This document provides guidance for surgeons on surgical practice during the COVID-19 pandemic. It recommends protecting oneself with appropriate personal protective equipment, frequent hand hygiene, and treating every patient as potentially COVID-19 positive. For surgical cases, it advises minimizing aerosol-generating procedures when possible and taking precautions such as proper ventilation and air filtration in operating rooms. Younger surgeons are encouraged to continue developing their skills during this time through online learning and teaching opportunities. The document emphasizes optimizing patient and staff safety while continuing to provide necessary surgical care during the pandemic.

2. Surgical Practice in India during
COVID-19 Pandemic
What to do & What not ?
Dr H V Shivaram
HOD, Surgery & Allied Specialties
Program Director, Bariatric & Metabolic Surgery
Aster CMI Hospital, Bangalore, India

4. This presentation is based on evidence and expert
opinion/recommendations/guidelines from the
literature & global surgical community &
associations available as on today
Please note:

5. Introduction
 Human race is in war with an invisible entity
 Significantly impacting lives and affecting our practice as
healthcare professionals
 ‘Stealth transmission‘ – biggest worry for surgeons
 Surgeons need to be proactive than reactive
 How to plan for resumption of work & elective surgery

7. The coronavirus
is no match for
plain, old soap

8. 4 Do’s for Surgeons
1. Protect your face appropriately
2. Do not allow surgical smoke, plumes to go to your lungs
3. Hand Hygiene
4. Treat every patient as possible Covid +ve

9. Our Priority
Save patient’s life at any cost
Provide timely & appropriate surgical care
Save & protect ourselves
Save & protect co-healthcare workers

10. Health care workers & Covid-19
 China > 3300 health care workers have been infected
 Dr. Li Wenliang - first to warn about new disease - died
 Italy - > 4800 health care workers have been infected
 Italy data –death rate 10 times higher for those between the ages of
60 and 69
 Other countries: USA -9000(15th April)
 India: Quarantined; died; Hospitals shutting down,
non availability of HCW

12. Self Protection
 First Consultation – Telemedicine / video consultation
 2nd Consultation- by appointment as far as possible
 Home to hospital: use simple dress with shoes; avoid suit, tie, watch,
wallet etc. Wear mask; avoid public transport
 Hospital: change to hospital scrub dress
Wear appropriate mask & protective gear as required
 Wear gloves – prevents touching fomites, own face
 Frequent hand wash, sanitizer
 Avoid touching mobile, sanitize mobile SOS
 While leaving hospital: change to own dress & send scrub for wash/iron
 Hospital to home: hand wash, change the dress immediately, wash,
take bath,sanitise car keys, mobile
 Surgeons above 65 years – ? supportive role

14. Surgical care at various levels
 Consultation chamber only
 Own small set up with minor OT/dressing room
 Nursing Homes; missionary hospitals
 Rural/Semi urban/urban places
 Corporate hospitals, DNB Teaching hospitals
 Government hospital of various levels
 Medical college Hospitals
 Younger colleagues: PGs,Registrars, Physician assistants
 Designated Covid-19 treatment hospitals – proper protocols
are available

15. Surgeons at crossroads
Most associations have formed guidelines & be vigilant
Visit websites including WHO, CDC, ICMR

16. Entry Pathway in the Non Covid hospital
(all will be screened at the entry; hand hygiene, mask, no or one visitor)
Separate entry for
1. Health care workers
2. Fever /Flu OPD – attached to the hospital with a separate entry
3. Emergency Room
4. For other purposes-maintenance staff
In- patient Area:
1. Admit from Flu clinic to designated Covid suspect ward / ICU
2. Designated OT for Covid suspect emergency
3. Rest of the admission area

17. Fever clinic entry
HCW entry
ER entry
Checking at entrance
Each hospital has to improvise

18. Hospital Covid Review Committee
Covid Review Committee consisting of:
Hospital Administrator
Infectious Disease Specialist/ Physician
Microbiologist/ Pathologist
Surgeon/Anesthetist/ICU Specialist
Nursing i/c
Make periodic guidelines & implementation as per the changing
scenario; can meet virtually SOS
Virtual MDT meeting amongst specialists SOS basis

