COVID-19: Pandemic Surgery Guidance

4open 2020, 3, 1
Ó B.L.D.M. Brücher et al., Published by EDP Sciences, 2020

https://doi.org/10.1051/fopen/2020002
Available online at:

www.4open-sciences.org
BRIEF REPORT
COVID-19: Pandemic surgery guidance

Björn L.D.M. Brücher1,2,3,*, Giuseppe Nigri4, Andrea Tinelli5, Jose Florencio F. Lapeña Jr.6, Eloy Espin-Basany7,
Paolo Macri8, Edouard Matevossian9, Sergio Ralon10, Ray Perkins11, Rainer Lück12, Rainer Kube3, Jose MC da Costa13,
Yoav Mintz14, Mesut Tez15, Sixtus Allert16, Selman Sökmen17, Arkadiusz Spychala18, Bruno Zilberstein19,
Frank Marusch20, Mohammad Kermansaravi21, Witold Kycler18, Diego Vicente22, Michael A. Scherer23,
Avraham Rivkind14, Nelson Elias24, Grzegorz Wallner25, Franco Roviello26, Lúcio Lara Santos27,
Raimund J.C. Araujo Jr.28, Amir Szold29, Raúl Oleas30, Marjan Slak Rupnik1,2,31, Jochen Salber32,
Ijaz S. Jamall1,2,33, Alexander Engel34, for the Pandemic Surgery Guidance Consortium (PSGC)
1
Theodor-Billroth-AkademieÒ, Germany, USA
2
INCORE, International Consortium of Research Excellence of the Theodor-Billroth-AcademyÒ, Germany, USA
3
Department of Surgery, Carl-Thiem-Klinikum, Cottbus, Germany
4
Department of Medical and Surgical Sciences and Translational Medicine, Sapienza University of Rome, St. Andrea University
Hospital, Rome, Italy
5
Department of Obstetrics and Gynecology, Veris delli Ponti Hospital, Scorrano, Lecce, Italy
6
Department of Otorhinolaryngology, College of Medicine-Philippine General Hospital, University of the Philippines Manila, Manila,
Philippines
7
Department of Surgery, Vall d’Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
8
Department of Thoracic Surgery, Istituto Clinico Humanitas CCO, Catania, Italy
9
Department of Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
10
Department of Surgery, Hospital General San Juan de Dios, Universidad de San Carlos de Guatemala, Calle, Guatemala
11
New Liberty Proteomics Corporation, New Liberty, KY, USA
12
Department of Surgery, Sana Klinikum Hameln-Pyrmont, Hameln, Germany
13
Centro de Imunologia e Biologia Parasitária, Scientific Director of Center for Study in Animal Science, ICETA, University of Porto,
Porto, Portugal
14
Department of General Surgery and Shock Trauma Unit, Hadassah-Hebrew University Medical Center, Ein Kerem,
Jerusalem, Israel
15
Department of Surgery, Ankara Numune Hospital, Ankara, Turkey
16
Department of Plastic, Aesthetic and Hand Surgery, Sana Klinikum Hameln-Pyrmont, Hameln, Germany
17
Colorectal and Pelvic Surgery, Dokuz Eylül University Hospital, Medipol University, Izmir, Istanbul, Turkey
18
Gastrointestinal Surgical Oncology Department, Greater Poland Cancer Centre, Poznan, Poland
19
Cancer Institute, Hospital das Clínicas, School of Medicine, University of São Paulo, São Paulo, Brazil
20
Department of Surgery, Ernst von Bergmann Hospital, Potsdam, Germany
21
Minimally Invasive Surgery Research Center, Iran University of Medical Sciences, Tehran, Iran
22
Department of Surgery, Uniformed Services University of the Health Sciences & the Walter Reed National Military Medical Center,
Bethesda, MD, USA
23
Department for Orthopedics and Trauma Surgery, Helios Amper Hospital Dachau, Dachau, Germany
24
Orthopedic Department, Vila Velha Hospital, Vila Velha, Espirito Santo, Brazil
25
Department of Surgery, Medical University of Lublin, Lublin, Poland
26
Surgical Oncology, University of Siena, Siena, Italy
27
Surgical Oncology Department – Portuguese Institute of Oncology, Porto, Portugal
28
Department of Surgery, Federal University of Piauí, Teresina, Piauí, Brazil
29
Assia Medical Group, Assuta Medical Center, Tel Aviv, Israel
30
Surgical Oncology, HPB and Liver Transplantation, Ecuadorian Cancer Institute, Quito, Ecuador
31
Center for Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria
32
Department of Surgery, UK Knappschaftskrankenhaus, Ruhr University, Bochum, Germany
33
Risk-Based Decisions Inc., Sacramento, CA, USA
34
Department of Colorectal Surgery, Royal North Shore Hospital, University of Sydney, Australia
*Corresponding author: [email protected]

