Indian Journal of Surgery

https://doi.org/10.1007/s12262-020-02173-3

ORIGINAL ARTICLE

Recommendations for Surgery During the Novel Coronavirus

(COVID-19) Epidemic
Zheng Liu 1 & Yawei Zhang 2,3 & Xishan Wang 1 & Daming Zhang 2,4 & Dechang Diao 5 & K. Chandramohan 6 &
Christopher M. Booth 7

Received: 29 March 2020 / Accepted: 31 March 2020

# Association of Surgeons of India 2020

Abstract
The whole world is going through an unprecedented period during the pandemic of COVID-19. This pandemic has affected all
aspects of daily life with far-reaching implications, especially in most aspects of healthcare. Practice of surgery across the globe is
in a standstill as of now. When we restart surgical practices across world, we have to bring new protocols and practices in place to
combat the transmission. This article discusses the major changes in surgical practice, which need to be brought in. This article is
based on scientific information about transmission of virus and experiences of some of the authors from China, a country which
successfully dealt with and contained the virus outbreak.

Keywords COVID 19 . Coronavirus . Practice of surgery

Background nearly 500,000 confirmed cases have been identified

worldwide, and nearly 25,000 people have died [2].
In December 2019, a series of patients with pneumonia Experience from China demonstrates that with highly ef-
caused by the novel coronavirus (COVID-19) emerged in fective contact tracing and case isolation, outbreaks of
Wuhan, Hubei, China [1]. The COVID-19 epidemic has COVID-19 can be brought under control within 3 months
spread very quickly. Even as we write this manuscript, [3]. Healthcare workers are on the front lines of caring for
patients with COVID-19 and have very high risk of ex-
posure to the virus. Shortages of protective equipment and
* K. Chandramohan knowledge regarding COVID-19 are causing infections in
drchandramohan@gmail.com healthcare workers [4]. As of February 11, 2020, more
than 1700 healthcare workers have been infected in
1
Department of Colorectal Surgery, National Cancer Center, National China [5]. In Italy, 2026 (9%) of the COVID-19 cases
Clinical Research Center for Cancer/Cancer Hospital, Chinese (as of March 15) occurred in healthcare workers [6].
Academy of Medical Science and Peking Union Medical College, However, there was no documented infection in 31 med-
Beijing 100021, China
ical teams comprised of more than 42,000 doctors and
2
Department of Surgery, Yale School of Medicine, New nurses sent from other provinces to Hubei [7]. This
Haven, CT 06510, USA
strongly suggests that adequate knowledge about disease
3
Department of Environmental Health Sciences, Yale School of Public transmission and use of protective gear and infection con-
Health, New Haven, CT 06510, USA
trol protocols are essential to prevent spread of infection
4
Department of Neurosurgery, The First Affiliated Hospital of Harbin among healthcare workers.
Medical University, Harbin 150001, Heilongjiang, China
Although surgeons are not frontline health workers,
5
Department of Gastrointestinal (Tumor) Surgery, Guangdong several series of infections emerged from operating the-
Province Hospital of Chinese Medicine, The Second Affiliated
Hospital of Guangzhou University of Chinese Medicine,
aters in China [5]. The purpose of this article is to provide
Guangzhou 510120, Guangdong, China recommendations to surgeons and other healthcare
6
Department of Surgical Oncology, Regional Cancer Centre
workers involved in perioperative care to improve staff
Trivandrum, Thiruvananthapuram, Kerala 695011, India and patient safety during this pandemic. These recommen-
7
Department of Oncology, Queen’s University, Kingston, Canada
dations are derived from some of the authors’ practices
 Indian J Surg

and various national guidelines for health professionals. Hierarchical Prevention and Control
At this stage, one of the immediate priorities for countries, of Inpatients
where community spread is a serious threat, is to prevent
its spread from patient to patient and to healthcare Surgical patients may be classified into three risk catego-
workers. ries for COVID-19: confirmed and suspected patients,
high-risk patients, and low-risk patients. They are defined
as follows:

Outpatient Management (1) Confirmed and suspected patients: COVID-19 was con-
firmed when real-time reverse transcriptase (RT)-PCR
Most hospitals have to cancel or reduce nonurgent outpa- diagnostic panels or serological (IgM and IgG) test re-
tient visits as part of their COVID-19 containment strate- sults was positive. The definition of suspected cases falls
gy. Surgeons should prioritize urgent or emergency visits into two categories. The first category will have contact
and procedures. Elective and nonurgent admissions history and meet any two of the clinical manifestations
should be rescheduled [8]. Patients who will face life- (fever and respiratory symptoms) with the typical find-
threatening consequences if treatment is delayed should ings of COVID-19 in the chest CT scan. The total num-
be prioritized for outpatient visit, phone call, or virtual ber of white blood cells in the early stage of the disease is
consultation by a member of the surgical team [9]. From normal or decreased, and the lymphocyte count is re-
China’s experience, it is advisable to set up a separate duced. The second category is without a clear epidemi-
triage area or fever clinic to screen for respiratory symp- ological history and shows three of the clinical manifes-
toms in any surgical patient. Patients with respiratory tations (fever and/or respiratory symptoms, with the typ-
symptoms should call before they leave home, so staff ical findings in the chest CT. The blood count will be as
can be prepared to care for them when they arrive [10]. described above [14].
Any patient with respiratory symptoms and flu-like symp- (2) High-risk patients: Patients who had traveled to high-risk
toms should visit the fever clinic in advance. Patients with areas or contacted patients with confirmed or suspected
suspected or confirmed COVID-19 should be assigned COVID-19 (who have developed fever and/or symptoms
private rooms with door closed [11] and should be pro- of acute respiratory illness within 14 days).
vided surgical face masks or face masks without exhala- (3) Low-risk patients: Patients with no history of close con-
tion valve. Social distancing is essential within clinics and tact with confirmed and suspected COVID-19 patients
hospitals. Doctors and patients should stay 6 ft apart ex- and with no fever or respiratory symptoms and without
cept during examinations; it may be necessary to forego CT manifestations of COVID-19 within 14 days.
all but the most essential elements of the physical exam to
minimize risk of transmission. Confirmed and suspected patients have a higher risk of
In addition to collecting routine disease-related informa- severe events that may require admission to the intensive
tion, staff should take a detailed epidemiologic history. care unit, ventilation support, and death [15]. Elective
Relevant questions include recent travel history (of patient surgeries for these patients should be rescheduled, and
and family) and contact history with people from endemic they should be assessed daily. For high-risk patients, sur-
regions. The staff should also screen for common symptoms geons should consider both medical and logistical needs.
of COVID-19 such as fever, dry cough, and dyspnea. For low-risk patients, elective surgeries should not be
According to the Chinese national guidelines, it is recom- abandoned unless there are constrained health resources.
mended that blood test for COVID-19 and chest CT scan For cancer patients who have to delay surgery, alternative
should be used as routine examinations for patients requiring treatment approaches to delay surgery can be considered,
admission. Even in other countries, it is desirable to test for such as neoadjuvant chemotherapy or additional chemo-
COVID-19 among all patients being admitted to hospital for therapy [16].
surgery. The risk level of all surgical patients should be evalu-
If there is a history of suspicious symptoms or contact, the ated before, or immediately after, admission to hospital.
patient should be assessed in a designated COVID-19 clinic in The treating team should evaluate the patient’s risk level
accordance with strict infection control principles. It is critical daily. High-risk, confirmed, and suspected patients must
to bear in mind that some patients can be highly contagious be kept in a single room, and all the necessary disinfec-
even when they have mild or no symptoms [12, 13]. After a tion and isolation measures should be implemented.
highly suspected or confirmed case is identified, the patient Emergency isolation wards need to be set up in all hospi-
should be isolated and reported to the infection control depart- tals to treat newly admitted high-risk, confirmed, and
ment immediately. suspected patients.
Indian J Surg

