A word of caution and call for cross-society collaboration to develop surgical guidance about COVID-19.

Editor

Experience from past weeks confirms that the impact of the COVID-19 pandemic on surgical systems is likely to last longer than anticipated, and might have already fundamentally changed the way we think surgical services should be organized.

As a response to this crisis, several societies have released guidelines that can be accessed on their websites to provide surgeons with directives useful for protecting themselves and their patients. Owing to the very nature of this contribution, it is not possible to reference all guidelines published to date, but most readers will be familiar with several of them.

In fact, most guidelines do not cover all areas of interest to surgeons and managers, and several recommendations should be combined to give a more exhaustive view, embracing all relevant facets.

The authors recognize the importance of society statements in helping surgeons and institutions make decisions when faced with an unprecedented situation. There are times when evidence is not available, and expert opinion or the experience of those who work in areas first hit or affected more heavily by COVID-19 can provide insight and guidance to fellow colleagues, but some considerations have to be made.

Only moderate agreement can be found concerning indication and modality of screening (especially for healthcare workers), and use/re-use of personal protective equipment. Minimally invasive surgery represents another area of debate, and many guidelines do not distinguish clearly between COVID-negative and COVID-positive patients. The authors feel that, unless proven otherwise, aerosol-generating procedures should be dealt with using all precautions available; although to date, there are no data on the presence of SARS-CoV-2 in laparoscopic plumes or surgical smoke. It would be interesting to have a plan to address this aspect.

Crisis derives from the Greek word κρίσις, meaning choice or decision. When the pandemic is under control and we are in the immediate post-COVID-19 era, the decision should be made to incorporate remote consultation and telemedicine into clinical practice. Almost all societies recommend telemedicine; but no detailed guidance is provided on how to effectively prepare services and patients for this relatively novel approach.

Few guidelines address some aspects that might need further consideration, i.e. precautions to be used by patients and conditions that do not affect life itself, but rather quality of life. The latter can be regarded as of secondary relevance when there is a looming existential threat, but appropriate safety nets are needed to protect those with chronic conditions that cannot access their treatments[4,5].

Available guidelines are being updated regularly, and should be considered dynamic statements; however, the authors suggest that the responsible entities consider including the level of evidence underlying each statement, particularly for newly added recommendations. If expert opinion is used to formulate a statement, this should be clearly explained and consistently justified. In the setting of a pandemic, international societies should commit to a collaborative effort to draw recommendations grounded in more robust or agreed pillars, as these are more likely to be adopted globally.