Clinical outcomes of low-pressure pneumoperitoneum in minimally invasive urological surgery.

The adoption of minimally invasive laparoscopic techniques has revolutionised urological practice. This necessitates a pneumoperitoneum (PNP) and the impact the PNP pressure has on post-operative outcomes is uncertain. During the current COVID-19 era guidance has suggested the utilisation of lower PNP pressures to mitigate the risk of intra-operative viral transmission. Review the current literature regarding the impact of pneumoperitoneum pressure, within the field of urology, on post-operative outcomes. A search of the PubMed, Medline and EMBASE databases was undertaken to identify studies that met the inclusion criteria. The Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines were adhered to. Ten studies, that included both randomised controlled trials and retrospective case series reviews, were identified that met the inclusion criteria. The effect of PNP pressure on outcomes following prostatectomy, live donor nephrectomy, partial nephrectomy and a variety of benign upper tract procedures were discussed. Low pressure PNP appears safe when compared to high pressure PNP, potentially reducing post-operative pain and rates of ileus. When compared to general surgery, there is a lack of quality evidence investigating the impact of PNP pressures on outcomes within urology. Low pressure PNP appears non-inferior to high pressure PNP. More research is required to validate this finding, particularly post-cystectomy and nephrectomy.

Safety and efficiency of gasless laparoscopy: a systematic review protocol.

BACKGROUND: Gasless laparoscopy, developed in the early 1990s, was a means to minimize the clinical and financial challenges of pneumoperitoneum and general anaesthesia. It has been used in a variety of procedures such as in general surgery and gynecology procedures including diagnostic laparoscopy. There has been increasing evidence of the utility of gasless laparoscopy in resource limited settings where diagnostic imaging is not available. In addition, it may help save costs for hospitals. The aim of this study is to conduct a systematic review of the available evidence surrounding the safety and efficiency of gasless laparoscopy compared to conventional laparoscopy and open techniques and to analyze the benefits that gasless laparoscopy has for low resource setting hospitals. METHODS: This protocol is developed by following the Preferred Reporting Items for Systematic review and Meta-Analysis-Protocols (PRISMA-P). The PRISMA statement guidelines and flowchart will be used to conduct the study itself. MEDLINE (Ovid), Embase, Web of Science, Cochrane Central, and Global Index Medicus (WHO) will be searched and the National Institutes of Health Clinical Trials database. The articles that will be found will be pooled into Covidence article manager software where all the records will be screened for eligibility and duplicates removed. A data extraction spreadsheet will be developed based on variables of interest set a priori. Reviewers will then screen all included studies based on the eligibility criteria. The GRADE tool will be used to assess the quality of the studies and the risk of bias in all the studies will be assessed using the Cochrane Risk assessment tool. The RoB II tool will assed the risk of bias in randomized control studies and the ROBINS I will be used for the non-randomized studies. DISCUSSION: This study will be a comprehensive review on all published articles found using this search strategy on the safety and efficiency of the use of gasless laparoscopy. The systematic review outcomes will include safety and efficiency of gasless laparoscopy compared to the use of conventional laparoscopy or laparotomy. TRIAL REGISTRATION: The study has been registered in PROSPERO under registration number: CRD42017078338.

Smoke Evacuation During Laparoscopic Surgery: A Problem Beyond the COVID-19 Period. A Quantitative Analysis of CO2 Environmental Dispersion Using Different Devices.

Background. The COVID-19 pandemic leads to several debates regarding the possible risk for healthcare professionals during surgery. SAGES and EAES raised the issue of the transmission of infection through the surgical smoke during laparoscopy. They recommended the use of smoke evacuation devices (SEDs) with CO2 filtering systems. The aim of the present study is to compare the efficacy of different SEDs evaluating the CO2 environmental dispersion in the operating theater. Methods. We prospectively evaluated the data of 4 group of patients on which we used different SEDs or standard trocars: AIRSEAL system (S1 group), a homemade device (S2 group), an AIRSEAL system + homemade device (S3 group), and with standard trocars and without SED (S4 group). Quantitative analysis of CO2 environmental dispersion was carried out associated to the following data in order to evaluate the pneumoperitoneum variations: a preset insufflation pressure, real intraoperative pneumoperitoneum pressure, operative time, total volume of insufflated CO2, and flow rate index. Results. 16 patients were prospectively enrolled. The [CO2] mean value was 711 ppm, 641 ppm, 593 ppm, and 761 ppm in S1, S2, S3, and S4 groups, respectively. The comparison between data of all groups showed statistically significant differences in the measured ambient CO2 concentration. Conclusion. All tested SEDs seem to be useful to reduce the CO2 environmental dispersion respect to the use of standard trocars. The association of AIRSEAL system and a homemade device seems to be the best solution combining an adequate smoke evacuation and a stable pneumoperitoneum during laparoscopic surgery.

