This study was approved by the Turkish Ministry of Health and Institutional Ethics Committee (G0 21/ 124).
This retrospective cross-sectional clinical study included all operations performed at the clinic of the Department of General Surgery, Hacettepe University, between March 11 and December 11, 2019 (pre-COVID-19 period), and between March 11 and December 11, 2020 (COVID-19 period). Due to normalization efforts and the onset of the vaccination drive from January 2021 in Turkey, we limited the study period to nine months for more accurate results.
All procedures were classified into five different categories based on their level of complexity (from A–E), defined by the Turkish Ministry of Health (15). Category A represents the most complex operations such as esophagectomies, total gastrectomies, hepatectomies, Whipple procedures, laparoscopic hemicolectomies, and low anterior resections, while category E represents simple operations such as suturing lacerations, drainage of superficial abscesses, and superficial lymph node biopsies which can generally be performed on patients in outpatient clinics under local anesthesia.
In this study, we only included operations under categories A–D, examining the procedures performed in the operation theaters (OT). Table 1 presents the categorization of common general surgery procedures.
Categorization of common general surgical procedures.
Morbid obesity procedures
Segmental small bowel resection
Primary repair of duodenal perforations
İnguinal hernia repair (emergent)
Bilateral inguinal hernia repair
Mastectomy (simple, modified radical)
Inguinal hernia repair (elective)
Pilonidal sinus excision
Perianal abscess drainage
Lymph node biopsy (deep, cervical, axillary)
Lymph node biopsy (superficial)
Suturing superficial lacerations
Simple abscess drainage
According to the institutional regulations, all operations were performed either by a faculty member or by a resident under the supervision of the responsible faculty member. Residents were grouped into three categories according to their seniority as first-year residents, second–fourth year residents, and fifth year residents.
Figure 1 presents the numbers and distribution of residents actively working at the department as of March 2019 and 2020. Due to resignations and rotations, there are minor changes to the number of active residents based on the date.
After the COVID-19 outbreak, all patients going in for surgery were screened using the reverse transcription polymerase chain reaction (RT–PCR) assay before their operation. Computed tomography (CT) of the thorax was performed for those who tested negative in the RT–PCR test but were symptomatic or clinically suspected patients. Only emergency operations were performed on COVID-19 positive patients under infection control regulations.
The demographic data of the patients, their preoperative diagnoses, indications (i.e., for a benign condition or suspected/confirmed malignancy), type of operation (emergency or elective), information about the performing surgeon and operation category, complication rate/grade based on the Clavien-Dindo classification, and the length of the patient’s stay at the hospital were all analyzed retrospectively (16). Preoperative diagnosis, indications, performing surgeon and operation category data collected from general surgery department’s data base which is active from 1996. All other data collected from institutional database which is open for all medical doctors working at Hacettepe University.
IBM Statistics SPSS Version 20 was used for data analysis. The results of age, admission time and length of hospital stay were presented as median and interquartile range, as they were nonparametrically distributed according to Skewness and Kurtosis analysis. The differences between pre-covid and covid period were calculated with the Mann Whitney-u Test. Chi-square test was used to compare categorical variables such as sex, surgery category, emergency status, complication, Clavien Dindo classification, mortality status, ASA score, malignancy status, anesthesia type, operator type, covid status between pre-covid and covid period. A p-value of less than 0,05 was considered to be statistically significant