Page 50 - World Journal of Laparoscopic Surgery
P. 50

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)
   45   46   47   48   49   50   51   52   53   54   55