Laparoscopic Gastrointestinal Surgery During COVID-19 Pandemic: Single-Center Experience

Background

In the present time of COVID-19 pandemic, many routine protocols of patient management have changed. Till 2 months back, minimally invasive surgical procedures were deemed to be the right choice for almost all intra-abdominal surgeries. COVID-19 era has put laparoscopic surgery a risk procedure because of a proposed theoretical risk of viral transmission. The discovery of COVID-19 virus RNA in stool of patients led to the fear of fecal-oral route transmission. The virus concentration in the peritoneal fluid was also found to be very high. Both reports led to fear of virus transmission during gastrointestinal surgery.^1,2 Also the virus was found in the peritoneal fluid in very high concentration. ³ Even clear evidence till date to demonstrate virus transmission from gastrointestinal tract or through peritoneal fluid is lacking, fear of transmission remains unanswered.

Pneumoperitoneum created during laparoscopy leads to relatively stagnant heated volume of gas in the abdominal cavity that may subsequently allow for a concentrated aerosolization of the virus. Thus, sudden bursts of this pneumoperitoneum from trocar valves during exchange of instruments or during the venting of trocars can allow for transmission of the virus. The fear of viral transmission during laparoscopy led many national and international societies to publish recommendations for minimally invasive surgeries during COVID-19 pandemic with specific guidelines of smoke evacuation.^4,5

We are reporting our experience of laparoscopic gastrointestinal surgery using a closed smoke evacuation/filtration system with ultra low-particulate air (ULPA) filtration capability (ConMed AirSeal^® System).

Methods

This was an observational study designed prospectively to evaluate efficacy of the closed smoke evacuation/filtration system with ULPA filtration capability (ConMed AirSeal System) during laparoscopic gastrointestinal surgery. As per recommendations, all planned/elective surgical and endoscopic cases were postponed. However, minimally invasive surgical care to patients presenting with urgent and emergent surgical conditions was continued at our center after considering medical, logistical, and organizational considerations. All patients were stratified based on CT scan of thorax. In the first month, COVID-19 reverse transcription polymerase chain reaction (RT PCR) test was done in high-risk patients only, but during the month of May, all patients underwent COVID RT PCR test in preoperative workup. All COVID-19 RT PCR test negative patients were taken up for surgery. Institutional review board approval was taken to use the closed smoke evacuation/filtration system with ULPA filtration capability during laparoscopic surgery. A written informed consent was taken from all patients who underwent laparoscopic surgery. All laparoscopic gastrointestinal surgeries that were done during the COVID time between March 22, 2020, and May 30, 2020, at the single institution were included. ConMed AirSeal System was used during all surgeries. Standard protocol of creating pneumoperitoneum was the open method. After attaching air seal triple lumen tube to air seal the access port, air seal mode was activated. Intra-abdominal pressure was maintained at 8 mm Hg. Utmost care was taken to minimize changing of instruments during surgery. Usage of energy was minimum during surgery. Specimen removal was done after air seal mode was stopped and abdomen completely deflated by the air seal system. Port closure was done only after the pneumoperitoneum deflated. Intra-abdominal drainage was avoided whenever possible. The laparoscope and all other trocars were removed only after stoppage of air seal mode and abdomen deflated. Escape of pressurized carbon dioxide (CO₂) from the pneumoperitoneum was strictly avoided during the procedure. Minimum essential staff was kept in the operation room. Operating room staff was asked to wear appropriate personal protective equipment (PPE). During the postoperative period, pain score was monitored. During postoperative period, standard intravenous analgesics were administered for 24 hours, and then on demand, analgesics were given.

Results

There were a total 14 patients who were operated through the laparoscopic technique. Totally, 17 males and 7 females who required urgent surgery. The most common indication for laparoscopic intervention was acute cholecystitis and complications related to acute cholecystitis (Table 1). The next most common indication was obstructive pathology of the intestinal tract. No inadvertent release of stagnant air occurred during any surgery. Owing to the better smoke evacuation system, low intra-abdominal pressure was maintained during all surgeries. Of all procedures, only 20 times the laparoscope was taken out for cleaning. Mean time for completion of surgery was 58 minutes. Compliance of surgical staff during laparoscopic surgery was high because of the use of a better smoke evacuation system. Median postoperative pain score was 1. Shoulder tip pain was present in only 5 patients. There was no major complication in the postoperative period. Mean hospital stay was 4.9 days (Table 2).

