEPA/ULPA filters against yet another 0% of male surgeons. On the other hand, 14.6% of male surgeons interestingly reported avoiding the use of energy devices against 0% of female surgeons.

The debate on whether to prefer open surgery or LS during the pandemic will probably go on, but the gist of it can be understood by the fact that the Royal College of Surgeons of England had advocated caution for surgeons in considering LS, and the Society of American Gastrointestinal and Endoscopic Surgeon (SAGES) had recommended filtering released CO₂ by employing apt filter systems during LS and robotic surgery.^6,27 On the contrary, the Association of Laparoscopic Surgeons of Great Britain and Ireland (ALSGBI) backed the use of the laparoscopic approach while the American College of Surgeons was of the opinion that in light of insufficient statistical evidence to propound for or against preferring open over LS approach, surgeons should bank on the approach with lesser operative duration and maximum safety.^28,29 Considering the differences in the practices of surgeons on multiple strata described in our study, and the lack of an established consensus on the link of LS to COVID-19 transmission, it is clear that there needs to be a collective effort by all stakeholders in healthcare to adhere to international guidelines for LS during COVID-19 as the slightest violation of the precautions or a lack of compliance may pose a significant danger for the entire OR staff, causing them additional psychological stress. On this ground, it would be worthwhile to limit the traffic of personnel in the OR, abstain from complex and complicated maneuvers, and assign experienced personnel.^5,14,15

CONCLUSION

The COVID-19 era has had a widespread effect on surgical practice and the healthcare system. This study shows the wide variation in LS practices and the lack of adherence to the recommendations of international Laparoscopic Surgical Associations in Pakistan. We feel that there is a dire need for efforts to establish a consensus and formulate practical local guidelines for surgeons involved in LS, tailored to the country’s healthcare system.

ORCID

Syed Ali Haider https://orcid.org/0000-0002-8156-1576

Muhammad Zubair https://orcid.org/0000-0003-1140-1646

Sumera Qazi https://orcid.org/0000-0002-3945-9500

REFERENCES

1. Worldometer. COVID-19 Coronavirus Pandemic. Worldometer. Available from: https://www.worldometers.info/coronavirus.

2. Pakistan Scientific and Technological Information Centre (PASTIC). COVID-19 S and T information resource portal. Available from: http://covid.pastic.gov.pk.

3. Gupta N, Agrawal H. COVID 19 and laparoscopic surgeons, the Indian scenario-perspective. Int J Surg 2020;79165–167. DOI: 10.1016/j.ijsu.2020.05.076.

4. Ng K, Poon BH, Kiat Puar TH, et al. COVID-19 and the risk to health care workers: A case report. Ann Intern Med 2020;172(11):766–767. DOI: 10.7326/L20-0175.

5. Zheng MH, Boni L, Fingerhut A. Minimally invasive surgery and the novel coronavirus outbreak: Lessons learned in China and Italy. Ann Surg 2020;272(1):e5–e6. DOI: 10.1097/SLA.0000000000003924.

6. Francis N, Dort J, Cho E, et al. SAGES and EAES recommendations for minimally invasive surgery during COVID-19 pandemic. Surg Endosc 2020;34(6):2327–2331. DOI: 10.1007/s00464-020-07565-w.

7. Li CI, Pai JY, Chen CH. Characterization of smoke generated during the use of surgical knife in laparotomy surgeries. J Air Waste Manag Assoc 2020;70(3):324–332. DOI: 10.1080/10962247.2020.1717675.

8. DesCoteaux JG, Picard P, Poulin EC, et al. Preliminary study of electrocautery smoke particles produced in vitro and during laparoscopic procedures. Surg Endosc 1996;10(2):152–158. DOI: 10.1007/BF00188362.

9. Mowbray NG, Ansell J, Horwood J, et al. Safe management of surgical smoke in the age of COVID-19. Br J Surg 2020;107(11):1406–1413. DOI: 10.1002/bjs.11679.

10. Barrett WL, Garber SM. Surgical smoke: A review of the literature. Is this just a lot of hot air? Surg Endosc 2003;17(6):979–987. DOI: 10.1007/s00464-002-8584-5.

