The Corona virus infection first started in Wuhan, Hubei, China in December 2019 with a cluster of patients with pneumonia1. Following this, first case outside China was reported in Thailand on January 13, 20202 and WHO announced COVID-19 as pandemic on March 11, 2020. Now this pandemic shows 16,922,232 new cases and 664,172 deaths.
The current virus SARS-2 virus is a single strand RNA virus which belongs to a large family of viruses called Corona virus and this is the seventh Avian influenza virus that is known to infect humans and other after (229E, NL63, OC43, HKU1) Corona virus and the original SARS virus3,4.
Among all population, health care workers are at very high risk of virus exposure. Because of a shortage in protective equipment and knowledge about disease infection rate, in health care workers it is high5. The death rate in health care workers continues to grow, with nearly 200 deaths highlighted, of which 157 were confirmed as of May 3, 20206. The front-line health care workers are at high risk of COVID-19 infection. In Italy 20% of responding health care workers were infected with COVID-19 infection7.
Patients undergoing surgery are a vulnerable group to get COVID-19 infection while in the hospital. Due to immune-suppressant state in surgery and because of proinflammatory cytokine release, pulmonary complications are more1,8. There are many recommendations mentioned in various article. One recommendation is that a negative pressure room is necessary for aerosol-generating endoscopy room9.
The main purpose of this article is to identify and provide safety measures and precautions for surgeons and other health care workers involved in peroperative period and to prevent infection of patients during treatment. We have collected information from various national health care guidelines and publications. Among these the guideline from organization include American College of Surgeon, Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), and Royal College of Surgeon England.
Available protective measures
In this pandemic we need all level of protection to prevent COVID-19 infection. Work uniform, disposable surgical cap, N95 mask, N99 mask, face shield, visor, goggles, gowns, shoe covers, disposable medical protective uniform, disposable latex gloves, half face mask particulate respirator, full-face mask particulate respirator, and powered air-purifying respirator are available personal protective equipment (PPE).
Commonest mode of infection spread is from respiratory droplets and body fluids. N95 masks or nonvalve respirators with head elastic loops provide good protection. According to Europe standards filtering face piece (FFP) score of 2 or 3 is better. It will filter at least 94% of particles that are 0.3 μm in diameter. N99 or FFP 3 filter mask have 99% filtration capacity. It is better to use dome-shaped mask than duck bill mask as study found high failure in facial fitness rate in duck bill10. Respirators can be used in operation theaters. There are 3 types of respirators available. A comparative study shows the protective factors of respirators in half face mask, full face mask, and powered air-purifying respirators are 14, 112, and 1328, respectively11. Powered air-purifying respirator is seeming to be more protective in operation theaters. For endo-nasal surgery we can utilize full powered air purifying respirator (an enclosed powered system with high efficiency particulate air filter12 (Figs. 1, 2).
There are 3 levels of PPE available (Table 1).
Table 1 -
Shows the 3 levels of PPE and its usage in various working areas.
||Gown and Body Cover
||3ply mask Or N95 mask
||Only if direct physical contact +gloves
||OHP face shield
||(1) Outpatient department (2) Triage
||Full sleeved gown +gloves +cap and foot cover
||Visor, face shield, goggles
||(1) CT room (2) Emergency room (3) Transferring patient to ward and OR room (4) Ward rounds
||N-99/FFP3 Respirators PARP (powered air purifying respirators)
||Fluid repellents hooded cover all with foot wear and head cover +double glove
||Visor, face shield, goggles
||(1) Operation theater (2) Any aerosol generating procedure (3) Intubation/extubation Ryle’s tube insertion
We must know about personal protective equipment (PPE) donning and doffing steps and proper disposal of PPE.
Is there any role of hydroxy chloroquine as a preventive medicine?
If there is no contraindication and no drug interaction, 400 mg of HCQ as an initial dose for first 4 days followed by 400 mg/wk for 6 months can be used. This is one of the prophylaxis used in clinical trials13. There are 41 clinical trials going throughout the world to find out benefit and side effect of this drug in health care workers in COVID-19 pandemic14. A study conducted in South Korea shows the efficacy of postexposure prophylaxis of hydroxy chloroquine15. While considering the risk benefit analysis HCQ in selected group of high risk contacts is a prudent approach16. Initial dose of 400 mg twice a day on day 1 followed by 400 mg/wk for 6 weeks is the prophylactic dose of HCQ advised by Indian medical council for health care workers at risk and house hold contacts with confirmed cases17. However, it should be considered carefully before drawing definitive conclusions, since no data has been provided yet to support this announcement. The final interpretation is therefore technically demanding, and in the absence of published data, it is difficult to reach any firm conclusion18.
Managing the outpatient treatment in COVID-19 Pandemic is a difficult scenario. Chances of infection from patient to patient or patient to doctors and nurses and spreading infection from asymptomatic carriers are more challenging issue. Online consultation before patient comes to hospital will reduce the number of patients. For many cases we can give online medication which provide safety for surgeon and patient. According to the SAGES guideline all nonurgent in-person clinic/office visits should be canceled or postponed, unless needed to triage active symptoms or manage wound care.
