Laparoscopy Urological Surgery in COVID 19 era - A brief overview of Safety and efficacy of Laparoscopy Urological Surgery during COVID 19 era

1. Is Laparoscopy Safe in Covid 19 Era ?
Dr Nitesh Jain
Consultant Endoscopic, Laparoscopic & Robotic Urologist
Apollo Hospital, Chennai (India)
drniteshjain@yahoo.com
www.urocarechennai.com

2. Disclosure
• I am a surgeon and Love doing Surgery specially Minimal Invasive
• My Practice involve 90% on MIS either endoscopic, Laparoscopic or
Robotics
• The evidence in COVID era for the COVID itself is evolving faster than
COVID
• I am not a COVID expert
• No conflict of interest with any company

3. Why are Debating against an Establish
Practice ?

4. Ashes will raise only when there is fire …!!!

5. Thousand known enemy are better than an
Unknown one …!!!

6. Old records….
• Raised concern of Viral transmission during Laparoscopy – taking leaf
from the past
• Other Virus = Corona Virus

7. Evidence from Past
• Activated Cornybacterium , HPV and HIV were detected in surgical
smoke
• Even though the evidence and transmission is less, but these virus
also were less Communicable compared to the current COVID 19 and
never led to complete Lockdown as now
• Aerosol – the root cause

8. Anesthesia GA versus SA + Epidural
• Laparoscopy needs GA
• We are lucky that majority of our surgery can be done under Regional
Anesthesia
• Regional Anesthesia have the advantage of
• Preservation of Respiratory function
• Decreased risk of aerosol dissemination
• Less risk of Viral Transmission
• Surgeons responsibility to safeguard his colleague

9. Anatomy – Avoiding Peritoneal Breach
• Fortunate that Urogenital Organs are
Retroperitoneum or Extraperitoneal
• Risk of Peritoneal and Fecal
transmission – Reported
• Peritoneal Breach can be avoided by
doing Retroperitoneal or
Extraperitoneal surgery
• Not many Comfortable doing Lap
Retro/Extra Peritoneal surgery

10. Aerosol
• An aerosol (abbreviation of "aero-solution") is a suspension of fine
solid particles or liquid droplets in air or another gas.
• 1996, Des Coteaux – presence of breathable aerosol and cell size
fragments in cautery smoke during Laparoscopy of size 0.1 to 25 mcm

11. Pressure cooker effect

12. Risk of Aerosol
• Conventional Lap Insufflators
• Increase Pneumoperitoneum
• Exchanging of Instruments
• Leak from the trocars
• Most of the trocar are one way
• Not uncommon to open trocar stopcocks allowing release of surgical
plume to improve vision
• Sudden Pneumoperitoneum released during specimen retrieval

13. Aerosol
• Use of electrosurgical / Ultrasonic equipment
even for 10 min increases aerosol much more
than open entire surgery
• Ultrasonic scalpel or scissors cannot effectively
deactivate the cellular component of Virus
• Kwak et al demonstrated HBV in surgical
smoke by PCR
• We Cannot avoid electrosurgical instrument in
Laparoscopy

14. Need of Equipment's – Adding cost
• ConMed Airseal – uses intelligent
flow system control unit
• Triluminal system for inflow,
outflow and pressure monitoring
with filter (0.01 micron m)
• RISK – as same gas is recirculated
thus risk of concentrating the
aerosolized virus
• PneumoClear –Dual Lumen, uses
traditional trocar
• Independent smoke evacuator
• Extra cost is involved which usually
is not needed regularly

15. Is open better … Is there evidence ?
• No documented proof
• Do a surgery which will decrease the
OR time significantly
• Probably the concentration of the
aerosol are less, and can be easily
sucked out by simple maneuvers

16. Recommendations
• Eau Robotic Urology Section (ERUS) - set of recommendation for patient
selection, aerosol management and surgical technique
• American College of Surgeons – there are insufficient data to recommend
for or against an open versus Laparoscopic approach
• Royal College of Surgeons (RCS) – Consider Laparoscopy only in select
individual cases
• Society of American Gastrointestinal and endoscopic Surgeons (SAGES) –
Use of filters for the release of CO2 during Lap and Robotic surgery
• European Society for Gynecological Endoscopy (ESGE) – Postponing
elective surgery for benign conditions until the pandemic ends with sets of
suggestions in case Laparoscopic surgery is done

17. Till we are not sure… take a route which is
less troublesome ?

18. Marie Curie
• “Nothing in life is to be feared, it is only to be
understood”