Transcription:
Is Laparoscopic Surgery Safe During COVID-19?

Melanie Cole, MS (Host):   This is the Northwestern Medicine podcast on COVID-19 dated April 22, 2020. Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole and today we’re discussing laparoscopy during the COVID-19 pandemic. Joining me is Dr. Magdy Milad. He’s the chief of gynecologic surgery in the department of obstetrics and gynecology at Northwestern Medicine and the Albert B. Gerbie professor of obstetrics and gynecology. Dr. Milad, it’s a pleasure to have you join us today. You recently published a perspective piece on laparoscopy as a safe surgical approach during COVID-19. Can you give us a brief summary and help us to understand really the scope of the problems?

Magdy Milad, MD, MS (Guest):   Amongst surgeons there's a lot of fear associated with this SARS-CoV-2 virus and its associated COVID-19 infection. Right now most hospitals, including Northwestern Medicine, are really doing just emergency surgeries and taking maximum precautions in the absence of being able to preoperatively test everybody, which is coming around the corner. So as a result of this maximum approach, the question has come up to whether we ought to be avoiding certain types of surgical approaches that might put surgical personnel at risk. Specifically should we be doing laparoscopy in patients that are COVID positive?

Host:   Well then explain to us why some members of the surgical community have challenged the use of laparoscopy. Tell us about some of their concerns and risks. Have you seen this as a common? Are they really concerned? What have you heard?

Dr. Milad:   Well for sure. Yeah, there's the whole range from people who are absolutely ardent laparoscopy is the safest thing to we should be opening every single person. So as we think about this, we should take a step back. When we do surgery whether it’s by laparoscopy or by open surgery, we make use of energy devices, electrical devices. Some people call it cautery devices. When we use those types of generators, it creates what’s called surgical plume. Plume can be defined as smoke and biologic matter. So it’s sort of like the stuff that’s being generated when you apply electrical energy to tissue. The smoke is essentially like cigarette smoke. It’s hundreds of different types of toxins and carcinogens and so on. We know from decades of experience that that sort of material can be toxic. Toxic to the surgical staff, toxic to the patient. Then there's also the biologic matter. So the question has been could there be the SARS-CoV virus in the tissue that we’re operating on in the pelvis. So that’s been the concern.

Host:   Wow. This is such an interesting topic. You and many professional organizations have strongly recommended laparoscopy for urgent gynecologic procedures during this pandemic. Explain a little bit how using it greatly outweighs the risk of using laparotomy both for your patients and for healthcare professionals.

Dr. Milad:   When I looked into this, every society that I looked into came out with an endorsement for laparoscopy as something that should be considered given the current data. Admittedly, things change. All we can do is evidence based medicine. The evidence right now points to laparoscopy as being considered safe. It’s important to sort of take a step back and think about what is the SARS-CoV virus. It’s an RNA virus. It’s almost exclusively respiratory. So it’s considered a respiratory pathogen. It travels typically in large droplets. So droplets that are above 100 microns in diameter and as a result during coughing it’s sort of is drawn with gravity to surfaces. Then there's the hand to face contamination. Then there's the question about aerosols. There's been a lot discussed about aerosol transmission. While it’s possible, there's not really well documented case of these types of viral particles that are really tiny—less than five millimeters in diameter—that sort of become airborne sort of like hairspray and just float around and stay in the air for hours at a time. So while it’s definitely debated, it’s not really something that’s been well documented.

So here it is. This is respiratory pathogen. It really has not been found outside of the respiratory system with the exception of in a small percentage of patients it’s been found in the blood stream, but at very low levels. It’s 1,000 less in the blood than it is in the respiratory system. It’s been found in stool, neither of which have been shown to be infectious. So it doesn’t seem like these viral particles are in the pelvis. If you take vertical transmission, like in a woman who is pregnant, could the uterus be somehow infected with the SARS-CoV virus sort of a thing. There really hasn’t been any incredible evidence to suggest that there are viral particles in the amniotic fluid, in cord blood, or in women that are COVID positive that give birth among those children. There were a couple of cases that were reported, but those cases the babies were immediately exposed to the mother and it’s thought that maybe those children were exposed after birth. Not necessarily before birth. So we’re not finding viral particles in the pelvis. We’re not really finding it at high levels in the blood stream. Even if we find those particles, it’s not necessarily infectious.