19. Be alert about fake news
STOP unnecessary forwards
Be sure what you are forwarding
Get Updated daily

20. Surgeons – various roles
OPD consultation
Evaluation
Decision on surgery
Called to ER
Opinion & Surgical pt.
OPD Procedures:
Dressings
Suture removal
I & D
small procedures
Ward rounds & IP care
- Rota if u have a team
- Minimal touching fomites,
hand sanitisation
Surgery in OT/ICU care
- safety precautions
- AGP
Emergency Surgery
Elective Surgery ?
Teaching
PGs,Residents,Registrars

21. Surgery category -Covid
1. Emergency Surgery < 1hr 2.Urgent Surgery < 24 hours
3. Urgent Elective surgery ~2 weeks 4. Elective Essential – 1-3 months
5. Elective(discretionary)->3months
Stahel Patient Safety in Surgery (2020) 14:8
https://doi.org/10.1186/s13037-020-00235-9

22. Surgeons called to ER
 Try & get detailed history from ER doctor , who has attended to the patient,
Referring physician may also give input; look at breathing & examine chest
 Consider that every patient who comes to ER may be Covid positive
& protect yourself appropriately from head to toe
 Spend minimal time in ER, do provisional diagnosis, order tests+ Chest X Ray,
management plan, follow it up with ER doctor; CT Chest if suspicious
or include Chest if ordering CT abdomen
 If planned for surgery – order Covid test( if available), PAC
 Surgery in designated OT & post op care in designated ward/ICU
 Follow up with Covid test after surgery & till the results come take precautions

23. 1.Covid positive patients
2.Covid Negative with suspicious respiratory symptom cases
3.Untested patients with suspicious respiratory symptoms
Refer them to Covid-19 designated hospitals
4.Untested patients without respiratory symptoms
5.Covid Negative no respiratory symptom cases
May have to operate on category 4 & 5
Surgical Emergency Patient Stratification
E
R

24. Take appointment booking by phone
Encourage Telemedicine consulataion
At the entry verify patient details ( allow one attendant only)
HCW will check: Flu Signs and Symptoms (Fever/Cold/Cough)
History of contact with family member/relatives who is sick (in
past 28 days) History of travel to hot spots
Does the patient
display signs and
symptoms?
Direct the patient to
Flu clinic for further
assessment
Direct & Fast track for registration
Obtain self-declaration from patient
Surgeon’s consultation
Direct patient to Radiology/
sample collection / procedure
room / pharmacy as required
Patient Exit
YES
NO
Physical distance to be maintained at all levels

25. OPD consultation
1. Initial consultation – by telemedicine is preferred
2. Detailed History – Fever,cough,throat pain, contact with Covid
(fever)cases, travel history, living area
History of surgical problem
Evaluation ordered
Explain about Covid-19 situation
3. Second Consultation- Visit to hospital, consent, PAC
Plan surgery - ERAS

26. OPD & OP Procedures
• Avoid Overcrowding in OPD
• One masked accompanying person
• Sufficient gap between appointments
• Well Ventilated Consultation Room
• Remember That Door Handles And water Taps Are Common Fomites
• Frequent Hand Washing/Sanitiser facility
• Use Of Proper PPE According To Procedure
Aerosol Generating Procedures Are Infective
• Both Upper And Lower GI Scopy -AGP
• All Procedures Should Be Done In minor OT
And Not In Consultation chamber/Table

27. Pre Op Assessment- non Emergency cases
1. Detailed History
- Travel History
- Covid contact history
- h/o cough, fever, throat pain, myalgia etc
- Breathing difficulty
2. Testing
- Covid test – RT-PCR
- Chest X Ray; ? CT Chest
Whenever possible better to buy some time (? 2 weeks)
& see if patient develops any symptoms & test 48hrs
before surgery

28. Emergency Surgery
 Emergency procedures are undertaken in life threatening
conditions and have no alternatives
e.g. bowel perforation, gangrene and unresolved obstruction
 Appropriate consent including Covid-19 situation
 Patient, Personnel, Procedural safety is the utmost priority
 Aim at short hospital stay/ERAS