11. Dobrogowski M, Wesołowski W, Kucharska M, et al. Chemical composition of surgical smoke formed in the abdominal cavity during laparoscopic cholecystectomy – Assessment of the risk to the patient. Int J Occup Med Environ Health 2014;27(2):314–325. DOI: 10.2478/s13382-014-0250-3.

12. American Society of Anesthesiologists. ASA-APSF joint statement on non-urgent care during the COVID-19 outbreak. American Society of Anesthesiologists. Available from: https://www.asahq.org.

13. Tivey DR, Davis SS, Kovoor JG, et al. Safe surgery during the coronavirus disease 2019 crisis. ANZ J Surg 2020;90(9):1553–1557. DOI: 10.1111/ans.16089.

14. Joseph JP, Joseph AO, Oomman S, et al. Laparoscopic versus open surgery: Aerosols and their implications for surgery during the COVID-19 pandemic. Eur Surg 2020 52(4):188–189. DOI: 10.1007/s10353-020-00644-1.

15. Guraya SY. Transforming laparoendoscopic surgical protocols during the COVID-19 pandemic; Big data analytics, resource allocation and operational considerations. Int J Surg 2020;8021–25. DOI: 10.1016/j.ijsu.2020.06.027.

16. Wong J, Goh QY, Tan Z, et al. Preparing for a COVID-19 pandemic: A review of operating room outbreak response measures in a large tertiary hospital in Singapore. Can J Anaesth 2020;67(6):732–745. DOI: 10.1007/s12630-020-01620-9.

17. Repici A, Aragona G, Cengia G, et al. Low risk of COVID-19 transmission in GI endoscopy. Gut 2020;69(11):1925–1927. DOI: 10.1136/gutjnl-2020-321341.

18. Liang T. Handbook of COVID-19 prevention and treatment. The First Affiliated Hospital, Zhejiang University School of Medicine, 2020. pp. 1–68.

19. ASGE Quality Assurance in Endoscopy Committee; Calderwood AH, Day LW, et al. ASGE guideline for infection control during GI endoscopy. Gastrointest Endosc 2018;87(5):1167–1179. DOI: 10.1016/j.gie.2017.12.009.

20. American Society for Gastrointestinal Endoscopy. Joint GI Society Message: COVID-19 clinical insights for our community of gastroenterologists and gastroenterology care providers. Available from: https://www.asge.org/home/joint-gi-society-message-covid-19.

21. Wax RS, Christian MD. Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients. Can J Anaesth 2020;67(5):568–576. DOI: 10.1007/s12630-020-01591-x.

22. Alp E, Bijl D, Bleichrodt RP, et al. Surgical smoke and infection control. J Hosp Infect 2006;62(1):1–5. DOI: 10.1016/j.jhin.2005.01.014.

23. Shabbir A, Menon RK, Somani J, et al. ELSA recommendations for minimally invasive surgery during a community spread pandemic: A centered approach in Asia from widespread to recovery phases. Surg Endosc 2020;34(8):3292–3297. DOI: 10.1007/s00464-020-07618-0.

24. Moletta L, Pierobon ES, Capovilla G, et al. International guidelines and recommendations for surgery during Covid-19 pandemic: A Systematic Review. Int J Surg 2020;79180–188. DOI: 10.1016/j.ijsu.2020.05.061.

25. Campanile FC, Podda M, Arezzo A, et al. Acute cholecystitis during COVID-19 pandemic: A multisocietary position statement. World J Emerg Surg 2020;15(1):38. DOI: 10.1186/s13017-020-00317-0.

26. Porter J, Blau E, Gharagozloo F, et al. Society of robotic surgery review: Recommendations regarding the risk of COVID-19 transmission during minimally invasive surgery. BJU Int 2020;126(2):225–234. DOI: 10.1111/bju.15105.

27. Royal College of Surgeons of England. Updated Intercollegiate General Surgery Guidance on COVID-19. Available from: https://www.rcseng.ac.uk/coronavirus/joint-guidance-for-surgeons-v2.

28. El Boghdady M, Ewalds-Kvist BM. Laparoscopic Surgery and the debate on its safety during COVID-19 pandemic: A systematic review of recommendations. Surgeon 2021;19(2):e29–e39. DOI: 10.1016/j.surge.2020.07.005.

29. American College of Surgeons. COVID-19: Elective case triage guidelines for surgical care. Available from: https://www.facs.org/covid-19/clinical-guidance/elective-case.