Laparoscopic Gastrointestinal Surgery During COVID-19 Pandemic: Single-Center Experience.

Background: COVID-19 era has put laparoscopic surgery a risk procedure because of theoretical risk of viral transmission of COVID-19. However, safe evacuation of stagnant air during laparoscopic surgery is also necessary to safeguard health care warriors. Methods: We are reporting experience of 24 laparoscopic surgeries using a closed smoke evacuation/filtration system using a ultra low-particulate air (ULPA) filtration capability (ConMed AirSeal® System) at a single center between March 22, 2020, and May 30, 2020. All surgeries were either urgent or emergency in nature. Results: Totally, 17 males and 7 females who required urgent surgery. Most common indication for laparoscopic intervention was acute cholecystitis and complications related to acute cholecystitis. Owing to the closed smoke evacuation system, low intra-abdominal pressure was maintained during all surgeries. Of all procedures, only 0.8 time per procedure, the laparoscope taken out for cleaning. Mean time for completion of surgery was 58 minutes. Compliance of surgical staff was high due to the deemed safe smoke evacuation system. Mean of postoperative pain score was low. Mean hospital stay was 4.9 days. Conclusions: We propose to use a closed smoke evacuation/filtration system with ULPA filtration capability or similar devices in each minimally invasive surgery to reduce risks of transmission as minute as possible until we have enough knowledge about the pattern of disease transmission.

Coronavirus disease 2019 pandemic and identifying insufflators with desufflation mode and surgical smoke evacuators for safe CO2 removal.

INTRODUCTION: Given the propensity of severe acute respiratory syndrome coronavirus 2 to spread, it is imperative that those continuing to perform surgery take precautions to limit the potential generation of contaminated aerosols in smoke from energy-based instruments. The aim of this study was to report current data regarding insufflators with desufflation mode and similar options to safely remove CO2 in minimal access surgery. METHODS: A non-systematic review of the scientific literature was conducted using the PubMed database, and the main companies that provide surgical devices were contacted for information. RESULTS: Most commercially available smoke evacuators use a combination of suction and mechanical filtering. There are also electrostatic precipitators that charge surgical smoke and retain the particles via electrostatic attraction. The search identified three insufflators with desufflation mode, four modular smoke evacuators using mechanical filtration, and only one device using electrostatic precipitation. However, none of these devices has been tested with viruses. CONCLUSION: This review identified commercially available equipment that employs mechanical filtering and electrostatic attraction principles that can be used for pneumoperitoneum evacuation during the present coronavirus disease 2019 pandemic. This pandemic should assist in raising awareness regarding protection measures and the risk of occupational exposure in surgery.

Coronavirus disease 2019 and laparoscopic surgery in resource-limited settings.

INTRODUCTION: During the coronavirus disease 2019 (COVID-19) pandemic, the use of laparoscopy has been discouraged by the Intercollegiate General Surgery because of its potential for aerosol generation and infection. In contrast, the Society of American Gastrointestinal and Endoscopic Surgeons and the European Association of Endoscopic Surgery recommend continuing to use laparoscopy but with devices to filter released CO2 aerosol particles. However, commercially available systems are costly and may not be readily available. Herein, we describe a custom-made system to safely remove surgical smoke and CO2 , as well as a case of laparoscopic cholecystectomy in which we used it. MATERIALS AND SURGICAL TECHNIQUE: The patient had had multiple episodes of biliary pancreatitis and required urgent cholecystectomy during the COVID-19 pandemic. Although India was in complete lockdown, it was decided to operate with precaution. A system was designed using underwater seal chest tube drainage and an electrostatic membrane filter with a viral retention function greater than 99.99%. The system was connected to an extra port for continuous controlled egression of CO2 pneumoperitoneum. A regular four-port cholecystectomy was performed at an intra-abdominal pressure of 12 mm Hg. The gas flow rate was 10 L/min. CO2 for pneumoperitoneum, surgical aerosol, and effluents passed through the system before collecting in the suction apparatus. The exchange of operating instruments through the ports was kept to a minimum. It was done after the abdomen was temporarily desufflated using this system. DISCUSSION: The system we designed appears safe and is cost-effective. In resource-limited settings, it will be handy in patients requiring laparoscopic surgery both during and after the COVID-19 pandemic.

