Hernia and abdominal wall surgery are the branches of general surgery, and types of diseases are relatively concentrated. Most of the operations are elective, including some limited time operations and emergency operations. During the NCP epidemic, diagnosis and treatment should be classified according to the condition. Our department had stopped the treatment of all patients undergoing elective surgery since the first level response was launched in Beijing. At the same time, confine operation should be postponed, but emergency operation was still needed. The emergency operation of hernia surgery is mainly incarcerated inguinal hernia, incarcerated umbilical hernia, incarcerated incisional hernia, incarcerated parastomal hernia and so on. In order to save medical resources and reduce the exposure of medical staff and patients, we could suspend the treatment of patients undergoing elective surgery as a special department for hernia and abdominal wall surgery. But for incarcerated hernia emergency patients, we could only choose active surgical intervention. For such cases, NCP guidelines should be done in accordance with the protection requirements of hospital and isolation to avoid hospital infection. At the same time, effective protection of medical staff and other patients could be carried out in the treatment of incarcerated hernia cases.
In terms of choice of surgical methods for emergency incarcerated hernia cases, we were faced with elderly patients, many basic diseases, long history or other characteristics. Many of these patients had a high risk of general anesthesia. Therefore, many emergency patients in our department chose open surgery under local anesthesia during NCP epidemic. According to previous limited experience, SARS-CoV-2, which was mainly transmitted by droplets, was similar to the Middle East respiratory syndrome (MERS) coronavirus found in September 2012. Seddiq reported the cases of MERS after CABG in 2017, without special protection during operation. No infection was found in 40 close contacts. Some hospitals in South Korea performed emergency operations for 4 suspected cases and 2 confirmed cases of MERS under strict protection. No staff infection was found. During the outbreak, a hospital in Wuhan performed cesarean section for 48 pregnant women suspected and confirmed NCP, and no infection was found among the medical staff. SARS-CoV-2 was similar to MERS coronavirus and could be transmitted through droplets and feces. In contrast, SARS-CoV-2 may even spread through aerosols. Considering the management of airway by general anesthesia intubation and the possibility of aerosol diffusion in laparoscopic surgery, most of our surgical methods were open surgery in NCP epidemic. The main anesthesia was local anesthesia combined with intravenous anesthesia in order to avoid the spread of pathogens, by cutting off route of transmission. Of course, there were also cases that were actually more suitable for laparoscopic surgery, such as incarcerated obturator hernia, which could also be performed under premise of good protection. However, the operating room should be regarded as "Red Area" and the corresponding high-level protection should be performed. During the epidemic period, proportion of laparoscopic surgery was 11.76%, and proportion of previous emergency laparoscopic surgery was 33.46%, although the difference was not statistically significant. But we preferred open surgery during NCP outbreak.
During NCP epidemic, treatment process of emergency incarcerated hernia patients was more complicated than ever, and more examinations and screening work had been carried out. Because in the process of admission, once it caused exposure or infection, it was fatal for the whole hospital. Although we had increased admission process, resulting in a significant increase in emergency surgery waiting time compared to cases in 2019, we believed it worthy during NCP outbreak. Moreover, compared with the previous emergency patients, strangulation of incarcerated hernia did not increase significantly. So we had reason to think that strict pre hospital screening process was necessary, including blood test and pulmonary CT. Of course, contact history of epidemic areas and family members was also essential. All the relevant examination results needed to be consulted by expert panel before entering the hospitalization process. The expert panel must be composed of specialists with rich experience. In our opinion, the expert group should be composed of senior doctors from respiratory department, infection department, radiology department, emergency department and intensive care unit. At least two groups of experts shall be equipped to ensure 24-hour standby status. However, after the operation, it was not allowed to enter the "Green area". It was necessary to return to the "Yellow Area" for at least one week of isolation observation according to the condition. If possible, we even suggested that the observation isolation time extended as much as possible. In the "Yellow Area", it is not allowed to visit or stay with family members. Since the incubation period of NCP was about 1~14 days, mostly 3~7 days, we chose to take the new NCP assessment when patients had been isolated for 7 days. In the early stage of the epidemic, patients in “yellow area” did not carry out nucleic acid monitoring 7 days after isolation instead of blood test and pulmonary CT examination. After consulting by expert panel again, patient could be transferred from buffer ward to general surgery ward ("Yellow to Green"). The rest of treatment continued in the general ward. In the Green area, a fixed family member was allowed to stay with patient, and the family member was not allowed to leave the ward until patient discharged. At present, we suggest that NCP test kit should be included in the routine screening examination, so as to ensure the accuracy of the examination. Discharge did not mean the end of isolation of patient. We still require patients to be isolated at home after discharge and did a good job of follow-up investigation. After NCP was excluded during the incubation period, surgical follow-up was continued. If NCP was suspected or diagnosed, the patients performed emergency surgery should be sent to Red area for treatment. Including the family members of the patients, nobody was allowed to enter Yellow or Green areas. It was better to transfer to a special designated hospital.
Compared with same emergency incarcerated hernia cases in 2019, hospital stay did not increase, and there was no significant difference in repair methods in NCP group. Therefore, we believed that it was safe to use mesh for emergency surgery during the epidemic. In addition, special protection did not increase the incidence of intraoperative complications. High level of protection was necessary for intraoperative protection, especially for suspected and confirmed cases. On the other hand, the emergency incarcerated hernia surgery under the epidemic situation should choose the simplest way of operation. The operation method that could achieve therapeutic effect in the shortest time was the one that should be selected during NCP epidemic.
So far, the number of newly confirmed NCP cases in China has declined rapidly. There have been no newly confirmed cases in Wuhan for two consecutive days, and most of confirmed cases are imported ones in China. The NCP epidemic prevention and control in China has achieved phased results. We hope to summarize the experience of emergency operation during NCP epidemic and achieve the highest efficiency of treatment and the safest protection in the face of similar situations.