19 Rules to have a safe & effective operation during COVID-19

Minimum number of staff in theatre([FOOTNOTE=https://www.rcseng.ac.uk/coronavirus/joint-guidance-for-surgeons-v2/],[ANCHOR=],[LINK=])
The number of surgical participants should be reduced. The operation should be performed by a well-coordinated surgical team to minimize the operation time.([FOOTNOTE=Recommendations for Metabolic and Bariatric Surgery During the COVID-19 Pandemic from IFSO],[ANCHOR=],[LINK=])

Appropriate PPE for all staff in theatre depending on role and risk.¹ All staff in the facility including surgeons, nurses and anesthesiologists shall carry out high level of precautions with protective equipment: Disposable surgical cap, medical protective mask (N95), disposable medical protective uniform, disposable latex gloves, full-face respiratory protective devices or powered air-purifying respirator.²

The best practice for mitigating possible infectious transmission during open, laparoscopic and endoscopic procedures is to use a multi-faceted approach, which includes proper room filtration and ventilation, appropriate PPE, and smoke evacuation devices with a suction and filtration system, as available.([FOOTNOTE=https://www.sages.org/resources-smoke-gas-evacuation-during-open-laparoscopic-endoscopic-procedures/],[ANCHOR=],[LINK=])

Operating rooms and equipment should be sterilized separately and thoroughly and should pass the evaluation by the infection management authorities before next use.²

Surgical equipment used during procedures with COVID-19 positive or Persons Under Investigation (PUI) /suspected COVID patients should be cleaned separately from other surgical equipment.([FOOTNOTE=https://www.escp.eu.com/guidelines/covid-19-recommendations],[ANCHOR=],[LINK=])

Higher risk patients are intubated and extubated in theatre – staff immediately present should be at a minimum.¹

The body temperature of all patients upon arrival at endoscopy units, clinics or inpatient wards should be checked and documented. All admissions to hospital should be screened for COVID-19 by chest computed tomography (CT) scan and be confirmed by real-time reverse-transcriptase polymerase chain reaction (RT-PCR) assay for nasal and pharyngeal swab specimens. COVID-19 should be diagnosed on the basis of the WHO interim guidance. Isolation precautions should be taken for those awaiting test results.([FOOTNOTE= https://link.springer.com/article/10.1007/s11695-020-04578-1],[ANCHOR=],[LINK=])

All patients should be asked about recent history of fever or respiratory symptoms, family members or close contacts with similar symptoms, any contact with a confirmed case of COVID-19 and recent travel to high-risk areas.⁵

Incisions for ports should be as small as possible to allow for the passage of ports but not allow for leakage around ports.([FOOTNOTE=https://www.sages.org/recommendations-surgical-response-covid-19/],[ANCHOR=],[LINK=])

CO₂ insufflation pressure should be kept to a minimum and an ultra-filtration (smoke evacuation system or filtration) should be used, if available.⁶

All pneumoperitoneum should be safely evacuated via a filtration system before closure, trocar removal, specimen extraction or conversion to open.⁶

All pneumoperitoneum should be safely evacuated from the port attached to the filtration device before closure, trocar removal, specimen extraction or conversion to open.⁴

Once placed, ports should not be vented if possible. If movement of the insufflating port is required, the port should be closed prior to disconnecting the tubing and the new port should be closed until the insufflator tubing is connected. The insufflator should be “on” before the new port valve is opened to prevent gas from back-flowing into the insufflator.⁴

During desufflation, all escaping CO₂ gas and smoke should be captured with an ultra-filtration system and desufflation mode should be used on your insufflator if available.⁴

If the insufflator being used does not have a desufflation feature, be sure to close the valve on the working port that is being used for insufflation before the flow of CO₂ on the insufflator is turned off (even if there is an in-line filter in the tubing). Without taking this precaution contaminated intra-abdominal CO₂ can be pushed into the insufflator when the intraabdominal pressure is higher than the pressure within the insufflator.⁴

The patient should be flat and the least dependent port should be utilized for desufflation.⁶ Specimens should be removed once all the CO₂ gas and smoke is evacuated.⁴

Surgical drains should be utilized only if absolutely necessary.⁴

Suture closure devices that allow for leakage of insufflation should be avoided. The fascia should be closed after desufflation.⁴

Hand-assisted surgery can lead to significant leakage of insufflated CO₂ and smoke from ports and should be avoided. If used to remove larger specimens and protect the wound, it can be placed after desufflation. The specimen can then be removed and the closure performed.⁴