Convert to open: the new paradigm for surgery during COVID-19?
Salomone Di Saverio, Francesco Pata, Mansoor Khan, Giuseppe Ietto, Elia Zani, Giulio Carcano
Abstract
Editor As general surgeons we have a vested interest in the evidence published on the safety and utility of laparoscopy during the COVID-19 pandemic1,2,3. There appears to be the potential of virus spread being higher with laparoscopic surgery4. Initial advice and guidance appeared to advocate against the utilization of laparoscopy, because of not only aerosolization due to pneumoperitoneum, but also vapour formed by heat-generating cautery devices5. All emergency general surgery patients should be tested for COVID-19, without delay. Awaiting the results of testing should not delay surgical treatment whenever this is needed urgently. The latest guidance from the Society of American Gastrointestinal and Endoscopic Surgeons suggests that laparoscopy has the potential to produce aerosolized blood-borne viruses; there is currently no evidence to indicate that this effect is seen with COVID-196. This advice is different from the stance taken by the Intercollegiate General Surgery Guidance in UK7. In this setting, of mainly urgent surgeries being taken to the operating theatre, we have elected to err on the side of caution. Colorectal surgery represents a significant proportion of emergency surgery, and perioperative practice recommendations on how to safely scrub and the use of protective measures/equipment have been described elsewhere8. Patients with imaging-proven (CT or ultrasonography) inflamed appendix should be distinguished from those with no evidence of perforation appendicitis (NPA) who would be better managed with initial non-operative management (NOM) and antibiotics, and those with perforated appendicitis, who mandate open operative intervention by described techniques. In patients with peritonitis or colonic pathology requiring operative intervention, exploratory laparotomy is the access of choice. We all know that an exploratory laparotomy can be performed without any use of cautery and, therefore, avoiding production of smoke. These skills are no doubt vital given the current climate of uncertainty and the theoretical transmission potential.