The ongoing outbreak of coronavirus disease 2019 (COVID-2019) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been declared a pandemic by the World Health Organization (WHO) and has imposed a large burden on global medical systems.1 Although most elective surgeries have been postponed in endemic areas, patients with potentially fatal acute abdomen still require urgent surgical interventions (eg, those with gastrointestinal perforation or acute purulent appendicitis) while the relevant evidence is scarce. The diagnosis of COVID-19 is based on the clinical manifestations, epidemiological history, chest computed tomography (CT) findings, and reverse transcription polymerase chain reaction (RT-PCR) testing for SARS-CoV-2.2 However, the shortage of RT-PCR test kits and the prolonged detection time limit its application in emergency circumstances. The present article describes the diagnosis and treatment of 4 patients with suspected COVID-19 who required urgent surgical intervention for acute abdomen.
DIAGNOSIS AND PREOPERATIVE TREATMENT
Table 1 summarizes the demographic features and clinical manifestations of the patients with acute abdomen and suspected COVID-19. From January 23, 2020 (the date of Wuhan lockdown) to March 23, 2020, 4 acute abdomen patients with suspected COVID-19 infection were admitted to our hospital: cases 1 and 2 showed signs of acute peritonitis, whereas chest CT and radiographic examinations in cases 3 and 4 indicated gastrointestinal perforation and acute peritonitis as well. Moreover, all 4 patients presented pulmonary opacifications or infiltrations in the lung lobes on chest CT, whereas 3three of them showed symptoms/signs of pneumonia. Given the epidemiological history was unclear and the clinical spectrum of SARS-CoV-2 infection appears to be wide,3–5 the risk of COVID-19 could not be totally ruled out in these patients. Oropharyngeal swab samples were immediately collected and sent for SARS-CoV-2 detection.
A multidisciplinary team comprising professionals from departments of general surgery, fever clinics, respiratory medicine, infection control, operating, and anesthesia center was urgently convened to make treatment decisions after critical evaluation and discussion.6 The repeated RT-PCR testing for SARS-CoV-2 would take 1 to 2 days to reveal the final results, but the surgical time window was narrow and the patients deteriorated quickly after conservative treatment failure. For example, case 1 patient displayed signs of septic shock after admission, indicating an urgent need for surgical intervention. Therefore, emergency laparotomy was scheduled for these patients in compliance with tertiary protection regulations,7 which means that all involved medical staff had to wear full personal protective equipment (PPE), including disposable N95/FFP2 respirators, double gloves, goggles, visors, caps, shoes, and body protection coveralls/gowns.
SURGICAL PROCEDURES AND OUTCOMES
The surgical procedures performed in these patients with suspected COVID-19 were similar to those normally performed for acute abdomen. All patients underwent exploratory laparotomy, followed by gastrointestinal repair or partial resection based on the surgical findings and decided by the surgeons. Suction devices were intensively used to remove the body fluid and smoke to prevent airborne and aerosol viral transmission. Postoperatively, all patients with suspected COVID-19 were transferred to isolated recovery rooms or ICUs to await final RT-PCR results for SARS-CoV-2. Although all 4 patients obtained negative results afterwards, the medical staff involved in the treatment of these patients complied with the tertiary protection regulations and wore full PPE throughout their treatment. Three of the 4 patients recovered and were discharged after 7 to 19 days, whereas 1 is still in hospital but is recovering well.
The following perspectives and precautions regarding clinical management and surgical procedures are based on our experience in treating and operating on these patients with suspected COVID-19 and acute abdomen.
- (1) Indications for emergency surgery under the pandemic of COVID-19 are considered to be the same as before in regular patients. There are difficulties in the decision-making regarding surgery for patients with suspected COVID-19, and in the differential diagnosis of COVID-19 from other types of pneumonia before surgery. Nevertheless, the principle concern is to balance the timely treatment of these urgent cases with the protection of all medical staff. Therefore, if COVID-19 infection cannot be totally ruled out, the highest level of protection should be adopted.
- (2) Before scheduling emergency surgery for patients with suspected or confirmed COVID-19, hospitals should designate negative-pressure operating rooms out of heavy-traffic zones, preferably isolated from the main surgical theaters. We also recommend the development of specific transfer pathways and isolated recovery rooms, ICUs, or medical wards in advance. Even in the potentially contaminated areas, patients suspected or confirmed to have COVID-19 should be placed in separate rooms to reduce the in-hospital transmission risk. Furthermore, infected patients need to be treated by a dedicated medical team comprising physicians, nurses, and other health care workers who avoid traveling across the whole hospital.
- (3) The scrub team performing emergency surgery in such patients should be equipped with full PPE as described above. The number of surgical, nursing, and anesthetist team members working in the ORs should be limited to the minimum required to perform the surgery.
- (4) During the surgery, the use of electrocautery or ultrasonic scalpels should be limited (or the power settings lowered) as much as possible to reduce the risk of aerosol viral dispersal, especially when the protection gear was insufficient. In all 4 of the present cases, exploratory laparotomy was chosen instead of laparoscopic procedures due to the manageable operation time and the uncertainty of airborne and aerosol transmission risk. And we suggested that surgeons who plan to perform minimally invasive procedures need pay more attention to the establishment and removal of artificial pneumoperitoneum, and any air leakage from the trocar sites as well.8
- (5) Wearing full PPE can be quite uncomfortable, and performing surgery under such conditions may be more challenging and technically demanding than usual. Even experienced surgeons need to be wary of the disturbances caused by the mist that forms in goggles and visors. The surgical nurse can help alleviate this distraction by wiping the mist.
- (6) Compared with regular patients, patients with suspected or confirmed COVID-19 need more frequent postoperative follow-up checks, and comorbidities need to be dealt with more actively, as the mortality rate for patients with COVID-19 with several comorbidities is higher than for those without comorbidities.4
The authors thank Prof. Jiandong Wang, Prof. Xiaohui Huang, Drs. Xinxin Wang, Jianxin Cui, Zhou Song, and all other surgical team members, medical professionals from Departments of Emergency, Respiratory Medicine, Infection Control, and Operating and Anesthesia Center who involved in the diagnosis and treatment of patients in the frontline.
1. World Health Organisation (WHO) Coronavirus disease (COVID-19) outbreak webpage. Available at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019
2. Cheng Z, Lu Y, Cao Q, et al. Clinical features and chest CT manifestations of Coronavirus Disease 2019 (COVID-19) in a single-center study in Shanghai, China. AJR Am J Roentgenol
3. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet
4. Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet
5. Wang D, Hu B, Hu C, et al. Clinical characteristics of 138 hospitalized patients with 2019 Novel Coronavirus-infected pneumonia in Wuhan, China. JAMA
6. Ti LK, Ang LS, Foong TW, et al. What we do when a COVID-19 patient needs an operation: operating room preparation and guidance. Can J Anaesth
7. National Health Commission of the People's Republic of China. Diagnosis and treatment of novel coronavirus pneumonia (7th version). 2020/03/04. Available at: http://www.nhc.gov.cn/xcs/zhengcwj/202003/46c9294a7dfe4cef80dc7f5912eb1989.shtml
8. Zheng MH, Boni L, Fingerhut A. Minimally invasive surgery and the novel coronavirus outbreak: lessons learned in China and Italy. Ann Surg