Laparoscopic Surgery in COVID-19 Era in a Tertiary Hospital in Nepal

Introduction: There is great concern and risk of transmission of COVID-19 infection from the aerosolized smoke during laparoscopic surgery although there is a lack of enough literature to prove this. To minimize these risks and get the benefit of laparoscopic surgery, we used a low-cost filtration system connected to an underwater seal bag filled with a 5% sodium hypochlorite solution. Materials and Methods: This is a retrospective study of prospectively maintained data of cases of laparoscopic surgeries using a low-cost filtration device system connected with an underwater seal bag filled with 5% sodium hypochlorite solution. Use of personal protective equipment, minimal staff in operative theatre, preoperatively testing of patients before admission for surgery was done. During surgery, minimal use of electrocautery in low power setting maintaining low pneumoperitoneum and cautious desufflation of smoke during and end of the procedure from one of the trocars fitted to heat and moisture exchanger Filter, connected through a tube to 5 % sodium hypochlorite solution in underwater seal bag, was performed. Results: During the lockdown from May 2020 to October 2020, 41 elective laparoscopic surgeries were done. All patients were tested negative before the procedure. No staff in operation theatre developed symptoms of COVID-19 or tested positive for COVID-19 infection for up to 2 weeks period. Conclusions: In this Pandemic situation, we have to co-habit with this SARS-Cov-2 virus. Minimally invasive surgeries can be continued with safety measures with modifications like the use of low-cost filtration devices for smoke filtration and evacuation.

After the first case of COVID-19 was reported in the Hubei Province of China on 31 st December 2019, it was declared Pandemic by WHO on 11 th March 2020. 1 The first case of covid-19 was detected in Nepal on 23 rd January 2020 in a 32-year old Nepali man returning from Wuhan. 2 Nepal imposed a strict first full lockdown on March 24, 2020, which was extended to 14 th June 2020 to contain the COVID-19 outbreak. 3 Surgery in the COVID era has been limited to emergency and semi-emergency oncologic surgeries. As per guidelines, elective surgeries should be postponed. Surgery for COVID positive patient can be postponed until the patient is tested negative.
We must cohabit with the Nobel Coronavirus until vaccines are available, so surgery should be done with safety measures. The most important thing is the patient testing before the surgery. Most centers recommend nasopharyngeal swab polymerase chain reaction (PCR) at admission, monitoring of body temperature during hospital admission, to ensure that patient is asymptomatic a week before surgery and is not in contact with a COVID-19 case in the last 2 weeks. Protection of staff in operation theatre (OT) is ensured by the use of PPE by all staff, minimum use of staff and people not directly involved in the operation, and curtailing training activities. 4 The main issues in laparoscopy in the COVID-19 era are the hazards within the surgical smoke and aerosol. The creation of pneumoperitoneum with the use of electrocautery for more than 10 minutes makes laparoscopy an aerosol-generating procedure. 8,9 There is a risk of aerosol exposure to operation theatre staff during instrument introduction, change, removal, specimen extraction, and desufflation. The increased pressure in pneumoperitoneum and sudden release of surgical smoke in pressurized CO 2 during desufflation poses more risks than open surgery. The use of energy devices causes aerosolisation of virus-infected tissues to as small as 0.07-0.42 microns by electrocautery, 0.1-0.8 microns by laser ablation, and 0.35 to 6.5 microns by an ultrasonic scalpel. 7,10 In general low temperature from commonly used energy devices in laparoscopy surgery cannot deactivate the virus cellular components. There has been evidence of activated virus of Human Immuno Virus (HIV), Hepatitis B in surgical smoke while operating on them and there is evidence of transmission to surgical staff from surgical smoke during an aerosol-generating procedure like surgery. The same is expected in surgical smoke of the Nobel coronavirus. One recent paper suggested that SARS-COV-2 has been found to be viable in aerosol for 3 hours and on surfaces for up to 72 hrs 7,11,12 Despite the guidance of surgical care by the Royal College of Surgeons of Edinburgh to avoid laparoscopy, using a filtration and evacuation system for pneumoperitoneum gases, smoke contamination can be avoided. Steps like instrument cleaning during surgery, releasing pneumoperitoneum before removing trocars as advised by a paper by Zheng et al in their Chinese and Italian experience can be followed. Different types of filtration devices like high-efficiency particulate air ( HEPA) filters, Ultralow particulate air (ULPA) filters can be used which can filter bacterial and viral particles effectively like 99.99% filtration capacity of HBV and HCV of diameter 42 and 30-60 nm respectively. HEPA filters can filter larger than 0.3 microns and ULPA can retain 0.1 microns at an efficiency of 99.9%. As the diameter of the SARS-CoV-2 virus is 70 to 90 nm, this filtration device is expected to filter this efficiently. 5,7,9,[13][14][15][16][17][18][19] Society of European Gynaecological Surgery advised for maintaining abdominal pressure less than 10 mmHg for Robotassisted, 10-15 mmHg for conventional Laparoscopy with filter for aerosol and smoke evacuation, minimal cautery use with low electrosurgery unit's settings, perioperative cleaning of instruments, minimal use of staffs for minimizing transmission of SARS-CoV-2. 7,9,15,20,21 Underwater seal evacuation of surgical smoke immersed under heated water has been advised as a cheap option for desufflation. 22 Virucidal effects of disinfectants like households bleach 1:49 and 1:99 titre have been demonstrated with non-detection of the virus titre at 5 mins, 15 mins, and 30 mins. 23,24 Instead of Heated water, an underwater seal container containing 4% sodium hypochlorite solution has also been recommended for the evacuation of smoke during laparoscopic surgery. 25,26 So this study was aimed to observe the effects of the use of filtration System (Heat and Moisture exchanger (HME) filter along with desufflation in underwater seal bag containing 5% sodium hypochlorite solution) in laparoscopic surgery on surgery staffs to reduce the cross-contamination and transmission of covid-19.

