Limitation of surgical services
- Surgical services need to be limited in this setting. The decision to maintain or cancel a procedure depends on many factors: level of urgency, morbidity/mortality risks of contracting COVID-19 for the patient, impact on hospital bed capacity, risk of community transmission and access to PPE.
- Urgent procedures cannot be cancelled: ruptured ectopic pregnancies, menometrorrhagia causing anemia, incomplete abortion, ovarian torsion, ovarian cysts with hemorrhage, rescue cerclage and tubal-ovarian abscess unresponsive to medical treatment
- Certain procedures cannot be postponed for long: cancers (delay 2 weeks in confirmed cases), suspected cancers, cervical cerclage.
- Ovarian cysts and postmenopausal bleed should be evaluated on an individual basis.
- Examples of procedures that can be delayed: urogenital prolapsus, fertility treatments, hysterectomy for benign masses, cervical conization for CIN 2-3, uterine fibroids without vital impact, polyp without unfavourable symptoms.
- Non-operative measures should be adopted when possible for patients with confirmed infection. Delay of surgery for 2 weeks or until test results are negative is recommended unless the condition is urgent. Confirmed or suspected cases can be transferred to highly equipped centers.
- Universal pre-operative testing is recommended by some. Others state that testing is not needed to determine the protective measures because all surgery should be treated as high risk in this setting. However, testing can influence the approach of treatment taken.
Laparoscopy, hysteroscopy or laparotomy?
- Laparoscopy is considered to be an aerosol generating procedure in particular due to the artificial pneumoperitoneum, the use of electrosurgical devices and the use of trocars. Risks may exist in hysteroscopy also. This risk is less pronounced in open surgery. There is no data on COVID-19 transmission via intra-abdominal dispersion of aerosols.
- Limited evidence has not shown transmission of SARS-CoV-2 via surgical smoke, but the possibility exists. The smoke is contained in the abdominal cavity as opposed to open surgery. Precautions must be taken to minimize the surgical smoke in all cases.
- Evidence has not suggested a higher risk of transmission via laparoscopy with adequate PPE.
- Laparoscopy and hysteroscopy are beneficial for the patient and the health system given reduced morbidity, faster recovery and return to activities, shorter hospital stays, etc.
- Recommendations are not unanimous. The majority recommend a laparoscopic or hysteroscopic approach when possible with enhanced PPE and specific precautions to minimize aerosol generation because its benefits are heightened in this setting despite the theoretical risks of transmission via aerosol generation.
- Gynecological procedures with potential for bowel involvement should be performed by laparotomy.
- The benefits of laparoscopy must be weighed against the theoretical risks of aerosol transmission. The final decision must consider many factors: safety of patients and personnel and hospital-associated circumstances such as testing accessibility, PPE supply and the prevalence of COVID-19.
General precautions (laparoscopy, laparotomy, vaginal surgery, hysteroscopy)
- Wear enhanced PPE and minimize personnel in the OR.
- Use a closed filtration unit to suction the surgical smoke. Set up an evacuation/filtration system for controlled release of surgical plume. An ultra-low particulate air filter is ideal.
- Reduce usage of energy modalities.
- Use lower abdominal CO2 pressures
- Minimize the number of port incisions, close the taps prior to insertion, install tightly fitted trocars and limit the exchange of instruments in the ports to prevent leakage. Remove the trocars only after desufflation of the abdomen.
- Avoid sudden release of pneumoperitoneum. Desufflate the abdomen with a suction device before removing the specimen bag from the abdomen.
- Use a containment bag for tissue extraction.
- Evacuate gas from the abdomen via a suction device and filtered ports. Remove the uterus only afterwards in laparoscopic hysterectomy.
- Reduce droplets of biological fluids as much as possible.
- RAS is comparable to laparoscopy
- A disadvantage is found in the decontamination process of the large robot platform.
- The bedside assistant should wear level III protection, whereas the console surgeon can wear level II protection.
