Surgery in the era of COVID-19: implications for laparoscopy and natural-orifice endoscopic surgery: a narrative review

Controversy exists regarding the use of minimally invasive surgery (MIS) during the corona virus disease 2019 (COVID-19) pandemic. Several surgical societies have issued recommendations regarding precaution measures during MIS, nonetheless these recommendations were conflicting with respect to the use of laparoscopy with little or no inference to natural-orifice endoscopic surgery. A comprehensive literature search was performed to explore the available evidence pertinent to the novel coronavirus 2 (SARS-CoV-2) transmission dynamics in MIS, and benefits of MIS procedures in patients with transmissible viral diseases. According to the current evidence, SARS-CoV-2 has a multi-route transmission, including fecal-oral transmission. Evidence on airborne transmission in the operative setting are however limited. In addition to nasopharyngeal screening, it would seem prudent to perform routine fecal testing for SARS-CoV-2 in patients undergoing positive-pressure transanal minimally invasive procedures. This is particularly relevant to regions with high level of epidemicity. In patients with confirmed SARS-CoV-2 infection, conventional laparoscopic and robotic approaches, and atmospheric transanal surgery with high volume smoke evacuation may be safer alternatives. Considering the high rates of postoperative pulmonary complications and mortality associated with SARS-CoV-2 infection, use of laparoscopy is advised in suspected or confirmed COVID-19 patients who require abdominal surgery, particularly older patients and those with comorbidities. Laparoscopy may decrease the probability of postoperative disease exacerbation, and provide earlier recovery, less morbidity and mortality, and shorter hospital stay with subsequent decreased risk of in-hospital secondary transmission. High index of suspicion in postoperative patients with fever or respiratory symptoms is necessary to timely diagnose COVID-19. Chest computed tomography scan has a higher sensitivity compared to real-time PCR and can potentially be used to assist in the diagnosis, particularly in elderly patients.

[1]  R. Malekzadeh,et al.  Personal Protective Equipment for Endoscopy in Low-Resource Settings During the COVID-19 Pandemic: Guidance From the World Gastroenterology Organisation. , 2020, Journal of clinical gastroenterology.

[2]  C. Macintyre,et al.  Aerosol transmission of SARS-CoV-2? Evidence, prevention and control , 2020, Environment International.

[3]  M. J. Broadhurst,et al.  Aerosol and surface contamination of SARS-CoV-2 observed in quarantine and isolation care , 2020, Scientific Reports.

[4]  K. Hotta.  Regional anesthesia in the time of COVID-19: a minireview , 2020, Journal of Anesthesia.

[5]  F. Pareja-Ciuró,et al.  Early implementation of protective measures defines surgical outcomes in the COVID-19 pandemic , 2020, Surgery Today.

[6]  A. Barberis,et al.  SARS-Cov-2 in peritoneal fluid: an important finding in the Covid-19 pandemic , 2020, The British journal of surgery.

[7]  Y. Li,et al.  Aerosol and environmental surface monitoring for SARS-CoV-2 RNA in a designated hospital for severe COVID-19 patients , 2020, Epidemiology and Infection.

[8]  T. Hibi,et al.  COVID-19: clinical issues from the Japan Surgical Society , 2020, Surgery Today.

[9]  K. To,et al.  Factors affecting stability and infectivity of SARS-CoV-2 , 2020, Journal of Hospital Infection.

[10]  Xianliang Ke,et al.  Direct Evidence of Active SARS-CoV-2 Replication in the Intestine , 2020, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[11]  R. Vunnam,et al.  Transmission of SARS-CoV-2: an update of current literature , 2020, European Journal of Clinical Microbiology & Infectious Diseases.

[12]  S. Muttini,et al.  SARS-CoV-2 RNA detection in the air and on surfaces in the COVID-19 ward of a hospital in Milan, Italy , 2020, Science of The Total Environment.

[13]  M. Lackemeyer,et al.  Persistence of Severe Acute Respiratory Syndrome Coronavirus 2 in Aerosol Suspensions , 2020, Emerging infectious diseases.

[14]  S. Calza,et al.  Factors Associated With Surgical Mortality and Complications Among Patients With and Without Coronavirus Disease 2019 (COVID-19) in Italy. , 2020, JAMA surgery.

[15]  K. To,et al.  Air and environmental sampling for SARS-CoV-2 around hospitalized patients with coronavirus disease 2019 (COVID-19) , 2020, Infection Control & Hospital Epidemiology.

[16]  A. Ouzzane,et al.  Cost-Effective Filtrating Suction to Evacuate Surgical Smoke in Laparoscopic and Robotic Surgery During the COVID-19 Pandemic , 2020, Surgical laparoscopy, endoscopy & percutaneous techniques.