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
2 B.L.D.M. Brücher et al.: 4open 2020, 3, 1
Abstract – Based on high quality surgery and scientific data, scientists and surgeons are committed to pro-
tecting patients as well as healthcare staff and hereby provide this Guidance to address the special issues cir-
cumstances related to the exponential spread of the Coronavirus disease 2019 (COVID-19) during this
pandemic. As a basis, the authors used the British Intercollegiate General Surgery Guidance as well as recom-
mendations from the USA, Asia, and Italy. The aim is to take responsibility and to provide guidance for surgery
during the COVID-19 crisis in a simplified way addressing the practice of surgery, healthcare staff and patient
safety and care. It is the responsibility of scientists and the surgical team to specify what is needed for the pro-
tection of patients and the affiliated healthcare team. During crises, such as the COVID-19 pandemic, the
responsibility and duty to provide the necessary resources such as filters, Personal Protective Equipment
(PPE) consisting of gloves, fluid resistant (Type IIR) surgical face masks (FRSM), filtering face pieces, class
3 (FFP3 masks), face shields and gowns (plastic ponchos), is typically left up to the hospital administration
and government. Various scientists and clinicians from disparate specialties provided a Pandemic Surgery
Guidance for surgical procedures by distinct surgical disciplines such as numerous cancer surgery disciplines,
cardiothoracic surgery, ENT, eye, dermatology, emergency, endocrine surgery, general surgery, gynecology,
neurosurgery, orthopedics, pediatric surgery, reconstructive and plastic surgery, surgical critical care, trans-
plantation surgery, trauma surgery and urology, performing different surgeries, as well as laparoscopy, thora-
coscopy and endoscopy. Any suggestions and corrections from colleagues will be very welcome as we are all
involved and locked in a rapidly evolving process on increasing COVID-19 knowledge.
Keywords: Anesthesia, Cancer, Cardiothoracic surgery, China, Coronavirus, COVID-19, Dermatology,

