Institutional Review of Laparoscopic Surgery during Coronavirus Disease - 2019: Recommendations for Developing Countries

Context: The outbreak of the Coronavirus disease 2019 (Covid-19) has posed new challenges to surgical care throughout the world. Laparoscopic guidelines were revised to address the theoretical risks associated with transmission of viral droplets and many elective surgeries were suspended. Aims: We aimed to describe strategies that lowered viral transmission risks such as alternative anaesthetic techniques and low-cost infection control and prevention practices for laparoscopic surgeries. Settings and Design: Seventy two patients who presented to hospital as acute surgical emergencies between April and July 2020 and analyzed clinical data of 50 patients who underwent laparoscopic surgeries. This was a prospective observational study. Methods and Material: Procedures were performed under spinal anaesthesia utilizing alternate electrosurgical units and simple smoke evacuation systems. Statistical analysis used: Continuous variables were summarized as mean and standard deviation (SD) or median and range. Discrete variables were summarized as frequencies and percentages. Univariate testing was performed using t test or Mann-Whitney U test. ANOVA or Kruskal-Wallis test was used for categorical data. Results: Of the 50 operated patients, the median age was 23 years with 54% females. The most frequently performed procedure was laparoscopic cholecystectomy, the overall median theatre time was 47 minutes, and 40% patients were managed as day cases with reduced hospital stay. Conclusions: Use of spinal anaesthesia, a simple smoke evacuator and some additional measures during laparoscopic surgeries reduce theatre time and length of hospital stay. These strategies could address and minimize the risks associated with Covid-19 transmission in surgical settings in low-resource countries.


Introduction
The global transmission of Coronavirus disease 2019 (Covid- 19) is fraught with widespread implications on traditional health care practices related to surgery. 1 Current practices such as laparoscopy, which has been instrumental in the practice of surgery for decades, were reconsidered, and guidelines were restructured to ensure patient safety and best clinical outcomes.5][6] Gradually, surgical societies adopted newer guidelines that allowed laparoscopy-provided protective measures to be strictly implemented. 7Some of these measures were limited due to the cost of devices and systems to support procedures. 8paroscopy has been the widely accepted gold standard for several organ procedures, such as cholecystectomy and appendectomy. 9Despite established advantages, consensus for laparoscopic surgical practice was modi ed to curb risks that increased viral transmission, such as hazardous smoke generation during surgical procedures. 81] Regarding the choice of anesthetic modalities, GA has been the mainstay of laparoscopic surgeries.In the past, various factors have discouraged the uptake of alternative anesthetic techniques, such as the notion of inadequate abdominal muscle relaxation during spinal anesthesia (SA). 12In contrast, emerging evidence supports merits of SA and good feasibility due to profound muscle relaxation, shorter recovery time and cites it comparable to GA in regards to laparoscopic procedures, complications and length of hospital stay. 13 relation to Bangladesh, the rst con rmed case of Covid-19 was declared on 8 th March 2020. 14ubsequently, the general public avoided hospitals, especially during the months of March and April, which led to a signi cant decrease in elective surgeries.Herein, we present measures adopted for laparoscopic surgical practice at a hospital in Bangladesh.We propose the safety of alternative anesthesia techniques, such as SA, and low-cost options of smoke evacuation that can signi cantly decrease the theoretical risks of viral transmission, reduce theatre time, and reduce the duration of hospital stay.

Subjects And Methods
Between 1 April 2020 and 31 July 2020, 72 patients presented to a tertiary care hospital in Chittagong, Bangladesh with acute surgical conditions amenable to laparoscopic procedures.Among these, 50 patients underwent laparoscopy, and the remainder improved on non-operative management.All patients had abdominal pain, and many had associated fever and were provisionally considered Covid-19 positive until proven otherwise.Except in a few cases where Covid-19 testing was not done and the decision to perform surgery was made despite non-testing, the majority of patients had the testing done.For this prospective observational study, we included medical records of all patients, and ethical clearance was obtained on March 14, 2020 (no/admin/SPH/189/2020) from the Ethical Committee of the Hospital.Informed consent was obtained from all patients and parents or legal guardians as appropriate.
Spinal anesthesia was used during all laparoscopic procedures.Ergonomics were such that the surgeon could operate with only one assistant so that fewer personnel were needed during laparoscopy.Smoke generation was minimized by the use of ligature (COVIDIEN Valleylab LS10) instead of diathermy.Smoke leakage was minimized by the use of an indigenous smoke evacuator that evacuated insu ated gas via the least dependent port through suction tubing into a jar containing detergent solution and from there to a bucket containing water mixed with detergent and bleach [Fig.1].All the patients wore a mask, and a screen separated the head end of the patient from the surgical team.
Data collection: We obtained data on age, gender, clinical and surgical variables, which included Covid-19 testing, diagnosis, treatment, theatre time and length of hospital stay.Data analysis: Data was collected using Microsoft Excel and statistical analysis was performed using the IBM SPSS Statistics for Mac, Version 25 (IBM SPSS Statistics for Windows, IBM Corporation, Armonk, NY).Continuous variables were summarized as mean and standard deviation (SD) or median and range when appropriate.Discrete variables were summarized as frequencies and percentages.Univariate testing was performed using a t test or Mann-Whitney U test based on the distribution of data.One-way analysis of variance (ANOVA) or Kruskal-Wallis test was used for categorical data.All P-values were twosided, and values ≤0.05 were considered statistically signi cant.