[17]  Z. Tong,et al.  Detection of Novel Coronavirus by RT-PCR in Stool Specimen from Asymptomatic Child, China , 2020, Emerging infectious diseases.

[18]  S. Purkayastha,et al.  Electrocautery, Diathermy, and Surgical Energy Devices , 2020, Annals of surgery.

[19]  T. Yeo,et al.  Detection of air and surface contamination by SARS-CoV-2 in hospital rooms of infected patients , 2020, Nature Communications.

[20]  Daniel J. Lin,et al.  Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study , 2020, Lancet.

[21]  Jincun Zhao,et al.  Infectious SARS-CoV-2 in Feces of Patient with Severe COVID-19 , 2020, Emerging infectious diseases.

[22]  O. Lavie,et al.  Hazardous Postoperative Outcomes of Unexpected COVID-19 Infected Patients: A Call for Global Consideration of Sampling all Asymptomatic Patients Before Surgical Treatment , 2020, World Journal of Surgery.

[23]  Yusen Duan,et al.  Aerodynamic analysis of SARS-CoV-2 in two Wuhan hospitals , 2020, Nature.

[24]  M. Luo,et al.  Asymptomatic SARS‐CoV‐2 infected case with viral detection positive in stool but negative in nasopharyngeal samples lasts for 42 days , 2020, Journal of medical virology.

[25]  L. Feldman,et al.  SAGES and EAES recommendations for minimally invasive surgery during COVID-19 pandemic , 2020, Surgical Endoscopy.

[26]  N. Wilson,et al.  Airborne transmission of severe acute respiratory syndrome coronavirus‐2 to healthcare workers: a narrative review , 2020, Anaesthesia.

[27]  Hyunsook Hong,et al.  Diagnostic Performance of CT and Reverse Transcriptase-Polymerase Chain Reaction for Coronavirus Disease 2019: A Meta-Analysis , 2020, Radiology.

[28]  B. Liu,et al.  Aerosol and Surface Distribution of Severe Acute Respiratory Syndrome Coronavirus 2 in Hospital Wards, Wuhan, China, 2020 , 2020, Emerging infectious diseases.

[29]  B. Zhu,et al.  Toilets dominate environmental detection of SARS-CoV-2 virus in a hospital , 2020, medRxiv.

[30]  S. Lei,et al.  Clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of COVID-19 infection , 2020, EClinicalMedicine.

[31]  Centers for Disease Control and Prevention CDC COVID-19 Response Team.  Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) — United States, February 12–March 16, 2020 , 2020, MMWR. Morbidity and mortality weekly report.

[32]  M. Zheng,et al.  Minimally Invasive Surgery and the Novel Coronavirus Outbreak: Lessons Learned in China and Italy , 2020, Annals of surgery.

[33]  G. Onder,et al.  Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy. , 2020, JAMA.

[34]  H. Shan,et al.  Prolonged presence of SARS-CoV-2 viral RNA in faecal samples , 2020, The Lancet Gastroenterology & Hepatology.

[35]  L. Poon,et al.  Stability of SARS-CoV-2 in different environmental conditions , 2020, The Lancet Microbe.

[36]  Dylan H. Morris,et al.  Aerosol and Surface Stability of SARS-CoV-2 as Compared with SARS-CoV-1 , 2020, The New England journal of medicine.

[37]  Huiying Liang,et al.  Characteristics of pediatric SARS-CoV-2 infection and potential evidence for persistent fecal viral shedding , 2020, Nature Medicine.

[38]  R. Lu,et al.  Detection of SARS-CoV-2 in Different Types of Clinical Specimens. , 2020, JAMA.

[39]  Oon Tek Ng,et al.  Air, Surface Environmental, and Personal Protective Equipment Contamination by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) From a Symptomatic Patient. , 2020, JAMA.

[40]  Saibin Wang,et al.  Fecal specimen diagnosis 2019 novel coronavirus–infected pneumonia , 2020, Journal of medical virology.

[41]  J. Low,et al.  Epidemiologic Features and Clinical Course of Patients Infected With SARS-CoV-2 in Singapore. , 2020, JAMA.

[42]  Xiangshi Wang,et al.  A Case Series of children with 2019 novel coronavirus infection: clinical and epidemiological features , 2020, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[43]  Zunyou Wu,et al.  Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention. , 2020, JAMA.

[44]  H. Shan,et al.  Evidence for Gastrointestinal Infection of SARS-CoV-2 , 2020, Gastroenterology.

