With the increasing number of confirmed Coronavirus disease 2019 or COVID-19 cases, doctors and hospitals need to understand the surgical operations recommendations during this pandemic to implement prevention and control of infection can be properly.

Surgical Recommendations During the COVID-19 Pandemic
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At the end of 2019, the world was shocked by pneumonia caused by the Coronavirus or SARS-CoV-2 in Wuhan, China. The spread of this virus is very fast to become a pandemic in a short time. Health care workers who are at the forefront in treating COVID-19 patients have a high risk of exposure to the virus. Lack of personal protective equipment (PPE) and knowledge about infection prevention and control (IPC) COVID-19 can increase the risk of infection transmission to health workers.

Although not at the forefront, surgeons, anesthetists, and other operating room health professionals have a high risk of contracting COVID-19, especially during surgery. In this review, recommendations for surgeons and other health workers involved in perioperative care will be discussed to improve patients and medical teams' safety and safety during the COVID-19 pandemic.

The Risk Levels of all Surgical in COVID-19 patients

First of all, it is important to know that patients who undergo surgery can be classified into three risk categories for COVID-19:

A. Patients confirmed or suspected of COVID-19.

In this category, COVID-19 is confirmed by the results of a real-time reverse transcriptase (RT-PCR) or rapid test (IgM and IgG) test for positive COVID-19 while the patient suspected cases of COVID-19 is divided into two categories.

1) The first category is patients who have a history of contact and meet two of the clinical manifestations (fever and respiratory symptoms) accompanied by a CT scan of the chest that matches COVID-19. In the early stages of infection, the total number of leukocytes can be normal or decreased, decreasing the number of lymphocytes.

2) The second category is patients without a clear epidemiologic history and shows three clinical manifestations (fever, respiratory symptoms, and chest CT scan images) compatible with COVID-19. The blood tests results are the same as in the first category (total leukocytes can be in the normal range or decrease, and the number of lymphocytes decreases).

B. Patients at Higher Risk from COVID-19

Patients in this category have traveled to areas with a high risk of COVID-19 or have made contact with confirmed cases or people suspected of COVID-19 (who have a fever or symptoms of acute respiratory disease) 14 days.

C. Patients at Lower Risk from COVID-19

Patients in this category are patients who have no history of contact with confirmed patients, or people with suspected COVID-19 without fever or respiratory symptoms, and they do not show typical imaging of COVID-19 on thoracic CT scan in the last 14 days.

All surgical patients' risk levels must be evaluated before or immediately after admission to the hospital. Also, these risk levels need to be evaluated every day. Confirmed patients, high-risk patients, and patients suspected of COVID-19 should be placed in an isolated room, and IPC protocols in the form of disinfection and isolation must be carried out. Keep in mind that patients confirmed and at high risk from COVID-19 may need intensive care, ventilation, or even death.

Recommendations for Emergency Surgical Operations

Surgeons, anesthetists, and operating room nurses need to practice to wear personal protective equipment (PPE) properly. The surgeon must schedule an operation based on the severity of the threat to the patient's life and health.

During a pandemic, the priority surgical operations are emergencies. All patients assessed as needing emergency surgery must undergo a blood test related to COVID-19 and thoracic CT scans before admission. Also, pharyngeal swab sampling must be completed before surgery. The patient must be placed in a transition area while waiting for the results of the examination. All emergency operating procedures must be carried out quickly and efficiently.

After hospital admission, the application of surgical operation protocols is based on the risk levels of COVID-19 patients:

Protocol for patients with suspected or confirmed COVID-19 
the surgeon needs to report to the hospital epidemic management, the infection prevention and control department (IPC), and the operating room before performing a surgical operation.

Surgery operation must be performed in a negative pressure operating room. Wearing 3rd level PPE (disposable surgical caps, N95 masks, work clothes, disposable medical protective clothing, disposable latex gloves, full face respiratory protective devices) is required for anesthesia and surgical procedures. After surgery, the patient is transferred to the isolation room

Protocol for patients at higher risk from COVID-19 
After the preoperative preparation is complete, anesthetists, surgeons, and nurses must wear level 3 PPE for anesthetic procedures and surgical procedures. After surgery, the patient is transferred to the isolation room.