Weber Lebrun et al. present recommendations to guide decision-making regarding surgical services during the pandemic. Alabi et al. alongside the Association of gynecological endoscopy surgeons of Nigeria (AGES) put forth recommendations on laparoscopy and hysteroscopy in a short communication. Brito et al. provide recommendations on elective surgeries and precautions in a letter based on the experience in Brazil. Brown explains the principles of decision-making regarding surgical techniques. Cohen et al. and Morris et al. present their stance on the use of laparoscopy versus laparotomy in this setting. Mallick et al. present a review of the existing information on gynecological laparoscopic surgery in an opinion paper. Kimmig et al. present a position statement on the use of robot-assisted surgery. Nohuz et al. issue recommendations on surgery delays and different types of gynecological surgery in a letter written in French.Radder et al. provide guidelines for elective surgery supported by the Dutch Society for Gynaecological Endoscopy (WGE). This information also comes from statements from Elevating Gynecologic Surgery (AAGL), The Royal College of Obstetricians & Gynaecologists (RCOG) alongside The British Society for Gynaecological Endoscopy (BSGE) and The European Society for Gynaecological Endoscopy (ESGE).
Alabi O.C., Okohue J.E., Adewole A.A., Ikechebulu J.I. (May 4, 2020). Association of gynecological endoscopy surgeons of Nigeria (AGES) advisory on laparoscopic and hysteroscopic procedures during the COVID-19 Pandemic. Nigerian Journal of Clinical Practice. https://doi.org/10.4103/njcp.njcp_163_20
Brito L.G.O., Ribeiro P.A., Silva-Filho A.L., FEBRASGO Brazilian Gynecological Surgery Group for COVID-19. (April 25, 2020). How Brazil is dealing with COVID-19 pandemic arrival regarding elective gynecological surgeries. The Journal of Minimally Invasive Gynecology. https://doi.org/10.1016/j.jmig.2020.04.028
Brown J. (April 3, 2020). Surgical Decision Making in the Era of COVID-19: A New Set of Rules. The Journal of Minimally Invasive Gynecology. https://doi.org/10.1016/j.jmig.2020.04.001
Cohen S.L., Liu G., Abrao M. et al (April 3, 2020). Perspectives on Surgery in the time of COVID-19: Safety First. The Journal of Minimally Invasive Gynecology. https://doi.org/10.1016/j.jmig.2020.04.003
Elevating Gynecologic Surgery. Joint Statement in Minimally Invasive Gynecologic Surgery During the COVID-19 Pandemic. (March 27, 2020). Retrieved from: https://www.aagl.org/news/covid-19-joint-statement-on-minimally-invasive-gynecologic-surgery/2/
The European Society for Gynaecological Endoscopy (2020). ESGE Recommendations on Gynaecological Laparoscopic Surgery during Covid-19 Outbreak. Retrieved from: https://esge.org/wp-content/uploads/2020/03/Covid19StatementESGE.pdf
Kimmig, R., Verheijen, R.H.M., Rudnicki M. et al. (April 3, 2020). Robot assisted surgery during the COVID-19 pandemic, especially for gynecological cancer: a statement of the Society of European Robotic Gynaecological Surgery (SERGS). Journal of Gynecologic Oncology. https://doi.org/10.3802/jgo.2020.31.e59
Mallick R., Odejinmi F., Clark T.J. (April 1, 2020). Covid-19 pandemic and gynaecological surgery: knowns and unknowns. Facts, Views and Vision in Obstetrics & Gynecology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7117791/
Morris S.N., Fader A.N., Milad M.P. et al. (April 3, 2020). Understanding the “Scope” of the Problem: Why Laparoscopy is Considered Safe During the COVID-19 Pandemic. The Journal of Minimally Invasive Gynecology. https://doi.org/10.1016/j.jmig.2020.04.002
Nohuz E., Dubernard G., Lamblin G. et al. (April 18, 2020). Gynecological surgery during the COVID-19 Pandemic: take home messages. Gynécologie, Obstétrique, Fertilité & Sénologie. https://doi.org/10.1016/j.gofs.2020.04.007
Radder C., de Leeuw R., Coppus S. (April 25, 2020). Point of view of the Dutch Society for Gynaecological Endoscopy (WGE) on surgery during the COVID-19 crisis. The Journal of Minimally Invasive Gynecology. https://doi.org/10.1016/j.jmig.2020.04.031
The Royal College of Obstetricians, The British Society for Gynaecological Endoscopy. Joint RCOG/BSGE Statement on gynaecological laparoscopic procedures and COVID-19. (March 26, 2020). Retrieved from: https://www.bsge.org.uk/news/joint-rcog-bsge-statement-on-gynaecological-laparoscopic-procedures-and-covid-19/
Weber Lebrun E.E.., Moawad N.S., Rosenberg E.I. et al. (April 3, 2020). COVID-19 Pandemic: Staged Management of Surgical Services for Gynecology and Obstetrics. American Journal of Obstetrics and Gynecology. https://doi.org/10.1016/j.ajog.2020.03.038