lets discuss few tips and tricks to safeguard our patients and ourselves as HCWs as we continue with surgeries during this COVID pandemic.

1. Performing
surgery during
COVID-19
pandemic
KESES
04th May, 2020

2. Introduction
• SARS-CoV-2
• Origin – Hubei province
• Pandemic in March 2020
• Various stages in different countries
– early, peak or post –peak plateau
• Human to human confirmed
• Main spread – respiratory
secretions, faeces, fomites

3. AIM
• Do safe surgery – protect patients and safeguard
ourselves while not stopping work.
• Stratify surgery based on risks
• Develop an algorithm for planning surgery
• Based on urgency, potential for
aerosolization and release of droplets from
surgical site.
• Protect the workforce
• What is the minimal recommended PPE?

4. Primum non nocere –
first do no harm
• Lets expand this principle to
include our patients and
also…….
Ourselves, the HCWs.
• so many HCWs all over affected
with very many mortalities as
well ……….. Related to higher
virus loads.

5. Classification of surgical
interventions
[NCEPOD]
• IMMEDIATE:
• Life, limb or organ-saving intervention
• Resuscitation simultaneous with
intervention
• Minutes to decide
• URGENT:
• Acute onset or clinical deterioration of
potentially life, limb or organ threatening.
• Hours to decide

6. • EXPEDITED:
• Early treatment where condition not an
immediate threat to life, limb or organ survival
• Days to decide
• ELECTIVE:
• Planned or booked procedure to suit patient,
hospital and medical staff

7. What are high risk
procedures?
Depending on viral load at the surgical site
• AGP
• Aerodigestive tract
• Endoscopy
• Lap surgery on bowel

8. What is an
AGP?
• Aerosol generating procedure
• Intubation/ extubation
• Tracheostomy
• Bag masking
• Bronchoscopy
• UGI Endoscopy
• Chest tubes
• Some dental procedure eg
high speed drilling
• Electrosurgery of GI tissue
• Nasogastric tube
• Ventilation – manual and
non-invasive
• Induction of sputum

9. Acute patients
are a
priority…..
History
COVID testing
CXR/ CT chest
Full protection of the team

10. Measures to mitigate risks to HCWs
Universal measures
Outpatient
Arrival to hospital
In the ward pre-op
Arrival to O.R
Procedure specific – open, lap,
vaginal, obstetrics, hysteroscopy
Post-op
Post discharge

11. Universal measures
• Social distancing
• Masks for all
• Universal evaluation –
history, questionnaire,
exposure, testing ONLY if
required.
• Treat as “positive unless
proven otherwise”
• Correct PPE
• Consent to cover risk of
exposure to COVID-19 to
either party.

12. Universal
measures
Different set of clothes in the clinic
Clean your hands on entering your car
Clean yourselves on arriving home
before anything else.
Avoid or delay elective surgery

13. Out-patient
• Non-urgent in person clinic visits postponed
• All patients to be allowed with max one
relative only
• Record on arrival – name, mobile, address –
for contact tracing if needed later
• Non-touchThermal screen
• All with masks
• Hand hygiene on arrival
• Appointment with staggering of timings

14. • Waiting area – spaced out
• Min required personnel only in clinics
• Preliminary history to include travel, fever, respiratory symptoms.
• In-person surgical consult with decision makers only
• Consider non-operative management where clinically appropriate
• Elective and endoscopic procedures postponed preferably.
• Detailed consent – include COVID

15. SURFACES CLEANED USING
0.05% HYPOCHLORITE
SOLUTION
DOOR HANDLES CLEANED
REGULARLY
DEDICATED MEDICAL WASTE
AND CONTACT WASTE
DISPOSAL SYSTEMS
SOAP WATER VERY GOOD FOR
GLOVES

16. Arrival to hospital
Preferably single
entrance
Non-touch thermal
screen
Hand hygiene
All patients with
one relative only
Masks for all
Social distancing in
clinical areas
Record for contact
tracing
“Follow hospital
policies” to be
explained

17. Wards
• All hospital personnel must wear protective clothing, cap,
mask, face shield
• Only one relative max
• Patient in mask
• AGP – full PPE
• Dressing – gown, cap, mask, face shield, gloves
• Biomed waste handled with extreme precaution

18. To the O.R
• Patient shifting with strict protocol and safe
transfer techniques
• Trolleys cleaned after every use
• Changing room for staff - ?
• Min staff as required to contact one patient
• Negative pressure theatre if available – most
are regular or positive pressure O.R
• Anaesthetic protocol
• Limit staff change between cases

19. • Careful biomed waste disposal
• Opening of doors during
procedure to be minimal

20. The correct minimal
PPE
• Anaesthetists and A.A – during GA
• N95, face shield, fluid resistant gown,
gloves, cap
• Cleaning staff:
• Droplet precautions – fluid resistant
surgical mask, face shield, plastic
apron, gloves, cap
• Surgical team AGP:
• F.r surgical mask, face shield, cap,
mask, plastic apron, f.r gown, gloves
• Surgical team non AGP:
• Routine outfit with added face shield

21. • Surgical team confirmed COVID:
• Full PPE
• OPD and wards:
• Surgical mask, face shield, gloves
• Others: - ICU, labour room, E.R,
transferring staff, laundry, CSSD, relatives
etc

22. The procedure itself…..
• Anaesthesia:
• Regional if possible
• If GA – full PPE
( cap, N95, face shield, plastic apron, fluid resistant gown,
shoe cover, gloves)
• IF GA – scrub team ready then step out or to a corner
of the room as intubation done.
• Extubation done similarly
• Anaesthesia gases expiratory circuit closed with filters