Host:   Well then I’d like to expand on that for a minute since there are so many unknowns about this virus, including as you just discussed about other regions of the body that it might be located in. You’ve mentioned the pelvis. Can it be potentially transmitted during laparoscopic procedures? What have you seen, doctor, with other pathogens like HIV, hepatitis? How does this influence your recommendations and approach?

Dr. Milad:   I mean as far as we know, we’re not finding it in the pelvis. We’re not finding it at infectious levels in the blood stream. So it doesn’t seem to be there. If we take the lessons from other viruses—for example, the SARS-1 virus or the MERS virus or even influenza—we don’t find a higher risk of transmission from the surgical plume at surgery. So we’re not seeing surgical personnel getting these infections because we were operating on those patients. In fact, if you take influenza you don’t even find genetic material from influenza in the blood stream. So it doesn’t seem like it’s really in the pelvis nor is it being transmitted in that surgical plume and the smoke that’s generated during surgery.

Host:   Well then for providers and for surgeons, what are some of the precautions that they can take to minimize the risk of exposure during laparoscopic procedures? Tell us a little bit about minimizing personnel during intubation and, as you said, managing the surgical plume. Speak about all of those precautions that you're taking right now.

Dr. Milad:   Exactly. It’s all about safety first. So the most important thing is that it’s a respiratory pathogen. The number one risk to the surgical personnel is during intubation and during extubation. So why not minimize personnel during that critical phase? Why are the surgeons in the room during intubation and extubation? They can certainly be outside the room. Obviously making use of protective equipment and making sure you put it on properly and take it off properly. Preoperative testing, by far, is probably the most important thing once that’s available. Room air filtration. So we want negative filtration to sort of suction up any kind of respiratory droplets since that’s the number one risk factor. Of course, sterilization of surgical surfaces, which we always do.

Then during laparoscopy itself, we’ve now had decades of experience with plume being toxic. So we should be managing that plume laparoscopically for the safety of the surgical personnel the way we did before, which we is keeping pressures in the abdomen low, making sure that the trocar sites are tight so there isn’t leakage along those sites, making use of minimal energy. So electrical energy, just making use of just enough for what we use. Then filtering whatever outflow there is. We don’t want to release the gas from the abdomen into the environment. That would be potentially dangerous separate from SARS. Just dangerous from those other toxins that we talked about and the smoke.

So we want to have a filter hooked up to the outflow. There’s HEPA filters and there’s ultralow filters called ULPA filters. These filter out very fine particles and droplets. So even if there are particles in the pelvis and even if those particles are infectious, these filters should really filter out to keep the surgical staff safe. Then finally at the end of the case, we want the abdomen to be empty of the gas. We don’t want to release that into the environment. So we want to decrease the gas through the filter, through suction, and not just sort of like open it up into the environment.

Host:   Well that’s an incredible protocol doctor. So before we wrap up, what else do gynecologists and surgeons need to know about COVID-19 to help manage their patients? Why is laparoscopy considered safe during this pandemic?

Dr. Milad:    I would probably reverse the question. What if we converted all of our elective case to laparotomy that we could have done laparoscopically? We have not eliminated the risk of surgical plume. In fact, it’s just the opposite. Now we’ve exposed the staff even more because it’s very difficult to scavenge the plume at open surgery. It’s very difficult to suction up that smoke whereas at laparoscopy we keep that gas in the abdomen and then we have control over it. So we've really made it worse if it is indeed in the plume. We’ve also increased the risk of complications like blood loss and incisional complications. With open surgery, they have a prolonged hospitalization. We’re making use of inpatient beds that those patients could have gone home. We make use of ICU beds that are critical for patients that have COVID-19. So it’s very poor use of resources. Then, of course, we’re exposing our patients who were COVID negative to potentially COVID positive asymptomatic carriers. Our nurses, our staff, our doctors could be positive and they're rounding on those patients and potentially exposing them where they would have been home if they hadn’t been opened. Then obviously the cost. So I think in the effort to sort of do the right thing, I would strongly recommend based on the data we have now to continue to use laparoscopy as our method of access of choice.

Host:   Really such an interesting topic. Thank you so much. You’ve made so many great points today. For other gynecologists and surgeons, thank you for joining us Dr. Milad. That wraps up this episode of Better Edge, a Northwestern Medicine podcast for physicians. To refer your patient or for more information on COVID-19, please visit our website at nm.org to get connected with one of our providers. Please remember to subscribe, rate, and review this podcast and all of the other Northwestern Medicine podcasts. I'm Melanie Cole.