Minimally Invasive Oncologic Care in the Era of COVID

The SARS-CoV-2 pandemic has led to innumerable changes in healthcare around the world, many of which will be enduring. Since the start of the pandemic, surgical societies including AAGL, SGO, SAGES and EAES have provided guidance to surgeons and endoscopists with regards to the safety of performing procedures [1-3]. An AAGL statement acknowledged the limitations of the available literature stating, “There is no available evidence from the COVID-19 pandemic, or from prior global influenza epidemics, to suggest definitely that respiratory viruses are transmitted through an abdominal route from patients to health care providers in the operating room” [1].

The Society of Robotic Surgery published a review of the available literature that outlined several of the key points including: no current evidence of COVID-19 in the CO2 plume (though hepatitis B and HPV have been identified [4,5]), minimally invasive surgery (MIS) will shorten hospital stays thereby saving resources and MIS should be offered based on patient indications and appropriate surgical procedure [6]. Chadi et al outline several common surgical scenarios (appendectomy, cholecystectomy and perforated viscus and obstructing cancer) and the improvements in resource utilization that are of particular importance during a time of limited PPE, hospital and ICU beds, etc. [7]. In addition, it has been suggested that patients who have COVID at the time of surgery, may have improved outcomes as MIS is less traumatic than laparotomy [7]. Particularly relevant to the patient with a gynecologic malignancy are the psychologic and oncologic issues surrounding the potential delay in care with SGO suggesting that 3-8 weeks may be acceptable if absolutely necessary [2].

Synthesizing the recommendations from the various societies and other peer reviewed literature the following represents the current best practice [1-3, 6-9]. It needs to be understood that the evidence and data will be evolving and recommendations will be changing over time. All scenarios cannot be considered, but in general:

1. All patients should undergo pre-operative testing.
2. Keep intra-abdominal pressures as low as possible, consider pressures of 12 mmHg or lower.
3. Use lower flow rates of 5-10 L/min of C02.
4. Minimize incision size and avoid lateral movements that may enlarge the incision.
5. Remove C02 from the abdomen prior to removing specimens and trocars. C02 should be removed via a close suction device.
6. Avoid the use of gauze as it can lead to “splatter” when removed through the trocar.
7. Desufflation should occur through the least dependent trocar.
8. Avoid the use of vessel-sealing and ultrasonic devices and harmonic scalpels as they may increase aerosolization of viral particles. Use the lowest possible electrocautery power settings.
9. Ensure adequate PPE for all healthcare personnel. Minimize unnecessary traffic in the operating room.
10. Carefully manage the C02 leakage from trocars and the vaginal cuff.
11. Minimize operative time.

While there are also associated risks of transmission with laparotomy, there has been more focus on MIS due to the C02 insufflation. Data regarding COVD-19 transmission during surgery is very limited and the recommendations are primarily based on expert opinion. Data will continue to emerge and we recommend the reader continuously refer to Society updates.

References:

1. 1. American Association of Gynecologic Laparoscopists. Joint Statement on Minimally Invasive Gynecologic Surgery During the COVID-19 Pandemic 2020, March 27 (Available from : https://www.aagl.org/news.covid-19-joint-statement-on-minimally-invasive-gynecologic-surgery/.
   2. Surgical considerations for gynecologic oncologists during the COVID-19 pandemic. https://www.sgo.org/resources/surgical-considerations-for-gynecologic-oncologists-during-the-covid-19-pandemic/.
   3. Francis N, Dort J, Cho E, et al. SAGES and EAES recommendations for minimally invasive surgery during COVID-19 pandemic. Surg Endoscopy 2020;Jun;34:2327-31.
   4. Kwak HD, Kim SH, Seo YS, Song KJ. Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery. Occup Environ Med 2016;73:857-63.
   5. Garden JM, O’Banion MK, Sheinitz LS, et al. Papillomavirus in the vapor of carbon dioxide laser-treated verrucae. JAMA 1998;259:1199-202.
   6. Porter J, Blau E, Gharagozloo F, et al. Society of Robotic Surgery Review: Recommendations regarding the risk of COVID-19 transmission during minimally invasive surgery. [published online ahead of print, 2020 May 8]. BJU Int. 2020;10.1111/bju.15105.
   7. Chadi SA, Guidolin K, Caycedo-Marulanda A, et al. Current evidence for minimally invasive surgery during the COVID-19 pandemic and risk mitigation strategies: A narrative review. [published online ahead of print, 2020 May 20]. Ann Surg. 2020;10.1097/
   8. Vigneswaran Y, Prachand VN, Posner MC, et al. What is the appropriate use of laparoscopy over open procedures in the current COVID-19 climate? J Gastrointest Surg. 2020; 24:1686-1691.
   9. Zheng MH, Boni L, Fingerhut A. Minimally invasive surgery and the novel coronavirus outbreak: lessons learned in China and Italy. Ann Surg. 2020;272(1):e5-e6.