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Table of Contents
Year : 2020  |  Volume : 17  |  Issue : 3  |  Page : 185-189

Minimally access laparoscopic and robotic surgery during the COVID-19 era

Department of Surgery, Indraprastha Apollo Hospitals, New Delhi, India

Date of Submission01-Jul-2020
Date of Acceptance08-Jul-2020
Date of Web Publication19-Aug-2020

Correspondence Address:
Arun Prasad
Department of Minimal Access, Bariatric and Robotic Surgery, Indraprastha Apollo Hospitals, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/am.am_76_20

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COVID-19, the novel coronavirus, has affected all aspects of life including the way we do surgery. While patients are being tested with real-time reverse trancriptase-polymerase chain reaction before admission for elective surgeries, there are a good number of false-negative tests. This has led to the concept of a minimum standard precautions in all the negative cases too. In our unit at Indraprastha Apollo Hospitals, New Delhi, we have done 84 minimally access laparoscopic and robotic surgeries during the lockdown. This included benign and malignant diseases. No staff in the operation theater (OT) was infected during any of these surgeries. Wearing personal protective equipment and use of smoke evacuation system in a pressure-adjusted OT is the key to safety.

Keywords: COVID-19, laparoscopic surgery, robotic surgery

How to cite this article:
Prasad A, Tiwari A, Osman N. Minimally access laparoscopic and robotic surgery during the COVID-19 era. Apollo Med 2020;17:185-9

How to cite this URL:
Prasad A, Tiwari A, Osman N. Minimally access laparoscopic and robotic surgery during the COVID-19 era. Apollo Med [serial online] 2020 [cited 2020 Oct 24];17:185-9. Available from: https://www.apollomedicine.org/text.asp?2020/17/3/185/292701

  Introduction Top

Coronavirus disease 2019 (COVID-19), that is caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), is now a global pandemic with > ten million confirmed cases and about 500 thousand deaths so far.[1] On January 30, 2020, India reported its first case of COVID-19 in Kerala.[2] Since then, about 500,000 confirmed cases and 15,000 deaths have been reported.[3]

The impact of COVID-19 on surgical practice affected the workforce, prioritization of surgeries, hospital staffing issues, and the risk of transmission.

We faced cancellation of scheduled surgeries, shortage of blood components, and restructuring of operation theaters (OTs). Developing new COVID pathways for outpatient department (OPD), ward admissions, and postoperative care were some of the early challenges considering the paucity of guidelines in the literature.

Elective surgery stopped initially, but then, the patients waiting with gall stones started to present with empyema and hernias got obstructed and strangulated. Cancer patients who waited initially started coming for surgery.

Surgery being aerosol generating became a risky proposition. Furthermore, there was a risk of asymptomatic positive patients developing postoperative respiratory complications. We developed a surgical protocol for treating the medically necessary surgeries at Apollo Hospitals.

  Materials and Methods Top

We started with the following:

  1. Creating a pandemic response plan including immediate postponement of elective operations, OT plans, and admission strategies
  2. Ensuring no emergency services suffered
  3. Educating the staff on personal protective equipment (PPE) [Figure 1] and the basics of COVID-19 management
  4. Developing anesthesia and surgical protocols for safe surgery
  5. Developing special steps and acquiring technology to reduce aerosol and smoke generation during surgery.

The standard protocol was followed as shown below:
Figure 1: Laparoscopy OT

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Before surgery

  1. All patients were screened in the OPD for COVID-19 symptoms
  2. In addition to the basic preoperative investigations and viral markers, real-time reverse trancriptase-polymerase chain reaction (RT-PCR) test for COVID-19 is being done for all admissions
  3. Patients who had to be admitted immediately (laparoscopic appendicectomy, laparoscopic hernia, etc.) were admitted in the pending COVID-19 floor while COVID-19 test was done on a priority basis. Once negative, they were shifted to the COVID-free floors
  4. Air conditioning of the OT is switched off half an hour before the intubation process. It is also switched off at the time of extubation till cleaning of the OT is complete
  5. Anesthesia is given with strict adherence to the protocol by the anesthesia society[4]
  6. During anesthesia induction, minimum staff is present in the OT. The rest enter after completion.