Laparoscopic or robotic intraoperative management to minimize aerosol dispersion: Adaptations to the context of the COVID-19 pandemic. / Manejo intraoperatório em cirurgia laparoscópica ou robótica para minimizar a dispersão de aerossóis: Adaptações ao contexto da pandemia por COVID-19.

The coronavirus infection, also known as SARS-COV2, has proven to be potentially fatal, representing a major global health problem. Its spread after its origin in the city of Wuhan, China has resulted in a pandemic with the collapse of the health system in several countries, some with enormous social impact and expressive number of deaths as seen in Italy and Spain. Extreme intra and extra-hospital measures have been implemented to decrease the transmission and dissemination of the COVID-19. Regarding the surgical practice, a huge number of procedures considered non-essential or elective were cancelled and postponed until the pandemic is resolved. However, urgent and oncological procedures have been carried out. In this publication, we highlight and teach adaptations to be made with commonly used materials in laparoscopy to help prevent the spread and contamination of the healthcare team assisting surgical patients.

A infecção pelo coronavírus determinante da doença COVID-19, também conhecida como SARS-COV2 foi classificada nos últimos meses como pandemia. Essa é potencialmente fatal, representando enorme problema de saúde mundial. A disseminação, após provável origem zoonótica na cidade de Wuhan, China, resultou em colapso do sistema de saúde de diversos países, alguns com enorme impacto social e número grande de mortes descritas na Itália e Espanha. Medidas extremas intra e extra-hospitalares têm sido implementadas a fim de conter a transmissão e disseminação da COVID-19. No âmbito cirúrgico, enorme quantidade de procedimentos considerados não essenciais ou eletivos foram prorrogados ou suspensos até resolução da pandemia. No entanto, cirurgias de urgência e oncológicas não permitem que o paciente espere. Nesta publicação, sugerimos e ensinamos adaptação a ser feita com materiais de uso corriqueiro em laparoscopias para evitar a contaminação ou a disseminação entre as equipes assistenciais e os pacientes.

Recommendations of the Brazilian College of Surgeons for laparoscopic surgery during the COVID-19 pandemic. / Recomendações do Colégio Brasileiro de Cirurgiões para cirurgia videolaparoscópica durante a pandemia por COVID-19.

During the current COVID-19 pandemic, the surgical community faces the possible risk of infection of health care professionals involved in the surgical procedure. This leaves to concerns and questions referred to the most adequate surgical approach at this moment. With the objective of guiding surgeons, and based in many different protocols published until now, the Brazilian College of surgeons brings recommendations about this subject. The aim of this technical note is, trough a compilaton of publications and recommendations from Scientific Societies of Surgery worldwide, to provide guidelines regarding laparoscopic access during the COVID-19 pandemic.

Diante do quadro de pandemia da COVID-19, a comunidade cirúrgica enfrenta o possível risco de contágio de profissionais envolvidos no ato operatório; gerando preocupações e dúvidas referentes a escolha da via de acesso mais adequada nesse momento. Com objetivo de orientar os cirurgiões, baseado em diversos protocolos publicados até o momento, o Colégio Brasileiro de Cirurgiões traz recomendações acerca deste assunto. O objetivo desta nota técnica é, através de uma compilação de publicações e recomendações de Sociedades Científicas de Cirurgia de todo mundo, trazer orientações relativas ao acesso laparoscópico durante a pandemia por COVID-19.

Enhancing safety of laparoscopic surgery in COVID-19 era: clinical experience with low-cost filtration devices.