MATERIALS AND METHODS
This study was conducted in the Department of General Surgery in Bir Hospital from March 2020 to October 2020. This is a cross-sectional retrospective observational cohort study done of prospectively maintained data of all patients undergoing laparoscopic surgery. All Laparoscopic surgeries conducted either elective or emergency during this period were included. This study was performed to study the impact of laparoscopic surgery with safety measures on the transmission of COVID infection to patients and staff. Statistical Package for Social Sciences (SPSS, Inc., Chicago, Illinois) version 16.0 was used to confirm the statistical significance of the data obtained. Continuous data are presented as mean ± Standard Deviation (SD). Categorical data are presented as proportions.
Each intervention was performed by high-experienced surgeons with only essential personnel in the operating room, with the suspension of unnecessary training and mentoring activities. Personal Protective Equipment (PPE) was used by staff and patients according to hospital regulations. For COVID negative cases, only N95 masks and face shields were worn by the scrubbed teams. For all status unknown cases, all staff used PPEs. Minimum OT staff were used. Patients were tested with a nasopharyngeal swab PCR for COVID-19 at admission and all the department staff were tested weekly as per the hospital policy. Operating Theatre was maintained at negative pressure.
During the procedure, A HME filter was attached to the CO 2 insufflator, which was connected to a Hasson port ( fig.1). After ports were placed, valves of all ports were closed; one of the ports was attached to a tube connected to an HME filter which was again fitted to an underwater seal bag filled with 5% sodium hypochlorite solution. The suction cannula was connected to a disposable suction bag filled with 5% sodium hypochlorite solution. Minimal use of electrocautery was done. During the procedure and after the procedure, CO 2 was released from the port connected to a filter ( fig. 2).
After the procedure was finished, ports were closed as usual and the system of connecter with filter and the disposable suction bag was disposed.

RESULTS
There were a total of 41 patients. The mean age of patients is 42 years. The female population contributed to 63.4% whereas the male population contributed to 36.6 %. The major bulk of surgery involved Cholelithiasis (63%) followed by Ventral Hernia (12%), Inguinal Hernia (19.5%), and Gall Bladder polyp (4.9%). (Table  1)

DISCUSSION
The use of energy devices causes aerosolisation of virus-infected tissues to as small as 0.07-0.42 microns by electrocautery, 0.1-0.8 microns by laser ablation, and 0.35 to 6.5 microns by an ultrasonic scalpel. 7,10 Sudden release of surgical smoke in pressurized CO 2 during desufflation and instrument change poses the risk of exposure of aerosol to operation theatre staff. 15 The surgical smoke during laparoscopy can harbor certain viruses like Hepatitis B Virus (HBV) in HBV positive patient. 11 There has been an occurrence of transmission of Human papillomavirus (HPV) virus from smoke from electrocautery in 4 health personnel with the development of HPV related cancers. 27 In cases of surgery of HBV positive case, smoke have found to contain HBV virus in laparoscopic surgery in a study done by Kwak et al. Another study by Dhaivat et al demonstrated 24 safe laparoscopic surgeries with a closed smoke evacuation/filtration system using an ultra low-particulate air (ULPA) filtration capability. Surgery was done for either emergency or semi-urgent cases in 17 males and 7 females. Low intra-abdominal pressure was maintained during all laparoscopic surgeries. The mean duration of surgery was 58 minutes. Compliance of operation theatre staff was high due to this deemed safe smoke evacuation system. 38 Zago et al described two types of configurations of connections using the same type of HME filter while performing laparoscopic surgery and during desufflation. They recommended the shortest length of connection from the trocar to the filter. In their study, 49 laparoscopic surgeries were done, 8 patients had COVID infection preoperatively, 9 had it postoperatively. No operating room personnel had illness consistent with covid or became covid positive. 9

CONCLUSIONS
The available data shows that laparoscopic surgeries can be performed with some system modifications. Personal protection with PPE, minimal use of staff, and preoperatively testing of patients for SARS-Cov-2 should generally be done. Use of lowcost filtration systems with trocars connected to HME Filters which is again connected to underwater seal bag filled with hypochlorite solution can be recommended with special attention to a minimal use of cautery in low power settings and lowering of pneumoperitoneum.