During minimally access and robotic surgeries

  1. Avoid open technique for entry into the abdomen as that can cause leak of CO2. Initial entry should be considered with a muscle-splitting optical trocar or balloon ports can also be used
  2. The skin incision for ports should also be kept as small as possible [Figure 2]
  3. Leaks around trocars, Nathanson, etc., during surgery need to be minimized by additional purse-string skin sutures, when needed
  4. Reduce the intra-abdominal pressure to as low as possible without compromising surgical exposure or patient safety
  5. Use one extra 5-mm port for suction cannula to suck simultaneously during energy usage [Figure 3]
  6. If the surgeon decides to change to another port for insufflation, the original port should be closed prior to disconnecting the tubing and the new port should be closed until the tubing is connected. The insufflator should be “on” before the new port is opened to prevent gas from back flowing into the insufflator
  7. Surgeons should aim to reduce smoke/vapor generation. Electrosurgery units should be set at the lowest possible settings
  8. Monopolar diathermy with attached smoke evacuator may be preferable. Ports should not be vented during the procedure. Bipolar, LigaSure™, and EnSeal® are safer than harmonic and Sonicision™
  9. During desufflation, the insufflator should be switched off and the port connected to the insufflator should be closed
  10. Careful and swift introduction of staplers and suture materials should be done to reduce leaks
  11. Careful gastric calibration tube handling should be done with all precautions that were taken during intubation
  12. Robotic surgeon at the console should also wear basic PPE and take precautions. There should be an experienced person by patient table who can handle leakage and smoke evacuation during the surgery [Figure 4]
  13. If possible, all CO2 gas and smoke should be captured with an ultrafiltration system. A number of commercial devices are available including ViroVac®(ConMed), RapidVac™ (Medtronic), PneumoClear (Stryker), MegaVac™ Plus (Ethicon), and S-PILOT®(Karl Storz), and it is recommended to procure one such system during the preparation period [Figure 5]
  14. Pneumoperitoneum should be evacuated from the port attached to the filtration device before trocar removal, specimen extraction, declamping of drain, or conversion to open [Figure 6]
  15. The patient should be flat and the least dependent port should be used for desufflation
  16. Surgical drains and nasogastric tubes should be avoided. If used, the drain should be clamped until complete desufflation
  17. Port closures in the deflated obese abdomen should be done carefully and if need be, incision should be extended by a few millimeters for this
  18. Improvisation for smoke evacuation used in early days [Figure 7] and [Figure 8] should be abandoned and dedicated equipment as mentioned above should be used.
Figure 2: Tight trocar

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Figure 3: Simultaneous suction

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Figure 4: Robotic surgery

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Figure 5: Smoke evacuator

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Figure 6: Smoke evacuator

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Figure 7: Innovation smoke evacuator

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Figure 8: Innovation smoke evacuator

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Data of all minimally access and robotic surgeries performed since the first declared COVID-19 case in India were analyzed [Table 1] and [Table 2]. We looked at operative times, patient stay in the hospital, postoperative development of COVID-19 infection, and health status of the healthcare workers involved.
Table 1: Surgeries done

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Table 2: Classification of surgeries

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  Results Top

A total of 84 surgeries were done during this period.

Three surgeries were postponed due to a positive COVID-19 test. These three patients are yet to get their surgery done.

Postoperatively, two patients needed intensive care unit admission for medical reasons. Three patients had surgical-site infections that were managed conservatively. There were no readmissions in the 30-day postoperative period. There was no postoperative mortality. None of the patients developed COVID-19 infection postoperatively.

  Discussion Top

The novel coronavirus (SARS-CoV-2/COVID-19) has spread worldwide causing acute respiratory illness. This has led to proactive decisions by hospitals to reduce the risk of infection.

