How to prevent uncontrolled abdominal desufflation during laparoscopy in times of the coronavirus pandemic.

Aerosolization during laparoscopy poses a theoretical risk of infection to healthcare providers by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). A simple, low-cost method of controlled abdominal desufflation during laparoscopy is described.

Due to widespread community transmission of the coronavirus disease 2019 (COVID‐19) in most countries, it is possible that patients who require emergency/essential abdominal surgery could be asymptomatic carriers. Laparoscopic surgery has become the gold standard for many abdominal procedures and there is concern that carbon dioxide (CO2) that escapes during abdominal desufflation may aerosolize virus particles from an infected patient. The risk of infection to healthcare workers in this manner is unknown at this point. Angiotensin‐converting enzyme‐2 receptor, the binding site for COVID‐19, is highly expressed in the digestive system. It is well documented that the virus is actively shed from the gastrointestinal tract of infected patients. Surgeries that transgress the lumen of bowel such as colorectal procedures or contaminated surgeries where the peritoneal cavity contains intestinal contents may potentially result in dissemination of the virus into the environment of the operating room when CO2 is desufflated.

Guidelines therefore suggest judicious use of laparoscopy. In fact, laparoscopy offers the advantage of being able to almost entirely contain the surgical plume with potentially viable viral particles in the abdominal cavity. In situations where the risks of avoiding surgery are unacceptable and benefits of laparoscopy are highly desirable, mitigation of risk (however small) due to aerosolization seems prudent. We describe the use of a closed system of gas evacuation from the peritoneal cavity using readily available, low‐cost, disposable equipment.

Gas can be desufflated slowly from one of the 5‐mm ports by attaching a heat moisture exchange (HME) filter and connecting it to the first bottle of a two‐bottle intercostal drainage apparatus. It is in turn connected to the second bottle which is connected in series to a mobile suction apparatus which has two bottles of 4 L capacity each (Fig. 1). All bottles are filled with water to half capacity. Hypochlorite solution (1–2.5%) can be an alternative to water as it has viricidal properties. The suction cannula can also be connected to the same closed system. At the end of the surgery, before specimen extraction, insufflation is stopped; CO2 is desufflated in a controlled manner through the suction cannula and the 5‐mm port to which the HME filter is attached. The technique is demonstrated in Video S1.

Fig 1

(a) Heat moisture exchange filter (arrow) attached to the 5‐mm port using in turn a 3.5 size endotracheal tube connector (arrow head) and a three‐way connector. The egress tubing should fit snugly and is connected to the closed suction intercostal tube drainage bottle system (b). This is in turn connected to the two‐bottle system (c) which completes the closed system for smoke evacuation during laparoscopic surgery, depicted schematically in (d). The solid black arrow depicts inlet for carbon dioxide.

Although there is no conclusive evidence that this practice will prevent the spread of infection to healthcare workers, the rationale for using both the HME filter and the closed suction drainage is sound. The COVID‐19 virions are approximately 0.125 μm in size and are most commonly transmitted as larger (> 20 μm) respiratory water droplets. The virus may also be aerosolized and transmitted in smaller droplets (<10 μm) in gas suspension. As per most manufacturers, the HME filter is highly efficient (99.99%) in filtering out microbes by both mechanical and electrostatic properties. We have used the Clear‐Therm from Intersurgical (Wokingham, Berkshire, UK) but any standard HME filter should serve the purpose. The closed circuit for gas evacuation ensures no leakage of potential aerosols into the atmosphere of the operating room. The cost of the intercostal drainage set and the HME filter is less than 50 USD. Although the evidence for spread of COVID‐19 by aerosolization during laparoscopy is not documented, using simple, cost‐effective precautions as opposed to doing nothing seems reasonable.

Commercially available smoke evacuation devices are expensive (10 000 USD and above) and may not be affordable by all. Even so, with these devices, the filtered gas is vented into the atmosphere of the operating room. The system described herein can be used by any centre and can be a useful adjunct even if commercial devices are being used. Appendix S1 briefly reviews current knowledge about spread of SARS‐CoV‐2 during laparoscopy and risk mitigation strategies.

Appendix S1. Aerosolization of SARS‐CoV‐2 during laparoscopy: current status, risk mitigation strategies.

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Video S1. Demonstration of controlled gas evacuation using a low cost, closed circuit during laparoscopy.

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