Prevention Measures for Healthcare Workers (1) For confirmed and suspected patients, surgeons need to
report to the hospital’s epidemic management depart-
Given the limited supply of personal protective equipment ment (if any), infection control department, and operat-
(PPE) in many centers, their use by healthcare workers should ing theater before surgery and then transfer to a negative
be determined by the risk level of each patient [17]. Healthcare pressure operating theater via a path. Tertiary protection
workers must take prevention measures in strict accordance measures are needed for anesthesia and surgical proce-
with the epidemic assessment level [18]. From the experiences dures. After the operation, patients are transferred to the
of some hospitals in Wuhan, surgeons are at high risk of in- isolation area.
fection. In times of extreme shortages, alternatives to PPEs (2) For high-risk patients, after the preoperative preparation
may need to be considered. is completed, the anesthesiologist, nurse, and surgeon
should follow tertiary protection measures for anesthesia
(1) When entering the ward of low-risk or high-risk patients and surgical procedures. After the operation, the patients
for daily activities and rounds, primary protection (dis- are returned to the original isolation ward according to
posable surgical cap, surgical mask, work uniform and the original transfer route.
disposable latex gloves or/and disposable isolation cloth- (3) For low-risk patients, the general protection measures are
ing if necessary) is needed. needed for anesthesia and surgical procedures. After the
(2) When carrying out routine activities and rounds with operation, patients are transferred to the original ward
confirmed and suspected patient wards, secondary pro- according to the original transfer route.
tection (disposable surgical cap, N95 mask, work uni-
form, disposable medical protective uniform, disposable
latex gloves and goggles) should be used. Protocols for Elective Surgery
(3) For special procedures such as collecting airway sam-
ples, tracheal intubation, airway care, and sputum suc- The logistics of triage for cancer surgery is challenging. From
tion, tertiary protection measures (disposable surgical the recommendations of the Society of Surgical Oncology,
cap, N95 mask, work uniform, disposable medical pro- decisions must be made on an individual case basis consider-
tective uniform, disposable latex gloves, full-face respi- ing the biology of each cancer, alternative treatment options,
ratory protective devices or powered air-purifying respi- and waiting time for rescheduled surgery. The American
rator) should be implemented as aerosol or spray may College of Surgeons (ACS) advises to postpone nonurgent
occur in airborne infection isolation rooms. surgeries during the beginning of the pandemic of COVID-
19. They have classified surgeries into various tiers according
Healthcare workers shall strictly follow the procedures for to the urgency of surgery. Up to Tier 2b (most elective surger-
putting on and taking off personal protective gear, and it is ies like hernia), they are advising postponing of surgery. For
forbidden to wear PPEs when one leaves the contaminated Tier 3a and 3b, where most cancer surgeries will fall, ACS is
area. Sanitation and disinfection need to be implemented ac- not advising postponement at the moment though it may
cording to the regionalized zoning management system and change [16].
patient epidemic classification, and different PPE should be Patients undergoing elective surgery should be given rea-
worn according to the working area. sonable recommendations regarding follow-up, and patient
should be shifted to high care facility if COVID-19 is
Protocols for Emergency Surgery suspected, and test should be ordered. According to guidelines
from the Indian Council of Medical Research, all high-risk
Surgeons, anesthesiologists, and nurses need to be trained in patients undergoing elective surgery (All symptomatic con-
the use of PPE. Surgeons should schedule surgery based on tacts of laboratory-confirmed cases and asymptomatic direct
the severity of threat to the patient’s life and health. During the and high-risk contacts of a confirmed case should be tested
epidemic, need for emergency surgery should be considered once between day 5 and day 14 of coming in his/her contact)
as a priority for admission. should undergo PCR test for COVID-19 before surgery [20].
All suspected patients who need emergency surgery need
to complete COVID-19 blood test and chest CT scan before (1) If the patient’s RT PCR test is twice negative, according
admission; pharyngeal swab sampling should be completed to the patient’s current epidemic level, surgeons can pro-
before surgery. Patients should be placed in the transitional ceed with surgical protocols.
area while waiting for results. All surgery should be per- (2) If the patient’s RT PCR test is positive, then the patient
formed in a quick and efficient manner [19]. After admission, needs to be transferred to the isolation ward to complete
different protocols will be applied based on the COVID-19 the preoperative preparation. Elective surgery should be
risk level of patients. deferred until the patient recovers. If we have to operate
 Indian J Surg

emergently on such patients for any reasons, all the pre- with suspected or confirmed COVID-19, there is a greater risk
cautions mentioned earlier for operating COVID-19- of complications such as deep vein thrombosis (DVT) and
positive cases as emergency should be strictly followed. secondary pulmonary infections.
The tertiary protection measures should be taken during For confirmed COVID-19 patients, once the temperature
the anesthesia and operation. After the operation, patients returns to normal for more than 3 days, the respiratory symp-
are returned to the isolation area. toms are significantly relieved, and the inflammation is clearly
absorbed, the isolation can be released when the RT PCR and
antibody test is negative on two consecutive occasions (sam-
pling interval ≥ 24 h). Doctors then can transfer them to the
Management During Surgery (Suspected general ward for treatment or discharge.
Emergency and Test Positive Elective Cases)

During the operation, all objects that come in contact with

patients including blood, secretions, and excreta should be
Conclusion
considered as potentially contaminated. In particular, medical
With the increasing number of COVID-19 cases worldwide,
staff in operating theater should avoid exposure to aerosols
there is an ongoing need for infection prevention and control.
generated while using electrosurgical equipment. There are
These principles are essential for both patient care and staff
many examples that viruses do survive in surgical smoke cre-
safety. In this paper, we outline an approach for the manage-
ated by electrosurgical instruments [21, 22]. Though it is not
ment of surgical patients in the context of the COVID-19
proven that coronavirus can be transmitted via surgical smoke,
pandemic. There is an urgent need for additional data to fur-
it may be worthwhile to take precaution until we have evi-
ther identify risk factors for transmission during, before, and
dence it does not. To reduce the hazards, surgical smoke
after surgery as well as to determine the optimal timing of
should be minimized by suction device, and electrosurgical
surgery in these patients. The general principles outlined in
equipment should be used at the lowest effective power. In
this report will need to be considered in light of the local
suspected cases, laparoscopy should be avoided as pneumo-
context, available resources, and the current activity of
peritoneum high-pressure trocar leaks enhance the risk of ex-
COVID-19.
posure to aerosol to operating theater staff. Surgeons and
nurses should avoid injuries such as stab wounds and needle
stick injuries. All PPE is only used in the isolated area, and it is Compliance with Ethical Standards
forbidden to leave the isolated area while wearing PPE.
Conflict of Interest The authors declare that they have no conflict of
Some airborne transmission happened in Wuhan because interest.
healthcare workers initially had little knowledge of the virus.
After using the strict management measures for operating the-
ater, airborne transmission ceased.
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