29.  Aerosol Generating Procedures (AGP)
 Infectivity of the aerosolized, blood or fluid- contain viral particles
 Particles in surgical smoke may contain a variety of toxic and virulent
materials ( not proved in Covid-19)
 Potentially capable of infecting those who inhale them
 Dissemination during MIS - pneumoperitoneum-associated aerosolization
of particles, presence of the virus in blood and stool
 MIS - higher concentrations of particulate matter due to the electrosurgical
devices employed, the low gas motility of pneumoperitoneum and gas
expulsion via ports or trocars
Issues with Covid -19 patient surgery

30. 1. Appropriate PPE; Laparoscopy Vs Open ?
2. Minimum number of personnel in the operating room
3. Avoid movement in & out
4. Smoke evacuator when using electro cautery
5. High-Efficiency Particulate Air (HEPA) filters have a minimum 99.97%
efficiency rating for removing particles greater than or equal to 0.3
microns in diameter
6. Ultra-Low Particulate Air (ULPA) filters can remove from a minimum of
99.999% of airborne particles with a minimum particle penetration size of
0.05 microns
Multi-faceted approach: proper room air filtration and ventilation,
ppropriate PPE, smoke evacuation devices with suction
and filtration system, minimal use of cautery & energy devices
What can be done in OT ?

31. Operating is now an occupational Hazard !

32.  Safe evacuation of CO2: from the port attached to the filtration device before closure,
trocar removal, specimen extraction or conversion to open
 Once placed, ports should not be vented if possible
 During desufflation, all escaping CO2 gas and smoke should be captured with an
ultra-filtration system ;be sure to close the valve on the working port that is being used
for insufflation before the flow of CO2 on the insufflator is turned off (even if there is
an in-line filter in the tubing). Without taking this precaution contaminated intra-
abdominal CO2 can be pushed into the insufflator when the intraabdominal pressure
is higher than the pressure within the insufflator.
 Specimens should be removed once all the CO2 gas and smoke is evacuated.
 Surgical drains should be utilized only if absolutely necessary
 Suture closure devices that allow for leakage of insufflation should be avoided. The
fascia should be closed after desufflation.
Filtration During Laparoscopy (SAGES)

33. 1. Negative Pressure room is desirable where possible
2. Minimum no.of personnel to be inside operating room
3. Limit the size of surgical team as much as possible
4. Avoid the operating room personnel stepping out of OT during the procedure
5. Minimum 1-hour time gap to be given between two procedures / surgeries.
6. Minimize duration of surgery
a. No surgical or nursing training during this period
b. Avoid multiple and complex procedures
7. Reusable accessories are cleaned and disinfected with appropriate solutions as
soon as the procedure is over.
8. 1% Sodium Hypochlorite solution cleaning is recommended for OT Tables and
trolleys as soon as the patient is shifted
inter association surgical practice recommendations in covid 19 era
Operation Theatre

34. 1. Air Changes Per Hour - > 20
2. Air Velocity -25-35 FPM (feet per minute)
3. Positive Pressure - 2.5 Pascal (0.01 inches of water)
4. Air Handling & Filtration - The AHU (air handling unit)- HEPA filters
5. Temperature & Humidity 21 C ± 3 C & 20 to 60%
Operation Theatre
Please check whether your OR meets these NABH requirements

35. Laparoscopy Vs. Open Surgery during Covid
A G P - viral contamination from CO2 /plumes
Manage the pneumo & plumes (smoke, tissue vapour)
Has to be a balanced decision - Benefit Vs. Risk
Surgeon may get infection due to port site leaks, plumes, spillage of
body fluids and closed room air circulation in OT

36. Post Op care/ward rounds
Medical staff- Minimal persons / take turns
Careful monitoring
Look for any fever or symptoms of Covid
Examine- Chest, CVS
Poor prognosis:
Lymphopenia - < 1500
Higher NLR – Neutrophil Lymphocyte Ratio

37. Principles of cancer Surgery during Covid
More susceptible to Covid since they are immunosuppressed group
1. Look at resources available:
ICU, HDU beds
2. Risks & Benefits
Delaying diagnosis
Delaying Surgery
Look at bridging alternatives: neoadjuvant therapy, staged procedures
3. Virtual tumour board / MDT / consent
4. Recommendations/ Guidelines