Discussion

Even today there no clear-cut evidence of viral transmission during surgery through laparoscopic or open approaches. There is lack of evidence that COVID-19 is transmissible through surgical smoke. Previous studies have, however, demonstrated the presence of different viruses in surgical smoke, including corynebacterium, human papillomavirus, poliovirus, human immunodeficiency virus, and hepatitis B virus.^6–9 The aerosol produced by laparoscopic or robotic surgery, particularly when using low-temperature ultrasonic devices, may not effectively deactivate the cellular components of a virus. ¹⁰ The novel coronavirus, COVID-19, has readdressed the issue regarding the risk of virus transmission to staff in the operating room. ¹¹ This concern was raised even more during laparoscopic surgery as release of stagnant air under pressure deemed to be more dangerous. This concern made many surgical societies to publish guidelines and consensus statements about protocols to follow during minimally invasive surgery.

The threat of COVID-19 pandemic and limited resources have made surgical decision making more complex. Not only patients' exposure and well-being but also the health care providers' exposure and well-being are also important considerations. The resource conservation that includes hospital beds, ventilators, PPE, and medications while not compromising outcomes is a difficult task. Therefore, the risks and benefits of every decision should be monitored carefully. However, urgent and emergent surgical procedures cannot be denied or delayed in the interest of patients. Minimally invasive procedure allows for a self-contained operative field with less and possibly no spillage of fluids and tissues, thus decreasing any risk to the operative staff. For this reason laparoscopic surgery was strongly encouraged over open surgery in patients during the acquired immunodeficiency syndrome epidemic in 1990.^6,7 Opening trocar stopcocks allowing release of the gas/surgical smoke into the room is traditional practice of laparoscopy. These traditional practices intend to increase risk of transmission of COVID-19. Several societies have recommended to prevent any release of pneumoperitoneum into the room by creating a closed circuit for insufflation with the use of a smoke evacuator device.

Several integrated insufflation and smoke evacuation systems exist. Independent smoke evacuator systems also exist that are supplemental to conventional insufflator systems. Either of the systems can be useful in preventing air leak. One of the most common systems that has been suggested for use during this COVID-19 pandemic is ConMed AirSeal. ConMed AirSeal device uses an intelligent flow system control unit. ¹² The benefits of this system include the valveless access port with small circumferential CO₂ nozzles within the trocar as opposed to a one-way valve, which minimizes any loss of pneumoperitoneum during instrument exchange. The trilumen flow tube set allows for three tubes for simultaneous (1) CO₂ inflow, (2) CO₂ outflow, and (3) pressure monitoring, and filters particles as low as 0.01 μm. One concern about using the AirSeal mode is recirculation of insufflated CO₂ rather than continually adding fresh cooler CO₂. This feature is beneficial for the technical aspects of laparoscopy and robotics to decrease fogging of the camera and minimizes use of CO₂. The trilumen flow tube set is disposable, and its cost is one major limiting point against widespread use of this system. We used the same mechanisms of AirSeal system for smoke evacuation. We found this system useful because it has reduced surgical time, no inadvertent loss of pneumoperitoneum, and low pressure was maintained. Postoperative pain is much less and so hospital stay was also not prolonged. It has been seen that surgical team stress was also reduced due to implementation of safety protocols, including use of the closed smoke evacuation/filtration system with ULPA filtration capability. ¹³ When resources are limited in countries such as India, <5 days of hospital stay in this kind of urgent surgeries would also help to conserve hospital beds for other emergent situations.

Conclusions

Although there is no scientific evidence to support transmission of COVID-19 virus during laparoscopic or robotic surgery, we understand there may be a theoretical risk of transmission from the abdomen of an asymptomatic infected individual. Fear of aerosol transmission led to laparoscopic surgery controversial. Based on our experience, we recommend to use the closed smoke evacuation/filtration system with ULPA filtration capability or similar devices in each minimally invasive surgery to mitigate any such possible risks of transmission of COVID-19 virus until we learn about the disease and transmission.