[45]  Yan Zhao,et al.  Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. , 2020, JAMA.

[46]  Zijian Feng,et al.  Isolation of 2019-nCoV from a Stool Specimen of a Laboratory-Confirmed Case of the Coronavirus Disease 2019 (COVID-19) , 2020, China CDC weekly.

[47]  Y. Hu,et al.  Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China , 2020, The Lancet.

[48]  Jar-Yuan Pai,et al.  Characterization of smoke generated during the use of surgical knife in laparotomy surgeries , 2020, Journal of the Air & Waste Management Association.

[49]  Wei Zhang,et al.  Molecular and serological investigation of 2019-nCoV infected patients: implication of multiple shedding routes , 2020, Emerging microbes & infections.

[50]  S. Smither,et al.  Experimental aerosol survival of SARS-CoV-2 in artificial saliva and tissue culture media at medium and high humidity , 2020, Emerging microbes & infections.

[51]  S. Noma,et al.  Laparoscopic surgery in patients with interstitial lung disease: A single‐center retrospective observational cohort study , 2019, Asian journal of endoscopic surgery.

[52]  A. Chughtai,et al.  Contamination by respiratory viruses on outer surface of medical masks used by hospital healthcare workers , 2019, BMC Infectious Diseases.

[53]  K. Davis,et al.  Symptomatic human immunodeficiency virus–infected patients have poorer outcomes following emergency general surgery: A study of the nationwide inpatient sample , 2019, The journal of trauma and acute care surgery.

[54]  D. Beyer,et al.  Is surgical plume developing during routine LEEPs contaminated with high-risk HPV? A pilot series of experiments , 2018, Archives of Gynecology and Obstetrics.

[55]  G. Strippoli,et al.  Robotic Versus Laparoscopic Minimally Invasive Surgery for Rectal Cancer: A Systematic Review and Meta-analysis of Randomized Controlled Trials , 2017, Annals of surgery.

[56]  Y. Seo,et al.  Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery , 2016, Occupational and Environmental Medicine.

[57]  B. Kim,et al.  Effects of intraoperative protective lung ventilation on postoperative pulmonary complications in patients with laparoscopic surgery: prospective, randomized and controlled trial , 2016, Surgical Endoscopy.

[58]  L. Marr,et al.  Simulation of vertical concentration gradient of influenza viruses in dust resuspended by walking. , 2015, Indoor air.

[59]  Rachael M. Jones,et al.  Aerosol Transmission of Infectious Disease , 2015, Journal of occupational and environmental medicine.

[60]  Jincun Zhao,et al.  T cell-mediated immune response to respiratory coronaviruses , 2014, Immunologic Research.

[61]  H. Sugita,et al.  Feasibility of laparoscopy-assisted gastrectomy for patients with chronic obstructive pulmonary disease , 2013, Surgical Endoscopy.

[62]  N. Nguyen,et al.  Outcomes of Laparoscopic and Open Appendectomy for Acute Appendicitis in Patients with Acquired Immunodeficiency Syndrome , 2011, The American surgeon.

[63]  L. Hurley,et al.  Surgical outcomes in human immunodeficiency virus-infected patients in the era of highly active antiretroviral therapy. , 2006, Archives of surgery.

[64]  C. Su,et al.  Acute Appendicitis in Patients with Acquired Immunodeficiency Syndrome , 2005, Journal of the Chinese Medical Association : JCMA.

[65]  C. Wong,et al.  Severe acute respiratory syndrome in surgical patients: a diagnostic dilemma , 2005, ANZ journal of surgery.

[66]  Y. Novitsky,et al.  The net immunologic advantage of laparoscopic surgery , 2004, Surgical Endoscopy And Other Interventional Techniques.

[67]  T. Saclarides.  Transanal endoscopic microsurgery. , 1997, Seminars in laparoscopic surgery.

[68]  M. Baril,et al.  Preliminary study of electrocautery smoke particles produced in vitro and during laparoscopic procedures , 1996, Surgical Endoscopy.

[69]  R. Roenigk,et al.  Risk of acquiring human papillomavirus from the plume produced by the carbon dioxide laser in the treatment of warts. , 1995, Journal of the American Academy of Dermatology.

[70]  W. Robinson,et al.  Human immunodeficiency virus‐1 (HIV‐1) in the vapors of surgical power instruments , 1991, Journal of medical virology.

[71]  D. Moher,et al.  Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. , 2010, International journal of surgery.

[72]  P. Hallmo,et al.  Laryngeal papillomatosis with human papillomavirus DNA contracted by a laser surgeon , 2005, European Archives of Oto-Rhino-Laryngology.