Page 43 - World Journal of Laparoscopic Surgery

Innovative Technique to Control the COVID‑19 Transmission by Surgical Fume
There are several reports where the virus, e.g., hepatitis B virus societies and experts and few already available devices to reduce
(HBV), human immunodeficiency virus (HIV), bovine papillomavirus, fume leak. Still, there is a suggestion or solution to contain the
and human papillomavirus (HPV) harvest from surgical plume fume/CO which is already out from the abdominal cavity. Here,
2
generated by energy sources. Most of the published reports on the we conceptualized a technique to contain the leaked CO /aerosol
2
risk of transmission seen in vitro analyzes. There are reports of HPV and its safe discharge. This concept further needs addition and
3
transmission during the treatment of laryngeal papillomatosis. improvement could provide all advantages of laparoscopic surgery
Although there was no biological activity or transmission potential in a safe and fearless environment.
4
seen in obtained viral DNA. Although there are reports of viable

HIV that have been harvested in cell culture; however, the potential clinicAl significAnce
5,6
risk of contamination by fume could not able to prove, and there COVID-19 pandemic came with a theoretical risk of surgical fume
are not enough data available which able advice to differing the causing disease transmission. However, no reports mentioned that
laparoscopic surgery or its replacement by open surgery. 7 surgical fume could transmit the infection, yet we could not deny
Although there are reports which suggested the presence its existence till we find any further evidence basis. In this article,
of virus DNA in the laparoscopic plume; however, no study was we have suggested an innovative technique to contain the surgical
able to prove their potential risk for transmission of viral. Several fume in an intermediate balloon and its proper discharge. We hope
international and national surgical societies have suggested that our concept and technique would able to control surgical fume
strategies and recommendations minimize the risk of transmission. and provide a fearless and safe environment for the operative team.
According to the Royal College of Surgeons, laparoscopy
should only be considered in select individual cases. The Society of declArAtion of PAtient consent

American Gastrointestinal and Endoscopic Surgeon (SAGES) states
that in the recent pandemic, the use of filters for the released CO We have obtained consent from patients or close kin for the images
2
during laparoscopy and robotic surgery should consider avoiding and other clinical information to be reported in the journal. They
the COVID-19 transmission. There are many suggestions by experts understand that the names and initials will not be published and
and adopted strategies from surgical societies to decrease the risk due efforts will be made to conceal their identity, but anonymity
of viral transmission. Most important is to avoid the traditional cannot be guaranteed.
practice of opening port outlet stopcock at the time of fogging of a
camera lens and uncontrolled deflation of the abdomen at the end Acknowledgment
of laparoscopic procedures. This entire maneuver should control We wish to thank Prof VK Kapoor, Professor and Unit Head of
and under the vision to avoid diffusion of surgical fume in the the Department of Surgical Gastroenterology, Sanjay Gandhi
operation theater. Better to avoid the practice to reuse laparoscopic Postgraduate Institute of Medical Science, Lucknow, India, for
ports with a tear or damaged one-way valves during procedures. guiding us and for his moral support and motivation for us.
There are many different insufflation systems and independent
smoke evacuation system which could supplement with
conventional insufflators in the present situation of COVID-19 reference
pandemic. ConMed Air Seal® and PneumoClear are available 1. Tushar P, Ashish P, Jayesh G, et al. The technique and justification
integrated insufflators, PneumoClear has the added feature of for minimally invasive surgery in COVID-19 pandemic: laparoscopic
8
controlled deflation at the end of the procedure. There is much anterior resection for near obstructed rectal carcinoma. J
advice from experts to decrease the chance of virus transmission. Laparoendosc Adv Surg Tech A 2020;30(5):485–487. DOI: 10.1055/s-
2003-44546.
Operating on low intra-abdominal CO volume and keeping 2. Mintz Y, Arezzo A, Boni L, et al. The risk of COVID-19 transmission by
2
insufflation pressure, lower than the standard 12–15 mm Hg 9,10 looks laparoscopic smoke may be lower than for laparotomy: a narrative
more logical and feasible. This way we could able avoids gush of review. Surg Endosc 2020;34(8):3298–3305. DOI: 10.1007/s00464-020-
CO /fume during port manipulation/instrument exchange. Some 07652-y.
2
experts also suggested keeping low settings of energy devices. 3. Calero L, Brusis T. [Laryngeal papillomatosis—first recognition in
Although there are many suggestions given by surgical societies Germany as an occupational disease in an operating room nurse].
and experts, e.g., keeping energy sources on lower settings, keeping Laryngorhinootologie 2003;82(11):790–793. DOI: 10.1055/s-2003-
44546.
the low intra-abdominal CO volume and low pneumoperitoneum 4. Garden JM, O’Banion MK, Bakus AD, et al. Viral disease transmitted by
2
pressure, and under vision evacuation of CO /surgical fume. laser-generated plume (aerosol). Arch Dermatol 2002;138(10):1303–
2
However, there are no strategies to contain the surgical fume when 1307. DOI: 10.1001/archderm.138.10.1303.
it is already out through the port. 5. Johnson GK, Robinson WS. Human immunodeficiency virus-1
Here, we have described the technique where we can contain (HIV-1) in the vapours of surgical power instruments. J Med Virol
the fume in the transparent/pliable bag and could safely discharge 1991;33(1):47–50. DOI: 10.1002/jmv.1890330110.
in the sanitizer-filled (underwater seal) system. 6. Hensman C, Baty D, Willis RG, et al. Chemical composition of smoke
produced by high-frequency electrosurgery in a closed gaseous
conclusion environment. An in vitro study. Surg Endosc 1998;12(8):1017–1019.
DOI: 10.1007/s004649900771.
The recent pandemic of the COVID-19 virus which highly contagious 7. Veziant J, Bourdel N, Slim K. Risks of viral contamination in healthcare
came with many challenges in the surgical field. Most important is professionals during laparoscopy in the COVID-19 pandemic. J Visc
the risk of transmission through aerosol/surgical fume produced Surg 2020;157(3S1):S59–S62. DOI: 10.1016/j.jviscsurg.2020.04.010.
during laparoscopic surgery. Here, we have not any evidence basis 8. Annino F, Topazio L, Autieri D, et al. Robotic partial nephrectomy
pressure pneumoperitoneum
for the above statement; however, the existence of transmission performed with airseal vs a standard CO 2
insufflator: a prospective comparative study. Surg Endosc
cannot deny. There are so many suggestions and tactics by surgical 2017;31(4):1583–1590. DOI: 10.1007/s00464-016-5144-y.

142 World Journal of Laparoscopic Surgery, Volume 13 Issue 3 (September–December 2020)