Results
There were 72 patients in the overall cohort with a median age of 18.50 years (range, 1 to 48 years), and 54.20% were female.Some patients were admitted with a probable diagnosis of either appendicitis or calculous cholecystitis.Conservative management improved their condition, and they were discharged.Of these, ve returned with similar complaints during the study period and were operated on, and their operation and hospital stay were counted considering both occasions of admissions.Descriptive statistics of the variables in the operative cohort are presented in Table 1.
The median age was 23 years (range, one to 48 years).Less than half had a negative Covid-19 test report before treatment (40%), and 38% of patients had a negative test after treatment (sample was taken before operation but reports came later).Only two patients (4%) had a positive report after treatment (sample was taken before operation).The majority of operative treatments during the period comprised cholecystectomy (22%), followed by appendectomy (18%) and appendectomy with peritoneal cleansing (16%).The overall median theatre time was 47 minutes (range, 32 to 75 minutes), and in most cases, procedures were performed as day cases (40%).The average theatre time by different treatments is displayed in Figure 2.There was no association of sex (P= 0.126) with theatre time; however there was associations with treatment (P= 0.001), a positive correlation with age (r=0.435,P = 0.002), and duration of stay (r=0.261,P= 0.067).During the four month period, we operated two Covid-19 positive cases.One of our OT staff had developed Covid-19 symptoms nine days after we had operated on a Covid-19 positive case and was sent to isolation.He later tested positive, but the source of infection was not clear, as he had a positive family history for at least seven days before his symptom development.

Discussion
The impact of Covid-19 on surgical practices has been immense globally.We presented our experience with 50 laparoscopic procedures from April to July 2020.In retrospect, we performed 176 laparoscopies during the same period in 2019, which translated to a reduction of laparoscopic procedures during the pandemic by approximately 75%.The drop in elective surgeries globally as a consequence of Covid-19 necessitates gathering appropriate information and advocating more e cient global surgical care. 15 laparoscopic restrictions and other health care concerns grew amongst the surgical community, we devised simpler solutions for approaches to surgical management in the context of our hospital setting.Re ecting on our practices, we propose that laparoscopy under regional anesthesia is a safe surgical approach for patients during the Covid-19 pandemic; by achieving adequate regional anesthesia/SA, we obviated the need for GA and its accompanying risks of aerosolization, which have been linked with increased viral transmission. 16The risks associated with SA were not substantiated; it was administered as an intrathecal injection over a few minutes, and patients left OT as soon as the operation was complete.There were additional bene ts, such as cost-effective containment of aerosolized products, markedly reduced theatre time and shorter hospital stay.
There have been concerns about smoke leakage during operations in relation to the use of electrosurgical units. 17We have been using Ligasure (COVIDIEN Valleylab LS10), a safe and effective vessel sealing system, which created less smoke than conventional diathermy. 18Evacuation of the insu ated gas was performed via a simple underwater submersion system that minimized smoke leakage and aerosolization. Our mean operative time for an appendectomy was 42 minutes.In contrast, a study on 55 laparoscopic appendectomy procedures using standard anesthetic techniques reported a mean operative time of 69 minutes. 21However, operative time parameters depend on several factors, such as patient characteristics and surgeon skills; surgeons can utilize these estimates to optimize surgical management by adapting improvised techniques that can save resources, nances and time by reducing the length of hospital stay. 22though we lacked a negative-pressure OT due to cost constraints, we followed all other standard protocols pre-, intra-and postoperatively as per guidelines for infection prevention.We had limited testing facilities for Covid-19 in the country, and testing results were often delayed.For practical reasons, we could not order testing for all patients, and using clinical judgment and acumen, we proceeded to operate on patients who were considered to be low risk.Nevertheless, we adopted every possible measure to reduce the risk of infection and dealt with all patients as if they were Covid-19 positive from the rst presentation to the emergency department until discharge from the hospital.On another note, conservative non-operative treatments for cases such as appendicitis could have greater interest in the future as hospitals adapt and produce standard operating guidelines during epidemics and pandemics.Evacuation of insu ated gas via a simple underwater submersion system.
Evacuation of insu ated gas via a simple underwater submersion system.

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