Page 50 - World Journal of Laparoscopic Surgery

Laparoscopic Surgery in COVID-19 Era

MAterIAls And Methods isolation only. Presence of SARS-CoV-2 virus was not detected in
This observational study was conducted at St Joseph’s Hospital, either endotracheal aspirate or surgical smoke.
In total, 14 (4.87%) patients had fever postoperatively, and 13
a tertiary care center for a period of 1 year from May 2020 had associated cough. All these patients underwent chest X-rays,
to May 2021. Total 301 patients reported in OPD for minimal and half of them had either pleural effusion or pneumonia. Two
invasive surgery, out of which 287 cases were enrolled and patients required a CT scan of the chest. Eleven patients had fall
underwent laparoscopic surgery, which included laparoscopic in saturation <90% post-operatively and required O support;
2
cholecystectomy, laparoscopic hernia repair (inguinal and ventral), however, only 4 of them had real breathing discomfort. These
laparoscopic appendectomy, ovarian cystectomy, salpingectomy, patients were managed conservatively and recovered well without a
total laparoscopic hysterectomy, diagnostic laparoscopy, and need for intubation and mechanical ventilation. In total, 17 patients
others. All emergency laparoscopic surgeries, cases converted had sore throat which resolved with steam and rest. Due to these
to open, and cases unfit for general anesthesia and laparoscopic symptoms, RT-PCR was conducted on 16 patients, and none of the
surgery were excluded from the study. All patients after screening reports were positive. The mean duration of stay was around 2.32
for fever, cough, cold, and other common symptoms of SARS-CoV-2 days, and most of the patients were discharged after 24 hours. In
infection were seen in OPD and worked up for surgery. Due to follow-up after 2 weeks, 12 patients had wound infections, and 2
precaution in the form of PPE kits, masks, and gloves were taken in developed fever and cough, out of which 1 was found positive for
OPD during patient examination. A thorough history of any recent SARS-CoV-2 infection and managed conservatively. None of the
contact with infected personnel was also sought. Apart from all healthcare workers, whether surgeons, OT staff, or ward nursing
relevant investigations and pre-anesthetic clearance, all patients staff contracted infection during the entire period (Table 1).
underwent RT-PCR for SARS-CoV-2 at least 24–48 hours prior to
surgery, and only those patients who reported negative were
admitted a day before surgery. Only 1 attendant was allowed with dIscussIon
the patient. Any patient whose RT-PCR report came positive was COVID-19 pandemic emerged as a global threat and created a state
advised home isolation for 2 weeks and was referred to a physician of uncertainty and confusion among the surgeons all over the
for management of SARS-CoV-2 infection. These cases were taken world. The patient’s overall safety and own safety was the prime
up after 4–6 weeks for surgery after getting clearance from a concern. The SARS-CoV-2 infection is transmitted by respiratory
physician, pulmonologist, and anesthetist with a negative RT-PCR droplets, which can be airborne and remain suspended in the air
report and normal X-ray of the chest. Total of 14 cases were declared for a significant period. Viral load is seen highest in respiratory
unfit due to cardiorespiratory contraindications. All surgeries were secretions. Aerosol-generating procedures like bronchoscopy,
performed in modular operation theater with proper air circulation, laryngoscopy, endoscopy, and endotracheal intubation carry a
adequate space, and negative pressure ventilation. The operating higher risk of transmission of infection. Many previous studies had
3,4
surgeon, assistant, scrub nurse, anesthetist, and floor nurse all shown the presence of Human Papilloma Virus (HPV), Hepatitis B
wore PPE, double gloves, face shield, and N95 masks. We used a virus (HBV), and Human immunodeficiency virus (HIV) in the surgical
low-cost smoke evacuation device in which smoke was evacuated smoke, which raised a theoretical concern of the presence of SARS-
from a single port through intravenous infusion set into a suction CoV-2 infection in the surgical smoke created during almost all
jar filled with 1% hypochlorite solution after passing through an laparoscopic surgeries. 14–17 Laparoscopic surgery is a closed system.
HME filter. All cases were done under general anesthesia. Samples Pneumoperitoneum is created through a trochar, and evacuation is
of endotracheal aspirate and evacuated surgical smoke (swab also done in a controlled manner through another trochar. We used
from HME filter) were sent for RT-PCR in all cases. All patients in a low-cost smoke filtration and evacuation during this pandemic.
postoperative period were kept in close observation. Any incidence However, almost all the recent studies on COVID-19 had clearly
of fever, cough, fall in oxygen saturation level, and other findings indicated that there is no such evidence of transmission through
were duly noticed. Various preoperative and postoperative surgical smoke. 18,19 Our study clearly showed that in patients who
parameters were analyzed. Patients were followed up for 1 month were asymptomatic and had negative RT-PCR reports prior to
in OPD as well as telephonically. surgery, the SARS-CoV-2 virus was not detected in endotracheal
Statistical analysis was performed using Statistical Package aspirate or surgical smoke.
for the Social Sciences (SPSS) for Windows (version 24.0), and data The most commonly performed elective minimally invasive
were organized using Microsoft Office 2010 software. Categorical procedure during this pandemic was laparoscopic cholecystectomy.
variables were described as frequency (percentage), and mean ± Study by Manzia et al. also stated that gall stone disease was most
5
standard deviation was used for continuous parameters. commonly postponed surgery during the pandemic. This clearly
observAtIon And results indicates that cholecystectomy is the most commonly performed
elective surgery. It was observed that with proper history taking and
A total of 301 patients were worked up from OPD and 287 screening in OPD, only 2.78% of cases were found positive for SARS-
underwent surgery over a period of 1 year. The mean age of the CoV-2 in preoperative work up. All of them were operated after 4
patients was 43.56 years. Out of 287, around 60% were female weeks, and none of them had any postoperative complications.
patients. Surgery most frequently performed was laparoscopic However, it was found somewhat challenging to convince patients
cholecystectomy (194 cases) followed by appendectomy and for RT-PCR test, especially when asymptomatic; however, with
9
hernia repairs. A total of 15 gynecological cases were done, and proper counseling, RT-PCR test was done for everyone. We cannot
10 diagnostic laparoscopies were done. Total 8 cases were found rely entirely on RT-PCR results, so history of symptoms and recent
positive for SARS-CoV-2 infection during work up. They underwent travel to an infected zone play a major role during preoperative
surgery after a gap of 4–6 weeks. None of the infected cases was evaluation. Very few patients had COVID-19-like symptoms in
found unfit for surgery, and all of them recovered well in home postoperative period, but none of the patients were found to be

146 World Journal of Laparoscopic Surgery, Volume 15 Issue 2 (May–August 2022)