key: cord-0911016-7043b5lm
authors: Tebala, Giovanni D.; Lami, Mariam; Bond-Smith, Giles
title: In response to: Laparoscopic surgery and the coronavirus disease 2019 pandemic: A word from a different hymn sheet
date: 2020-07-01
journal: J Trauma Acute Care Surg
DOI: 10.1097/ta.0000000000002843
sha: 4b93e8624cb48a7eb931ab0567c678d7b7366f5b
doc_id: 911016
cord_uid: 7043b5lm

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However, we find ourselves in disagreement with some of their statements. The mentioned article takes for granted the risk of viral spread through the surgical smoke and pneumoperitoneum and suggests avoiding the laparoscopic approach as much as possible.

While agreeing on the concept of the potential risks of surgical smoke for the theater staff, which have been widely demonstrated, we feel that our clinical decisions during this pandemic must be evidence based to the greatest extent.

On this particular topic, there is no published proof of the presence of COVID-19 in the surgical smoke, and the suspect is only indirect. 2 The available evidence of the presence of active hepatitis B virus (HBV), human immunodeficiency virus (HIV), and human papillomavirus (HPV) viral particles in the surgical smoke is low level and may not apply directly to the COVID-19. At our knowledge, up until now, only one article demonstrated the presence of HBV in the surgical smoke in 10 of 11 HBV-positive patients undergoing laparoscopic or robotic surgery. 3 Several articles demonstrated the presence of HPV in the laser plume, 4 whereas the results of studies on HIV yielded contrasting results. 5 Although there is evidence of patient-surgeon transmission of HPV through the laser smoke, the particular kind of surgery for HPV-related warts, where the surgeon usually stays very close to the surgical field and easily inhales the smoke, makes HPV a biased experimental model for viral transmission during laparoscopic surgery. Despite HIVand HBV being blood-borne viruses, laparoscopic surgery is being performed in HIV and HBV patients for many years, and no clear demonstration is available of viral transmission through the pneumoperitoneum or surgical smoke. On the contrary, COVID-19 has a special tropism for the upper and lower respiratory tract. Viral RNA has been found in stools and blood, but no infective virus has ever been demonstrated in the gastrointestinal tract and in the blood. Furthermore, it must be emphasized that smoke production and evacuation may be even more difficult during laparotomy than laparoscopy, for the absence of a unique smoke escape channel.

For these reasons, we do not believe that results from the available literature can be extrapolated to the COVID-19 pandemic as to justify the current too restrictive guidelines on laparoscopic surgery against the evident and well-known and evidence-based advantages of laparoscopy with respect to the open approach in many fields of surgery. We feel that replacing a grade of recommendation A (known benefits of laparoscopic surgery) with a grade D (avoid laparoscopy on the basis of perceived dangerous laparoscopic smoke) is not consistent with a modern healthcare system.

Last but not the least, we feel that the restrictions placed on the practice of laparoscopic surgery during the pandemic may not be consistent with ethics and professionalism because they reduce the level of care and abdicate to the already world widely accepted criterion standards in surgical care. While this can be acceptable in war scenarios with limited resources, they may not be totally acceptable in the current juncture where, despite undoubtedly facing a challenging pandemic, resources and expertise are widely available and access to the highest standard of care must be granted to everyone.

Laparoscopy at all costs? Not now during COVID-19 outbreak and not for acute care surgery and emergency colorectal surgery: a practical algorithm from a hub tertiary teaching hospital in northern Lombardy

Safe management of surgical smoke in the age of COVID-19

Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery

Is surgical plume developing during routine LEEPs contaminated with high-risk HPV? A pilot series of experiments

Presence of human immunodeficiency virus DNA in laser smoke

Authors' response: Laparoscopy and COVID-19: An off-key song?Dear Editor, W e thank Tebala et al. for their interest and comments on our article. 1 At the end of their letter, the authors point out that "resources and expertise are widely available" during coronavirus disease 2019 (COVID-19) outbreak and a restrictive use of laparoscopy would have been acceptable only in a war scenario. Unfortunately, the current data resemble many features of this kind of scenario, with shortage of personnel, reduction of surgical services, operating rooms converted in intensive treatment unit (ITU) beds, and surgeons shifted to medical tasks as a global response to the pandemic. 2 As of May 12, 2020, 163 doctors died after contracting COVID-19 in Italy, 3 and health workers are heavily affected globally. In this setting, any additional source of contagion may produce catastrophic effects and threat the entire health system. A tailored strategy to protect health workers and patients, avoiding unnecessary risks, is a priority. 4, 5 A second worst pandemic wave, as in the Spanish flu, cannot be excluded, and a self-preserving strategy must be already in place to guarantee an adequate surgical response in the future outbreak peaks, despite the shortage of personnel, beds, and operating rooms.Regarding the lack of evidence of SARS-CoV-2 presence in the peritoneal fluid, some anecdotal evidences are emerging. Viral RNA was detected in the peritoneal fluid of a COVID-19 patient who had undergone a laparotomy for a nonischemic small bowel volvulus 6 and in the peritoneal waste of a patient treated with peritoneal dialysis. 7 Thus, a prudential approach may be reasonable until