Coronavirus disease (COVID-19), an infectious disease caused by a newly discovered coronavirus, is spreading rapidly around the globe. To allow for adequate hospital capacity to treat a surge of (typically adult) patients suffering from COVID-19, many hospitals worldwide have canceled elective operations for adults and children, and preserved operating room capacity only for emergency procedures. Under normal circumstances, these emergency operations are often carried out using minimally invasive techniques, supported by the evidence of their advantage over the open approach.1,2 For example, laparoscopy is the preferred approach for common emergency conditions including acute appendicitis, acute cholecystitis, gynecological emergencies, and trauma. Specifically, due to the high incidence of acute appendicitis and the common laparoscopic approach to its treatment, COVID-19 may affect the way patients with acute appendicitis are managed.
A number of safety concerns about the use of laparoscopy during the COVID-19 pandemic have been raised but none substantiated by evidence specific to this virus. During laparoscopic surgery, an intra-abdominal workspace is created most commonly by insufflating carbon dioxide under positive pressure. This might lead to leakage of gas around the surgical instruments which, were it to contain virus, may risk infection of surgeons and other operating room practitioners. Consequently, several renowned organizations including the American College of Surgeons, the Society of American Gastrointestinal and Endoscopic Surgeons, and the Royal College of Surgeons of England have made recommendations that include significant limitation of laparoscopic surgery. Current advice from the Royal College of Surgeons of England (and the other UK Royal Colleges) recommends that surgeons “consider laparoscopy only in selected individual cases where clinical benefit to the patient substantially exceeds the risk of potential viral transmission”.3
Previous research has shown that laparoscopy can indeed lead to aerosolization of blood-borne viruses.4–6 A study of laparoscopic operations on patients with hepatitis B also revealed that the surgical smoke generated from cauterization devices contained hepatitis B virus in 91% of patients even if the viral load was undetectable in the patients’ blood.4 Although the most common manifestations of COVID-19 are respiratory symptoms, features like diarrhea, nausea, vomiting, and abdominal discomfort can be present at the onset of the disease. COVID-19 virus has been found in multiple cells in the gastrointestinal tract and bodily fluids including saliva, enteric contents, and stool.7 Patients can persistently test positive on rectal swabs even after nasopharyngeal testing was negative, raising the possibility of fecal-oral transmission.8 Interestingly, the first case of confirmed COVID-19 in the United States presented with nausea, vomiting and then passed a loose bowel movement. We note that the risk of viral transmission during laparoscopic surgery specific to COVID-19 has not been scientifically evaluated.
To minimize the risk to healthcare workers acquiring COVID-19 infection while performing general anesthesia and emergency laparoscopic surgery, various maneuvers can be adopted. These include (1) testing all patients for COVID-19 infection before surgery; (2) using personal protective equipment including special goggles, visor, mask, and body protective garb; (iii) management of aerosol and smoke dispersal using filters, traps, smoke evacuators as well as avoidance of 2-way pneumoperitoneum insufflators; (iv) minimization of electrocautery use with more frequent use of laparoscopic staples; (v) reducing to a minimum the abdominal insufflation pressure and (vi) carefully deflating the abdomen via the laparoscopic ports and eliminating the gas via a filter. None of these maneuvers has been subjected to rigorous scientific evaluation. Further challenges to their implementation include delay in obtaining COVID-19 test results, personal protective equipment availability and difficulty implementing gas and air scavenging systems, particularly in hospitals or countries with suboptimal resources. To eliminate the risks of viral transmission that are specifically related to minimally invasive surgery these emergency procedures such as appendectomy, cholecystectomy, and gynecological procedures could be performed via a traditional laparotomy. We note there do not appear to be any data indicating that open surgery reduces the risk of viral transmission compared to laparoscopy, and smoke generation and aerosolization clearly can occur during open surgery. From a patient perspective, clinical outcomes such as length of hospital stay, and postoperative complications might be higher after open surgery compared to laparoscopy. However, the risk of viral transmission during surgery is not limited to minimally invasive procedures. Any surgical procedure carries a transmission risk, and this is not only to the operating surgeon and nurses but also for anesthetists, their assistants and other non-medical personal in the operating room. Indeed, airway manipulation including tracheal intubation has been highlighted as an intervention during which there is particularly high risk of viral transmission. Furthermore, it must also be considered that there is a risk of viral transmission to the patient during any surgical procedure from sources including asymptomatic healthcare workers and contact with potentially contaminated objects in the anesthesia, operative and postoperative rooms.
An alternative approach to the management of some of these emergency conditions would be to pursue nonoperative treatment. In theory, this would remove the need for surgery altogether, thereby achieving the complete minimization of risk of transmission to healthcare staff during surgery (Table 1).
The condition most likely to be affected by widespread change in treatment approach is acute appendicitis. Acute appendicitis is a common condition—in North America, the incidence is 100 per 100,000 person-years with nearly 400,000 diagnoses in 2015.9 In other parts of the world such as Asia, the Middle East, Southern America, and Africa, the incidence is known to be increasing and may in fact be higher than in some Western countries. Appendectomy remains the cornerstone of treatment for acute appendicitis and at present is mostly performed laparoscopically. However, in recent years, there has been great interest in nonoperative management with the use of antibiotics alone. Studies performed in adults and children suggest that uncomplicated acute appendicitis can be treated with antibiotics and without an operation in many cases. A recent meta-analysis indicated that nonoperative antibiotic treatment of uncomplicated appendicitis is safe and, in most cases effective. Interestingly, nonoperative antibiotic treatment and appendectomy showed a similar length of primary hospital stay and no significant difference between children and adults.10
We wish therefore to draw attention to nonoperative antibiotic treatment of a group of patients with uncomplicated acute appendicitis as this may change the paradigm of care for adults and children during the COVID-19 pandemic. This is an evidence-based intervention that appears to meet all the criteria for reducing the risk of viral exposure during surgery (of any description) to both staff and the patient whilst not necessarily resulting in worse patient-focused outcomes. It is possible that with the correct oversight, such as telemedicine and telephone consultations, patients having nonoperative treatment may achieve an even shorter hospital stay by receiving part of their treatment in the community and even at home. This would further reduce exposure to viral transmission in hospital, decrease the burden to specialized hospitals and decrease the cost of care. We do acknowledge that nonoperative treatment may not be applicable for all cases of acute appendicitis and there may be challenges in case selection. Specifically, a subset of patients who have radiological evidence of intraabdominal abscess or appendicolith at presentation may fail antibiotic treatment.10
Whilst the use of nonoperative treatment of uncomplicated acute appendicitis to date has been limited, we propose that now is the right time to expand the use of this treatment modality as we strive to limit the exposure of healthcare workers and patients to the transmission of COVID-19 during hospitalization and during surgery in particular.
1. Jaschinski T, Mosch CG, Eikermann M, et al. Laparoscopic versus open surgery for suspected appendicitis. Cochrane Database Syst Rev. 2018; 11:CD001546
2. Coccolini F, Catena F, Pisano M, et al. Open versus laparoscopic cholecystectomy in acute cholecystitis. Systematic review and meta-analysis. Int J Surg. 2015; 18:196–204
3. Royal College of Surgeons. Updated intercollegiate general surgery guidance on COVID-19. 2020. Available at: https://www.rcseng.ac.uk/coronavirus/joint-guidance-for-surgeons-v2/
. Accessed April 3, 2020
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