The Argentine Society of Laparoscopic Surgery letter on COVID-19.

To the Editor:

Argentina does not escape the current world crisis that is due to the worldwide outbreak of the coronavirus disease (COVID-19). We are astonished at the speed in the worsening of the epidemiologic situation at the international level, the incredible transmission capacity, and its unpredictable repercussion.

The Argentine Society of Laparoscopic Surgery, through its board of directors, has elaborated norms not only for “the medical act” but also to direct the care and protection of our surgeons, operating room personnel, and patients. We have resorted to the use of virtual tools to avoid interruption of our continuing medical education and board meetings.

We have conducted a comprehensive analysis and evaluation of the available reported protocols and guidelines in our country and internationally. Some of the organizations that were reviewed included, but were not limited to, our national, provincial, and municipal public health reports, as well as the guidelines provided by our Argentine societies: surgery (Argentine Association of Surgery), anesthesiology (Argentine Federation of Associations, Anesthesia, Analgesia and Reanimation), infectious disease (Argentine Society of Infectology), gynecologic oncology (Argentine Association of Oncological Gynecology), and reproductive medicine (Argentine Society of Reproductive Medicine) and those of the various international organizations: American Society of Laparoscopic Gynecology (American Association of Gynecologic Laparoscopists), American College of Surgeons, International Society of Gynecological Oncology (International Gynecologic Cancer Society), and Spanish Surgical Society (Spanish Association of Surgeons).

As a result, we adhere to the globally provided recommendations (subject to continuous review) and advise our healthcare personnel on the following:

Guidelines on elective surgery

Elective surgeries are suspended. We are evaluating the continuity of this recommendation.

Emergency surgeries are performed according to medical criteria.

Oncologic surgeries are prioritized according to medical criteria (weighing COVID-19 mortality against oncologic mortality, especially in high-risk patients).

Guidelines on the use of personal protective equipment (PPE) during surgery

PPE is used in cases of patients who are positive for or suspicious of COVID-19.

PPE is not used in cases of patients who are negative for COVID-19.

Guidelines on the surgical approach: laparoscopic versus laparotomic

We believe that we should not modify our preferred surgical approach and technique because it would be safer to the patient and the team. These should be based on a medical criterion, including patients with surgical emergencies and severe acute respiratory syndrome coronavirus 2 infection.

–COVID-19 negative case: laparoscopy (specialist surgeon, PPE 2 [surgical chinstrap, coat, gloves, hat and goggles or diving suits], non-COVID operating room)

–COVID-19 positive case: laparoscopy (expert surgeon, PPE 3 [chinstrap N-95, anti-fluid long-sleeved gown, surgical gown under the gown, gloves, hat, goggles and diving suits, leggings], COVID operating room)

Guidelines for vaginal and hysteroscopic surgery:

If a vaginal and/or hysteroscopic approach is required, the same recommendations as those for the abdominal approach are used.

Specific recommendations to minimize severe acute respiratory syndrome coronavirus 2 transmission risk 1, 2, 3, 4:

Surgeries should be performed by an expert surgeon

Not being in the operating room during the endotracheal intubation/extubating procedure [5]

Limit surgical personnel to a bare minimum to run a safe operating room

Use of PPE as recommended [6,7]

Minimal or no use of energy

Low pressure pneumoperitoneum; optimal <12 mm Hg

Avoid steep Trendelenburg position

Surgical instruments in optimal conditions according to each surgeon's preference cart

Surgical devices to filter released carbon dioxide gas

Thoroughly aspirate the pneumoperitoneum before removing trocars and/or surgical specimens

By working together and permanently and with a strength of spirit, we hope to overcome the adversity we face.