Letter to the Editor: Robot-Assisted and Minimally Invasive Pediatric Surgery and Urology During the COVID-19 Pandemic: A Short Literature Review

Patient selection: All elective surgeries that can be delayed without any risk for the patient should be postponed to after resolution of the COVID-19 outbreak.^6,15 As performed in our divisions, surgery should be reserved to emergent/urgent and oncological indications.

Admission screening: All patients admitted to pediatric surgery service should receive adequate anamnestic interview (the patient and family) about presence of recent symptoms such as fever, cough, or respiratory distress and recent social interaction with a COVID-19+ subject. Before admission, they should also receive body temperature measurement and COVID-19 screening test.^6,10 In our hospital, we adopt the (COVID-19) IgG/IgM rapid diagnostic test (RDT) that assays patient antibodies (IgM and IgG) to SARS-CoV-2 or viral antigen from blood samples from a finger prick, saliva samples, or nasal swab fluids. The sensitivity of the RDT ranges between 57% and 81%. ¹⁶ The same screening should also be extended to the parent accompanying the patient. Furthermore, only 1 parent should be allowed to assist the child during hospital stay and no visitors should be admitted. ⁶

General protection of health care professionals: Based upon our current practice, all the rooms in the ward should be set with a single bed during the pandemic to avoid crossing infection between admitted children or their accompanying parents. Considering the possibility of false negative results of COVID-19 RDT, ¹⁶ all health care professionals should always wear all appropriate protective disposals, including surgical mask, goggles, face shield, disposable caps, and gloves, before performing routine medical work and especially procedures such as dressing change, drainage removal, or other maneuvers directly exposing to contact with patient's blood, body fluids, or excretions.^6,17 Adequate hands cleaning and disinfection using bactericidal alcohol gel should be performed before and after each contact with the patient.^6,10

General protection of patients: Patients and accompanying parents should reduce their permanence and wear a mask in the ward public area. ⁶ The body temperature of patients and accompanying parents should be measured at least twice a day and any symptoms such as fever, cough, or other, appearing during hospitalization, should be referred to the clinicians. ⁶

General protection of surgical team: Surgical team, including surgeons, anesthesiologists, nurses, and all transiting persons in the operating room (OR), should always wear surgical masks, protective glasses or masks, isolation gown, protective suits, and shoe gloves to protect work clothes, face, and eyes from contamination by spatter of blood, body fluids, or secretions, irrespectively, of known or suspected COVID status of the patient. In case of a suspected or diagnosed COVID-19+ patient, the three-level protection measures must be applied, including FFP2/3 masks with face shield and body protective garb. ¹⁸ During robotic procedures, the console surgeon should also wear a sealed visor mask to avoid any contact with droplets, and the head support of the console should be adequately cleaned between surgical cases. ⁸ Special attention must be paid to prevent sharp wounds or damage of the protective equipment, especially gloves and body protection. ⁶

OR setting: COVID-19+ patients who need to perform urgent surgery should be operated in a dedicated OR with limited surgical staff following the general recommendations for OR staff protection. ¹⁰ If not possible, greater OR turnover time and increased ventilation and air purification should be applied for OR sanitation between surgical procedures. ⁶

Intraoperative management: Different technical aspects should be carefully managed during robotic and MIS procedures to reduce the risk of viral contamination:

Management of aerosol dispersal: the use of a suction-assisted smoke evacuation device may reduce the risk of gas leakage through trocars during the insertion, manipulation, and instrument change. ¹⁰ Surgeons should verify that trocar stopcocks or luer connectors are closed before insertion to avoid unnecessary gas leakage. Skin incisions for ports should be as small as possible to avoid gas leakage around ports. In both robotic and laparoscopic procedures, use of integrated flow system can be advantageous. This must be configured in the smoke evacuation mode that, using a 0.01 μm Ultra Low Penetrating Air (ULPA) Filter according to the guidelines established by the Association of Perioperative Registered Nurses (AORN), ¹⁹ allows capturing of particles >0.01 μm and the COVID-19 particle size has been reported in the range of 0.06–0.14 μm. ²⁰ As a consequence, use of such devices with smoke evacuation filters may be helpful to reduce the diffusion of COVID-19 during robotic and MIS procedures.

Management of pneumoperitoneum: after trocars placement, the pneumoperitoneum pressure and CO₂ ventilation should be kept as low as possible without compromising the surgical field exposure or patient's safety. ¹⁰ The Trendelenburg position's time should be lowered as much as possible to minimize the effect of pneumoperitoneum on lung function and circulation and reduce susceptibility to infection. ¹⁰ In our practice, we perform controlled desufflation of CO₂ using an adapted suction system consisting of a disposable filter, an endotracheal tube, and a luer connector to attach to one of the working ports before closure, trocar removal, or any extraperitoneal maneuver (Fig. 1). Specimen extraction should be performed after complete CO₂ desufflation. The use of a locking grasper to secure the specimen before desufflation may be helpful. Specimen retrieval bags may also be useful to limit the release of fluids during specimen extraction.

Management of surgical devices: use of monopolar coagulation, advanced bipolar devices, or any other sealing devices should be minimized or avoided to prevent the production of excessive surgical smoke and particle aerosolization. If needed, the electrocautery should be adopted using the lowest possible power for the desired effect.^10,21

Recommendations for surgery: all robotic and MIS procedures should be performed by experienced surgeons and with the minimum number of surgical team members, to reduce the operating time, the risk of postoperative complications, and viral contamination.^6,10 Presence of SARS-CoV-2 nucleic acid has been demonstrated in urine and stools of COVID-19+ patients. ²² Although no evidence of virus transmission through the urines and stools has been reported yet,^22,23 certain maneuvers such as bowel handling and opening or urethral and ureteral catheterization during robotic and laparoscopic procedures should be minimized or performed using extreme caution, if pneumoperitoneum is already induced.