23. Limit no of people in theatres, limit trainee involvement
Surgery by senior person – short time
Don and doff PPE with help of second person
Doffing by inside out technique near the Bin
Open surgery where possible and especially if AGP
Minimal electrosurgery use and with active suction next to it
If electrosurgery - min settings
Dressings should be non-permeable and occlusive

24. Dissection and vascular control using
non-electrosurgical methods
Avoid prolonged desiccation times
Ultrasonic – low power setting and short
bursts
Slow and steady to minimize blood and
droplet spray

25. Laparoscopy
• Level of risk theoretically high , but not yet
established.
• The advocated safety mechanisms are
difficult to implement e.g filters, traps, careful
deflation etc
• Level of PPE deployed very crucial
• Lap in selected cases where clinical benefits
outweigh risks
Keeping in mind………

26. CO2 gas and surgical plume at
laparoscopy has been reported
to carry viruses like HBV, HIV
and HPV
BUT…….

27. • Regarding COVID specifically, there is no data on
surgical exposure translating to definitive risk to
the OR team
• With this dearth of info, the health care team has
2 solutions:
• Continue normal practice till it becomes clear
about harm
• Become proactive rather than reactive and
adopt a conservative, yet balanced approach
protect the HCPs.
• This may require a few changes to our current
practice :

28. Laparoscopy
• Bio-aerosol transmission possible during:
• Gas leak from trocars and incisions
• Smoke removal through trocar venting
• Deflating of the pneumoperitoneum
• Leaks during insertion of instruments,
endoloops, endobags, surgicel, gauze etc
• Portable suction machine without any
filter between.
• Electrosurgery and ultrasonic use
• Morcellation, even when contained.

29. • Droplet transmission risk:
• Specimen retrieval
• Trocar removal
• Port closure
• Through leaking
instrument cleaning
channels.

30. Risky procedures in
laparoscopy
• Bowel involvement surgery
• Gen surgery
• Rectovaginal
endometriosis
• Adhesiolysis
• Multiple previous
surgeries

31. Steps – reduce
risks in
laparoscopy
• Appropriate PPE
• Closed direct trocar or veress entry preferable –
open entry more leakage likely
• Small incisions
• No leak of CO2 during primary trocar ensured by
keeping valve closed
• No venting of trocars into the open room
• Low operating pressure settings – 10-12 mmHg
instead of 15 if feasible
• If available – smoke evacuation/filtration system
with ULPA ( ultra-low particulate filtration)

32. MIN USE OF ELECTROSURGERY
AND LOW SETTINGS
CENTRAL WALL SUCTION WITH
FILTRATION AND NOT PORTABLE
SUCTION IF POSSIBLE
SUCTION SMOKE INSTEAD OF
VENTING THE TROCAR
ALL INSTRUMENTS TO HAVE
CHANNELS CLOSED
ALL TROCARS LEAK TESTED
PRIOR
SUCTION TUBE CAN HAVE A
FILTER FITTED BETWEEN THE
PATIENT AND THE MACHINE

33. Always desufflate using suction/ filtration system:
• Before specimen removal
• Before conversion
• Before trocar removal
• Before port closure
(not directing venting the trocars into the room)

34. Vaginal surgery
Regional anaesthesia
Concern about aerosolization with use of hand-held electrosurgical devices.
Care about droplet spread
Safe to continue with the appropriate PPE

35. Hysteroscopy
• Regional or no anaesthesia if and
when possible
• Standard droplet precautions
• Use of electrosurgery relatively
safe
• Hys. Morcellators have an edge
over electrosurgical
resectoscopes.
• Suction connected to the outflow
sheath

36. Obstetrics

37. Obstetrics
Conduct of
vaginal
delivery
Caesarean
section
Ectopic
pregnancy
Miscarriage
and suction
evacuation

38. Post – op
Minimal hospital stay Routine PPE
Avoid prolonged rest –
surgery and covid are
both hypercoagulable
states
Prophylactic LMWH

39. Post
discharge
• Pre-decided follow-up visit
• Avoid prolonged rest
• Maintain social distancing with minimal
assistants for support at home
• Multidisciplinary, including psychosocial
support

40. The future……
• Approach to COVID positive patients….
• Recommencement of elective procedures in the
post-peak era
• Psychological support for the involved hCWs
• Burden of backlogged cases
• Tele-consultation – ethics and feasibility: will it
change our style of working in the future?
• Long term changes in our surgical practice.
• Smoke management will be compulsory
practice.

41. References:
• NCEPOD classification of intervention
• Min Hua Zheng et al. Minimally invasive surgery and the novel coronavirus outbreak: lesson learned in China and Italy. Annalsof
Surgery, March 2020
• Johnson GK, Robinson WS. HIV-1 in the vapors of surgical power instruments, 1991, 33: 47-50
• Gloster HM, Roenik RK. Risk of acquiring HPV from the plume produced by the carbon dioxide laser in the treatment of warts. J Am
Acad Dermatol 1995; 32: 436-441.
• Alp E, Bijil D et al. Surgical smoke and infection control. J Hosp Infect. 2006; 62: 1-5
• Wang U et al. Detection of SARS-CoV-2 in different types of clinical specimens. JAMA 2020 Mar 11. doi: 10.1001/jama.2020.3786
• AAGL statement regarding Gynecologic surgery during the COVID-19 Pandemic
• IAGE: good clinical practice recommendations for gynaecological endoscopy during the COVID-19 pandemic
• Protecting surgical teams dring the COVID-19 outbreak: a narrative review and clinical considerations

42. Performing Surgery During COVID-19
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KESES
04th May, 2020
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