Safe Gynecological Laparoscopic Surgery during COVID Times

Abstract

Background: SARS-CoV-2 virus is largely transmitted via respiratory droplets and the highest transmission risks arise when undertaking aerosol generating procedures like laparoscopy. Most national societies had advised the urgent suspension of elective surgery with the focus shifting to emergency and cancer surgery only during this pandemic. However very little is known regarding the risks to the health care professionals undertaking emergency laparoscopic procedures.

Aims and objective: To demonstrate safety at laparoscopy by modifying the technique for safe management of patients during the COVID-19 pandemic.

Design and setting: This is an observational cohort study. This study was done at a tertiary care reference hospital for minimal access gynaecological surgery. Safety of 42 semi-urgent and emergency laparoscopic surgeries in patients was evaluated for a period of 5 months after taking informed written consent of patients to participate in the study.

Materials and methods: Use of double closed circuit laparoscopic suction evacuation and filtration systems with closed circuit anaesthesia with specialized Heat and Moisture Exchangers (HME) bacterial & viral (BV) filters to make laparoscopic surgery safe.

Results: 57.14% of the patients were 41 years or more. 47.6% presented either with menorrhagia, irregular vaginal bleeding or post-menopausal vaginal bleeding and 26.19 % patients were keen to conceive. In 50% patients, surgery was done in 60 minutes or less. Post-operatively, none of the patients had any complications and all were followed up for 14 days for COVID-19 infection. No staff, doctors or anaesthetist were detected COVID-19 positive during the follow up period. The limitation of the study was, that it was an observational study done in COVID-19 negative patients only.

Conclusions: Safety at laparoscopy can be maintained when it is performed by an experienced surgeon who has full knowledge of safe laparoscopic techniques and performs it in the shortest time possible and with all due precautions.

Keywords: COVID-19; Laparoscopy; Minimally invasive surgery; SARS-CoV-2; Viral diffusion.

Figure 1

Heat and moisture exchangers + bacterial and viral filter assembly in anesthesia closed circuit: A (red arrow) gas flow toward patient through the filter, B (blue arrow) gas returning from patient, filtered, and protecting soda-bi-carb canister

Figure 2

Specialized intubation hood with use of video laryngoscope

Figure 3

CO₂ insufflator with heat and moisture exchangers + bacterial and viral filter: A (green arrow) flow of CO₂ gas through the filter toward patient

Figure 4

Closed circuit system for laparoscopy: A (green arrows) flow of filtered CO₂ gas from insufflator toward primary trocar, B (red arrows) flow of returning gas during smoke evacuation/desufflation toward suction bottle with inner tube submerged below sodium hypochlorite solution, C (pink arrow) flow of gas into smoke filter system for accidental leaks, D (turquoise arrows) flow of gas from suction bottle toward Endomat protected by Heat and moisture exchangers + bacterial and viral filter

Figure 5

Double suction assembly for laparoscopy: A (red arrows) flow of returning gas during smoke evacuation/desufflation toward suction bottle with inner tube submerged below sodium hypochlorite solution, B (turquoise arrows) flow of gas from suction bottle 1 towards Endomat 1 protected by heat and moisture exchangers + bacterial and viral filter, C (pink arrows) flow of body fluids – blood and peritoneal or irrigation fluid from laparoscopic suction cannula toward suction bottle with inner tube submerged below sodium hypochlorite solution, D (green arrows) flow of gas from suction bottle 2 toward Endomat 2 protected by heat and moisture exchangers + bacterial and viral filter

Figure 6

Two heat and moisture exchangers + bacterial and viral filters protecting two Endomats: A (red arrow) flow of gas from suction bottle 1 toward Endomat 1 protected by heat and moisture exchangers + bacterial and viral filter, B (blue arrow) flow of gas from suction bottle 2 toward Endomat 2 protected by heat and moisture exchangers + bacterial and viral filter

Figure 7

Master schematic representation of the entire assembly: A closed circuit for anesthesia gas inflow from machine to endotracheal tube and a return of gases with heat and moisture exchangers + bacterial and viral filters protecting soda-bi-carb canister. Another closed circuit from CO₂ Insufflator with Heat and Moisture Exchangers + bacterial and viral filter for inflow tubing to primary trocar. Right lower port through a three-way cannula is connected to smoke filter and tubing which goes to Endomat bottle 1. The laparoscopic suction tubing goes to Endomat bottle 2. Both the Endomat bottles have a long tube which is submerged below sodium hypochlorite solution in the bottle. The other tubings from the bottles go through heat and moisture exchangers + bacterial and viral filters to Endomat machines set at a low pressure of 50–100 mmHg