All surgical OPD patient should go in to a separate triage room or fever clinic to rule out fever and respiratory symptoms and contact history before entering to surgical OPD. If there are any suspicious symptoms, patient directly needs to follow the COVID-19 screening medical department and needs further evaluation.
Only restricted number of persons should stay inside OP room and patient’s attender can stay outside the consultation room. Surgeon and nurse should wear N95 mask with face shield and if possible PPE. Distance between Doctors and patients should be adequately maintained except examination time. No aerosol-generating procedure to be done in OPD. Wound dressing must be done in separate room with all precautions and protections. Doctors and nurses should follow hand hygienic with proper technique. Before and after examination of each patient doctor needs to change the gloves and sanitize the hands. Medicine prescription should go to pharmacy directly by digital prescription and it is better to prescribe the medicine longer and safer period to avoid repeated patient visits. Fumigation of the OPD room at the end of the day is very important to prevent infection19.
Considerations in admissions
As per the SAGES guideline, virtual meeting with multidisciplinary team with core team members which includes surgeon, pathologist, oncologist, radiologist, and coordinator is helpful in decision making for admitting the patients for surgery. All patients who needs emergency procedure must be admitted. Elective surgeries like malignancies needs admission. The Royal College of Surgeon Edinburgh guideline shows all preoperative surgery patients needs isolation for 14 days before and after surgery.
The gold standard test RT-PCR in pharyngeal swab must be done for all admitted patients. Same test to be done even for the attender who will stay together. Attender should not change during hospital course. These test to be done for elective cases 24 hour before the admission and for emergency patients test to be done at the time of admission. If test become positive patients must be isolated and need to follow the national COVID-19 public health protocols20. The median incubation time for patients is 5.1 days (mean IT 5.5 d). The estimated median IT to fever was 5.7 days. So, we must always assume the admitted patients to be potential carriers of virus throughout the hospital. So RT-PCR test must repeated every week in hospital stay. Unfortunately, the false-negative rate of RT-PCR testing is 67% in the first 5 days of infection and 21% on day 8 of infection21.
Chest computed tomography (CT) has a high sensitivity for diagnosis of COVID-19. Chest CT may be considered as a primary tool for the current COVID-19 detection in epidemic areas22. In corona high prevalent countries pooled sensitivity of CT-chest is 94% and sensitivity for RT-PCR is 89%. In low prevalent countries positive predictive value for CT-chest is low (1.5%–30.7%)23.
We must consider all patients as a suspected patients and extra precautions must be taken. In operation theater level 3 PPE needs to be used. Separate rooms used for donning and doffing of PPE. All medical staff involved in surgery must be screened properly because of chances of cross infection between staffs and to the patient. So daily assessment of personal health care status and recording temperature should be followed. Any suspicious symptoms in medical staffs should be isolated and must undergo further investigations.
Anesthetic equipment must be used by one person only and anesthesia machine is strictly disinfected every new cases. Intubation carries high risk due to close proximity to the patient’s oropharynx and exposure to airway secretions is high with high viral loads24. Level 3 PPE must be used by anesthetist with respirators. Awake intubation should be avoided. First time successful intubation is better than repeated attempts. Rapid sequence intubation should be considered to avoid manual ventilation and potential aerosolization. High quality heat and moisture exchange filter, HMEF is ideal to remove 99.97% of airborne particles equal to or greater than 0.3 μm. HEPA filter can be connected to both inlet and outlet tubes of patients with ventilator25. If patient shifted with endotracheal tube to ICU, separate dedicated ventilator must be connected. While changing the ventilator the ET tube to be clamped to avoid spillage.
Minimal number of persons in surgical team will reduce the infection rate. All staffs need thermal screening before surgery. All instruments in the operative field must be kept dry in all time to avoid spillage of fluid. smoke evacuators must be used to reduce the smoke from electrocautery. Spray mode must be avoided and need to use the minimal effective power to reduce the smoke. Care must be taken for aerosol-generating procedures like bronchoscopy, endoscopy laparoscopy and Ryle’s tube insertion, chest tube insertion, intubation, and extubation. Fluid spillage is more in laparotomy cases, cesarean section, trauma surgery cases, and orthopedic procedure like nailing drilling the bone. Both electro-cautery and harmonic produce smoke with hydrocarbon but comparatively harmonic is preferable than electro-cautery26.
Care for emergency surgeries
For emergency department separate triage and early recognition of possible COVID-19 patients and immediate isolation is essential. A door to door connectivity between emergency room, CT room, and operating room (OR) is better for infection control.