38. Elective Surgery on Patients Recovered from COVID-19
 Long term effect of Covid disease is not known
 Wait & watch policy for sometime
 If surgery is needed MDT decision

39. What to do if Post Surgery Covid Test comes Positive
for Unsuspected/Asymptomatic Case
 Hospital Covid Committee meeting
 Detailed interview with all those involved in patient care from ER to ward
& OT/ICU
Appropriate PPE use, duration, find fact not fault, any lacunae ?
A. Preventive measures taken, but there was lacunae
@HCW: Home quarantine for 2 weeks
Start HCQ prophylaxis
Daily twice temp check; Covid test after 4 days
@Area: Sanitise
B. All preventive measures taken& there is no lacunae
- HCW can work; twice daily temperature check
- Monitor for 4 weeks

40. Covid Testing

41. Corona Virus testing methods
1. rRT-PCR : Real-time reverse-transcription polymerase chain reaction
Nasopharyngeal swab technique - from the throat behind the nose,
containing a mixture of mucous and saliva
(rRT-PCR) assay - detects the presence of "specific genetic material from the
pathogen
2. Serological tests
Serology tests tells about possible infection or exposure in the past, but not
if currently infectious;
helps to detect the rate of infection in a community
Caution:
RT-PCR- False Negative up to 30%

42. Pre -Surgery testing for Covid
Antigen
IgM
IgG
Throat Swab: RT-PCR

43. All PPEs are not same

45. Face Shields/ Mask

46. Indications:
1.Asymptomatic HCW involved in the care of suspected or confirmed Covid cases
2. Asymptomatic household contacts of laboratory confirmed case
Dose:
Cat 1:
400 mg twice a day on Day 1, followed by 400 mg once weekly for next 7 weeks
Cat 2:
400 mg twice a day on Day 1,followed by 400 mg once weekly for next 3 weeks
Prescription drug; after physician’s approval
HCQ Prophylaxis – ICMR recommendation

47. 1. Physically active – exercise, Yoga, Pranayama, meditation
2. Eating right – mediterranian diet (high intake of monounsaturated fats, plant proteins,
fruits, vegetables, fish, and whole grains); Stay hydrated, drink plenty of water
3. Good sleep – Lack of sleep - stress hormones, like cortisol and adrenaline
4. Vitamins C(250 to 1000mg) , D (1000-4000IU), Zinc( 40mg ) per day
5. Keep mind active – read books, write a book
6. Distance Socialising – by phone, skype etc
7. Avoid smoking, alcohol, addictive substances

48. Younger surgical colleagues – tough time
(true Covid warriors)
 Refresh your knowledge
 write or Publish an article
 Edit your surgical videos
 Teach – take online class; do webinar on your own
 Write Blogs; your You tube channel; start your facebook page,
website
 Listen to motivational talks; spiritual talks
 Acquire knowledge / degree - online courses

49. Teaching during pandemic
 Virtual teaching platforms
 Online assessments
 Thesis work
 Webinars
 Online free/paid courses

50. Surgeons working in Covid Hospitals
MOH laid down procedures

51. Protect your family members

53. How to prepare for new life after
coronavirus lockdown ends ?
 Be optimistic – human race have won all previous pandemics
 wear simple cloth mask while going out
- masks will become an essential part of human's dress code
- new fashion statement !?
 Avoid public transport buses and local trains
 Lockdown may be repeated if there is recurrent outbreak
 Manage stress & finances
 Hygienic Rules will continue: carry a soap, towel;
face mask, a pair of hand gloves, sanitizer etc
 Distance socializing: Tele medicine / tele health care

54. Resumption of Elective Surgery
To be considered carefully after lockdown period is over
Local hospital Covid committee is the right authority
I. Know your Community & Testing availability
Hot zones; areas of containment; recurrent waves
II. Preparedness
Health care workers preparedness
Health care facility/OT preparedness & supply chain
Inter departmental cooperation
III. Patient issues
communication; consent issues; Prioritization
IV. Delivery of safe and high-quality care
Phase I: Preoperative Period
Phase II: Immediate Preoperative Period
Phase III: Intraoperative Period
Phase IV: Postoperative Period
Phase V: Post Discharge Period
April 17, 2020, American College of Surgeons