Authors' response: Laparoscopy and COVID-19: An off-key song?

Dear Editor,

We thank Tebala et al. for their interest and comments on our article.[1] At the end of their letter, the authors point out that “resources and expertise are widely available” during coronavirus disease 2019 (COVID-19) outbreak and a restrictive use of laparoscopy would have been acceptable only in a war scenario. Unfortunately, the current data resemble many features of this kind of scenario, with shortage of personnel, reduction of surgical services, operating rooms converted in intensive treatment unit (ITU) beds, and surgeons shifted to medical tasks as a global response to the pandemic.[2] As of May 12, 2020, 163 doctors died after contracting COVID-19 in Italy,[3] and health workers are heavily affected globally. In this setting, any additional source of contagion may produce catastrophic effects and threat the entire health system. A tailored strategy to protect health workers and patients, avoiding unnecessary risks, is a priority.[4,5]

A second worst pandemic wave, as in the Spanish flu, cannot be excluded, and a self-preserving strategy must be already in place to guarantee an adequate surgical response in the future outbreak peaks, despite the shortage of personnel, beds, and operating rooms.

Regarding the lack of evidence of SARS-CoV-2 presence in the peritoneal fluid, some anecdotal evidences are emerging. Viral RNA was detected in the peritoneal fluid of a COVID-19 patient who had undergone a laparotomy for a nonischemic small bowel volvulus[6] and in the peritoneal waste of a patient treated with peritoneal dialysis.[7] Thus, a prudential approach may be reasonable until definitive evidence is established. Several systems for a safe smoke and pneumoperitoneum evacuation during laparoscopy have been described,[8] but they are time-consuming and add a further burden of intraoperative maneuvers. Furthermore, some operative steps, such as a rapid conversion because of a major bleeding or trocars' removal under vision at the end of the procedure, may compromise a thorough gas exsufflation and, then, may potentially increase the risk of aerosolization and smoke dispersion in the operating theater.

In experienced hands, laparotomy is a quick and gasless procedure with no significant differences in the long-term outcomes compared with laparoscopy.[9]

According with many surgical societies,[10] we recommend to implement nonoperative management strategies whenever clinically appropriate. Thus, treating by laparotomy a reduced number of high-priority elective cases and surgical emergencies (sometimes failures of nonoperative management and, then, associated with a nonnegligible risk of conversion) may represent the safest option for patients, health workers, and system sustainability during the critical periods of COVID-19 outbreak.