While trying to handle the large number of infected patients with urgent and nonurgent problems, the medical resources have been utilized for their treatment. This has led to postponement and cancellation of nonurgent surgeries, also known as elective operations. Patients with gall stones, hernias, and hemorrhoids that form the bulk of any surgical practice have had to suffer, and a lot of them have landed in complications. Other diseases which affect the quality of life such as morbid obesity have also taken the brunt with a marked reduction in the number of bariatric surgeries.

Surgical societies have issued guidelines for surgeons in terms of appropriate surgical practice during the ongoing viral pandemic. Some questions have been raised regarding the safety of performing minimally invasive surgery.

Concerns have risen from a fear that the environment created in a pneumoperitoneum during laparoscopy creates a stagnant volume of gas in the abdominal cavity, which may lead to a concentrated aerosolization of the virus.[4]

With careful steps as outlined above, minimally access and robotic surgery would actually turn out to be beneficial for the following reasons:

  1. Reduced lengths of hospital stay compared to open surgery and faster recovery times
  2. Reduce the need for medical treatments, and
  3. Maximize the bed availability and other crucial resources.

Vigneswaran et al.[5] after a review of the current scientific knowledge regarding viral transmission during laparoscopic and open surgery, found no evidence to support open surgery over laparoscopic for reducing viral transmission. Other authors also have found some of the earlier mentioned measures useful in reducing the risk of infection.[6]

RT-PCR should be considered for all patients undergoing planned surgery. It has false-negative rates for which we need to have additional precautions.[7]

Hence, it is important for all surgical staff to wear additional PPE during elective operations, whether open, laparoscopic, or robotic. Wearing additional PPE comes with difficulties to the surgeon, as it restricts mobility, limits peripheral vision, and can be quite frustrating in long-duration surgeries and complex situations. Surgeons who have been performing many surgeries a day in the past find it tiring to do even half the number of surgeries.

The OT staff should be trained in correct donning and doffing, and there are technical and administrative steps needed for ventilation of the OT.

The total time taken per surgery can be increased by an hour in these circumstances, and this needs to be factored in when planning surgeries.

  Conclusions Top

Analysis of the risk–benefit shows that minimally access laparoscopic and robotic surgeries should be performed when appropriate, with specific adherence to local policies which would be based on national and international guidelines.

We have successfully carried out surgeries though in lower than usual numbers without any adverse effects on the health of patients and the hospital staff.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

World Health Organization. Coronavirus Disease 2019 (COVID-19) Situation Report – 87; April 27, 2020. Available from: https://www.who.int/docs/default-source/coronaviruse/situation-reports/20200427-sitrep-98-covid-19.pdf?sfvrsn=90323472_4. [Last accessed on 2020 Jul 28].  Back to cited text no. 1
Kerala ConfirmedFirst Novel Coronavirus Case in India. India Today; 30 January, 2020.  Back to cited text no. 2
Evolutionary History of Life. COVID-19 Pandemic in India; 2020. Available from: https://en.wikipedia.org/wiki/COVID-19_pandemic_in_India. [Last accessed on 2020 Jul 29].  Back to cited text no. 3
Olson MT, Triantafyllou T, Singhal S. Resumption of elective surgery during the COVID-19 pandemic: What lessons can we apply? Eur Surg 2020;52:1-3. [doi: 10.1007/s10353-020-00645-0].  Back to cited text no. 4
Vigneswaran Y, Prachand VN, Posner MC, Matthews JB, Hussain M. What is the appropriate use of laparoscopy over open procedures in the current COVID-19 climate? J Gastrointest Surg 2020;92:903-8.  Back to cited text no. 5
Francis N, Dort J, Cho E, Feldman L, Keller D, Lim R, et al. SAGES and EAES recommendations for minimally invasive surgery during COVID-19 pandemic. Surg Endosc 2020;34:2327-31.  Back to cited text no. 6
Li Y, Yao L, Li J, Chen L, Song Y, Cai Z, et al. Stability issues of RT-PCR testing of SARS-CoV-2 for hospitalized patients clinically diagnosed with COVID-19. J Med Virol 2020;92:903-8. [doi: 10.1002/jmv.25786].  Back to cited text no. 7


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]

  [Table 1], [Table 2]


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