BACKGROUND: Surgery in the era of the current COVID-19 pandemic has been curtailed and restricted to emergency and certain oncological indications, and requires special attention concerning the safety of patients and health care personnel. Desufflation during or after laparoscopic surgery has been reported to entail a potential risk of contamination from 2019-nCoV through the aerosol generated during dissection and/or use of energy-driven devices. In order to protect the operating room staff, it is vital to filter the released aerosol. METHODS: The assemblage of two easily available and low-cost filter systems to prevent potential dissemination of Coronavirus via the aerosol is described. RESULTS: Forty-nine patients underwent laparoscopic surgeries with the use of one of the two described tools, both of which proved to be effective in smoke evacuation, without affecting laparoscopic visualization. CONCLUSION: The proposed systems are cost-effective, easily assembled and reproducible, and provide complete viral filtration during intra- and postoperative release of CO2.

COVID-19: impact on colorectal surgery.

AIM: The rapid spread of the COVID-19 pandemic has created unprecedented challenges for the medical and surgical healthcare systems. With the ongoing need for urgent and emergency colorectal surgery, including surgery for colorectal cancer, several questions pertaining to operating room (OR) utilization and techniques needed to be rapidly addressed. METHOD: This manuscript discusses knowledge related to the critical considerations of patient and caregiver safety relating to personal protective equipment (PPE) and the operating room environment. RESULTS: During the COVID-19 pandemic, additional personal protective equipment (PPE) may be required contingent upon local availability of COVID-19 testing and the incidence of known COVID-19 infection in the respective community. In addition to standard COVID-19 PPE precautions, a negative-pressure environment, including an OR, has been recommended, especially for the performance of aerosol-generating procedures (AGPs). Hospital spaces ranging from patient wards to ORs to endoscopy rooms have been successfully converted from standard positive-pressure to negative-pressure spaces. Another important consideration is the method of surgical access; specifically, minimally invasive surgery with pneumoperitoneum is an AGP and thus must be carefully considered. Current debate centres around whether it should be avoided in patients known to be infected with SARS-CoV-2 or whether it can be performed under precautions with safety measures in place to minimize exposure to aerosolized virus particles. Several important lessons learned from pressurized intraperitoneal aerosolized chemotherapy procedures are demonstrated to help improve our understanding and management. CONCLUSION: This paper evaluates the issues surrounding these challenges including the OR environment and AGPs which are germane to surgical practices around the world. Although there is no single universally agreed upon set of answers, we have presented what we think is a balanced cogent description of logical safe approaches to colorectal surgery during the COVID-19 pandemic.

Emergency surgery during the COVID-19 pandemic: what you need to know for practice.

INTRODUCTION: Several articles have been published about the reorganisation of surgical activity during the COVID-19 pandemic but few, if any, have focused on the impact that this has had on emergency and trauma surgery. Our aim was to review the most current data on COVID-19 to provide essential suggestions on how to manage the acute abdomen during the pandemic. METHODS: A systematic review was conducted of the most relevant English language articles on COVID-19 and surgery published between 15 December 2019 and 30 March 2020. FINDINGS: Access to the operating theatre is almost exclusively restricted to emergencies and oncological procedures. The use of laparoscopy in COVID-19 positive patients should be cautiously considered. The main risk lies in the presence of the virus in the pneumoperitoneum: the aerosol released in the operating theatre could contaminate both staff and the environment. CONCLUSIONS: During the COVID-19 pandemic, all efforts should be deployed in order to evaluate the feasibility of postponing surgery until the patient is no longer considered potentially infectious or at risk of perioperative complications. If surgery is deemed necessary, the emergency surgeon must minimise the risk of exposure to the virus by involving a minimal number of healthcare staff and shortening the occupation of the operating theatre. In case of a lack of security measures to enable safe laparoscopy, open surgery should be considered.

Gynecological laparoscopic surgery in the shade of COVID-19 pandemic

A global public health problem with a high rate spread and transmission, Coronavirus outbreak has become the most talked-about matter throughout the world. We are severely affected by the nations with vast numbers of deaths; it was hard to predict such a colossal pandemic with terrifying consequences. Elective surgeries are limited, but situations requiring an urgent gynaecological or obstetric surgical approach must still be performed during the COVID-19 pandemic. Concerns regarding surgical safety and the risk of viral transmission during surgery are of great importance. In this review, we aimed to summarize the concepts related to laparoscopic gynecological surgery during COVID-19 pandemic in the light of current literature.