The global transmission of Coronavirus disease 2019 (Covid-19) is fraught with widespread implications on traditional health care practices related to surgery.1Current 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. Elective surgeries were suspended by the surgical and allied societies since the start of the pandemic and judicious triage protocols were adopted.2-3 Laparoscopic procedures were avoided in all cases due to risk of viral transmission from aerosol-generating products (AGP) during procedures performed under general anesthesia (GA) during intubation and ventilation and smoke generation from insufflated gas.4-6 Gradually surgical societies adopted newer guidelines which allowed laparoscopy provided protective measures were strictly implemented.7 Some of these measures were limited due to the cost of devices and systems to support procedures.8
Laparoscopy has been the widely accepted gold standard for several organ procedures such as cholecystectomy and appendectomy.9 Despite established advantages, consensus for laparoscopic surgical practice was modified to curb risks that increased viral transmission such as hazardous smoke generation during surgical procedures.8 And indeed societies published new recommendations discouraging laparoscopy in favour of open surgeries during Covid-19 pandemic; however, guidelines evolved with time.10-11 In regards to 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).12 In 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
In relation to Bangladesh, the first confirmed case of Covid-19 was declared on 8th March 2020.14 Subsequently, the general public avoided hospitals especially during the months of March and April which led to a significant 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 significantly decrease the theoretical risks of viral transmission, reduce theatre time, and 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 as Covid-19 positive until proved 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 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 surgeon could operate with only one assistant so that less personnel was needed during laparoscopy. Smoke generation was minimized by use of Ligasure (COVIDIEN Valleylab LS10) instead of diathermy. Smoke leakage was minimized by use of indigenous smoke evacuator which evacuated insufflated gas via least dependant 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 analyzed with Stata/IC 16.0 for Mac. 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 t test or Mann-Whitney U test based on distribution of data. One-way analysis of variance (ANOVA) or Kruskal-Wallis test was used for categorical data. All P-values were two-sided and values ≤0.05 were considered statistically significant.