For trauma patients primary and secondary survey must be done with effective protection. Dynamic evaluation strategies should be followed in trauma care. Injury assessment directly to be done by radiology. FAST scan and complete x-ray including chest x-ray will assess the injury. In major trauma and blunt injury abdomen cases complete CT screening to be done. In that CT, chest images can help to identify the changes for COVID-19 patients like small plaque shadows, interstitial changes, and ground glass appearance. For patients like splenic injury and penetration chest and abdominal injuries lifesaving procedure must be done faster. Tertiary protection measures are needed for both anesthesia and surgical procedure. As in trauma protocol more critical patients to operated first. Before operating next case, 30 minutes disinfection of operating room to be done27. After surgery patients needs to go to isolation room.
Care for elective surgery
According to American College of Surgeon elective surgery acuity scale surgeries are classified in to various tires. Up to tire 2b, cases like ureteral colic, low risk cancer, nonurgent spine surgeries can be delayed and rescheduled. But cases in tire 3a (high acuity with healthy patient) and 3b (high acuity with unhealthy patients) need elective surgery without postponement28.
According to Surgical Society of Oncology, decision must be taken on individual case basis considering the cancer biology.
Patients undergoing elective surgery should be given reasonable recommendations regarding follow-up. Patient should be shifted to high care facility if COVID-19 is suspected and tests should be ordered.
Many surgical societies recommend laparoscopy surgery but they also recognize that the risk of aerosolization of virus is unclear. The Royal College of Surgeon recommends to choose the laparoscopy in selected cases. According to the American college of Surgeon there is no data to compare the laparoscopy versus open surgery in COVID-19 pandemic. SAGES advice to use filters for released CO2 in laparoscopic and robotics surgery.
Recommendations in laparoscopy:
- The valve less access port with small circumferential CO2 nozzles within the trocar as opposed to a 1-way valve will minimizes loss of pneumo-peritoneum during instrument exchange.
- Need to close all ports tap before insertion.
- To use small incision to avoid side leak from port site.
- Attaching a CO2 filter system to one of the port tap to open it during surgery to deliver smoke evacuation. Rest of ports tap never to be opened during surgery.
- It is better to minimize the usage of cautery system to avoid smoke formation.
- Certain gas insufflators with inbuilt smoke evacuators like Conmed-air seal or Pneumoclear can be used. If smoke evacuator not available suction with filter can be used but safety is not equivalent to smoke evacuator.
- End of surgery desuflation of gas must be done with suction or smoke evacuator to avoid gas leak into room.
- Specimen removal also should be done after desuflation of gas.
- We propose that the use of lower pneumoperitoneum pressures 10–12 mm Hg which lower the risk and reduce the volume of aerosolized particles.
- Deep neuromuscular blockade to optimize the surgical space in laparoscopy with low CO2 pressure29.
Surgery in COVID positive patient—recommendations
- Very first operating room in or block must be allotted separately for COVID positive patients in order to avoid environmental contamination, so that simultaneously the other operating rooms can work for non-COVID patients.
- Swift transfer of patient in and out must be followed.
- Separate pathway for transfer is safe to minimize the contamination. While transferring the patients, transfer person must be a trained person with PPE. Lifts and area through which patient transferred to be sanitized.
- Only for operating COVID-19 positive patients, separate on-call shift to be used. The operating team should have quarantine period of 14 days.
- Negative pressure operating room with high air exchange rate helps in reducing the viral load.
- In order to reduce the infection risk staff in and out must be reduced. whoever entered into OR should not leave the OR until procedure over and once exit the OR the person should not reenter.
- All requirement for the surgery should be planned before starting surgery and all must be kept ready to avoid confusions and contamination.
- Separate set of instruments to be used for COVID-19 patients. Generally disposable material is preferable including drapes and linen.
- All staffs and doctors must enter on time in OR without delay. All possibilities must be used to reduce the operating time.
- At all-time surgical instruments needs to be kept dry and once procedure over used instruments to be kept under sodium hypochloride solution or any other disinfectant solution.
- All potentially infected disposable material must be transferred in separate container and must be sealed. Reusable materials should be decontaminated meticulously.
- Once surgery completed the OR and surrounding exchange areas must be sanitized. All electro medical equipment like ventilator must be cleaned with chloro-derived solution.
- Specimen should be labeled separately as COVID-19 positive and should be handled as infective specimen for pathology department.
COVID-19 negative patient can be transferred to regular surgical ward and regular monitoring of patient is important daily assessment of temperature and breathing pattern must be followed. New onset of fever and respiratory symptoms needs further evaluation for COVID-19.
For COVID-19 positive and suspected patients should be kept separately in negative pressure isolation room. Postoperative rounds and dressing must be done carefully by surgical team with all protective measures. Medical staffs involved in suspected cases or confirmed cases needs quarantine and observation for 14 days.
Sources of funding
No funding support for this publication.
S.K.R.K.: contributed in conception and design of work. M.T.: contributed in drafting the work and final approval. V.S.D.K., N.P.V., and R.V.: helped in revising it critically for important intellectual content.
Conflict of interest disclosures
The authors declare that they have no financial conflict of interest with regard to the content of this report.
Research registration unique identifying number (UIN)
Dr Manuneethi Maran Thiyagarajan.
The authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors/publishers of all those articles, journals, and books from where the literature for this article has been reviewed and discussed.
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