Protocol for patients with a low risk of COVID-19
Wearing PPE in general (disposable surgical caps, surgical masks, work clothes, and disposable latex gloves and isolation suits) can be applied during anesthetic and surgical procedures. After surgery, the patient is transferred to the ward.

Recommendations for Elective Surgical Operations

At the beginning of the pandemic, the American College of Surgeons (ACS) recommended delaying non-urgent operations. At present,  ACS has classified the elective operations into various levels according to the operation's urgency. From groups, 1a to 2b, where most are elective surgeries, such as colonoscopy and carpal tunnel release, are advised to be postponed. For groups 3a and 3b, mostly cancer operations, a delay is not recommended although this decision may change later.

Elective Surgery Acuity Scale (ESAS) from St. Louis University can be a guide for conducting elective surgery during the COVID-19 pandemic era, with the following details:

According to the Indian Council of Medical Research, high-risk patients who will undergo elective surgery need to undergo a COVID-19 RT-PCR examination before surgery, with the following guidelines:
  • Do operate if the results of the RT-PCR test are twice negative
  • If the patient's RT-PCR test result is positive, the patient must be transferred to the isolation room to complete the preoperative preparation. Elective surgery must be postponed until the patient recovers. If an emergency operation needs to be performed, all the precautionary protocols and recommendations previously mentioned for emergency surgery for the COVID-19 case must be strictly followed. Level 3 PPE needs to be worn for anesthetic and surgical procedures. After surgery, the patient is returned to the isolation room.

Management during surgical operations

During surgery, all patients' body fluids (blood, secretions, and excreta) must be considered potentially contaminated. In particular, the operating room's medical team must avoid actions that can produce aerosols when using electronic surgical equipment.

There are some opinions that viruses, such as HIV, HPV, and HBV, can survive in the smoke produced by surgical instruments. Although there is no evidence that COVID-19 can be transmitted through surgical smoke, it is better to take precautions. Minimize surgical smoke by vacuum, and use surgical equipment that produces smoke with the lowest power to reduce the danger.

Avoid Laparoscopy because leakage of high-pressure pneumoperitoneum from trocar increases the risk of aerosol exposure on the surgical team. Surgeons and nurses must avoid injuries, such as puncture wounds and injuries caused by syringes during surgery.

1. Huang C et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497–506.
2. Huh S. How to train the health personnel for protecting themselves from novel coronavirus (COVID-19) infection during their patient or suspected case care. J Educ Eval Health Prof. 2020;17:10.
3. Liu Z et al. Recommendations for Surgery During the Novel Coronavirus (COVID-19) Epidemic.Indian J Surg. 2020 Apr 11: 1–5.
4. National Clinical Programme in Surgery. Intraoperative recommendations when operating on suspected COVID infected patients. https://www.rcsi.com/dublin/coronavirus/surgical-practice#panelcdff32282a8b4027aff395b05ca7794b March 2020
5. American College of Surgeons. COVID-19: guidance for triage of non-emergent surgical procedures. https://www.facs.org/about-acs/covid-19/information-for-surgeons/triage
6. Johnson G K, Robinson W S. Human immunodeficiency virus-1 (HIV-1) in the vapors of surgical power instruments, 1991, 33: 47–50
7. Weyandt GH, Tollmann F, Kristen P, Weissbrich B. Low risk of contamination with human papilloma virus during treatment of condylomata acuminata with multilayer argon plasma coagulation and CO2 laser ablation. Arch Dermatol Res. 2011;303(2):141–144.
8. Kwak HD, Kim SH, Seo YS, Song KJ. Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery. Occup Environ Med. 2016;73(12):857–863.
9. Bogani G, Raspagliesi F. Minimally Invasive Surgery at the Time of COVID-19: The OR Staff Needs Protection. J Minim Invasive Gynecol. 2020 Apr 12.