Elective surgery, Emergency, Endocrine surgery, Endoscopy, ENT, Epidemic, Epidemiology, Europe, Face
masks, General surgery, Germany, Guidance, Gynecology, Inflammation, Italy, Laparoscopy, Laparotomy,
Morbidity, Mortality, N95 masks, Neurosurgery, Orthopedics, Pandemic, Patient safety, Pediatric surgery,
Pneumonia, Protection, Reconstructive and plastic surgery, Surgical critical care, Respiratory masks, SARS-
CoV-2, Sepsis, Surgery, Thoracoscopy, Transplantation surgery, Trauma surgery, Urology, Virus
Introduction conditions to date [9]. After entering the host, the SARS-
CoV-2 genome is transcribed and translated with common
On January 30, 2020 the World Health Organization cold-like symptoms after an incubation time of 2–14 days
(WHO) stated on its Situation Report – 10 that “the Emer- with a mean incubation period of 5.2 days (95% confidence
gency Committee on the novel coronavirus (2019-nCoV) interval [CI]: 4.1–7.0) [3]. The wide spectrum of reported
under the International Health Regulations (IHR 2005) is symptoms includes fever, cough, myalgia and fatigue with
meeting today to discuss whether the outbreak constitutes the most common serious manifestation being pneumonia.
a public health emergency of international concern” [1] Less common symptoms are headache, sputum produc-
and stated on March 11, 2020 in its Situation Report – tion, diarrhea, malaise, shortness of breath/dyspnea and
51, that “. . ..the assessment that the Coronavirus disease respiratory distress and even anosmia, hyposmia, and dys-
2019 (COVID-19) can be characterized as a pandemic” [2]. geusia [10] explain why its impact in COVID-19 patients
COVID-19 is caused by a single-stranded ribonucleic from the ENT perspective was raised [11]. Importantly
acid (ssRNA) virus associated with severe acute respiratory anosmia (loss of smell) as a symptom of COVID-19 infec-
syndrome corona virus 2 (SARS-CoV-2) which was first tion in the absence of other symptoms was reported which
detected in Wuhan, Hubei province in China in December is of significance, as “those patients do not meet current cri-
2019 [3]. COVID-19 is a clade within the subgenus Sarbe- teria for testing or self-isolation” [12].
covirus, Orthocoronavirinae subfamily, but differs from In terms of severity, some 81% are mild (e.g., no or mild
two other strains, the Middle East respiratory syndrome pneumonia), 14% have been reported as being severe
coronavirus (MERS-CoV) and the severe acute respiratory (dyspnea, respiratory frequency 30/min, blood oxygen
syndrome coronavirus (SARS-CoV), and is suggested to saturation 93%, partial pressure of arterial oxygen to frac-
have originated in bats and/or pangolins [4, 5]. tion of inspired oxygen ratio <300, and/or lung infiltrates
Before the outbreak, SARS-CoV-2 circulated among >50% within 24–48 h) and 5% have been noted to be crit-
individuals for several weeks and one way it likely entered ical (respiratory failure, septic shock, and/or multiple organ
Europe was through an unrecognized infection by a traveler dysfunction or failure) with an overall case-fatality rate
from Singapore to France on January 24, 2020 where some (CFR) of 2.3% [13]. It is important to note that patients
21 people were exposed at a ski resort [6]. Coronavirus trans- between the ages of 70–79 years have an 8.0% CFR and
mission occurs by physical contact, and through the inhala- cases 80 years and older have a 14.8% CFR with 49% of
tion or mucous membrane absorption of airborne droplets critical cases reporting a fatal outcome. Taken together,
from infected individuals [7, 8] and contrary to assumptions, some 80% of infections will be mild, and 20% will be mod-
SARS-CoV-2 has shown no weakening in warm and humid erate or seriously ill.
B.L.D.M. Brücher et al.: 4open 2020, 3, 1 3
Figure 1. Calculated assumption of a triple 10% scenario for Germany with 83,783,942 citizens, which has 450,000 hospital beds and
28,000 intensive care unit (ICU) beds although it is a likely underestimation of reality. This figure reveals the necessity of increasing
hospital capacities urgently needed during COVID-19 pandemic. Citizen numbers in accordance to Worldometers Website [14].
(Access at March 19, 2020).
These data have made clear that such an outbreak with Guidance is a simplified way to address decision-making
an exponential increase of infected patients can rapidly for our colleagues and staff performing surgery, for the
overwhelm any healthcare system. To understand why hos- healthcare team and to ensure patient safety and care
pital capacities need to be increased rapidly, an assumption (Fig. 3).
of a triple 10% scenario (a likely underestimation of the Suggestions and corrections from colleagues will be wel-
reality but provided here as an illustration) calculation for come as we are all involved in a dynamically developing
Germany with 83,783,942 citizens, which has 450,000 hospi- process on increasing our collective COVID-19 knowledge.
tal beds and 28,000 intensive care unit (ICU) beds shows Therefore, the proposed recommended steps are listed fol-
that hospital capacities will urgently need to be increased lowed by the rationale for each component of the Guidance.
(Fig. 1, Data retrieved from [14]).
A detailed, complete comprehensive and robust infec-
tion workflow for a COVID-19 case had been proposed Considerations
most recently [15, 16]. Otherwise practical guidance was
(1) Emergency Surgery
missing, until our British colleagues provided on March
26, 2020 the Intercollegiate General Surgery Guidance on
COVID-19 and updated it on March 27, 2020 (Fig. 2) [17]. ! COVID-19-testing and risk assessment.
The following recommendations serve as Pandemic Sur- ! Pneumonia assessment by plain chest X-ray versus 3
gery Guidance during the current exponential spread of the quadrant ultrasound versus thoracic CT.
COVID-19 throughout the world (Fig. 3). ! Every surgery entails higher patient and staff risk.
The objective is to take responsibility to provide guid-
ance for surgery in the COVID-19 crisis in a more practical
way addressing practice, healthcare staff and patient safety.
1 Rationale
As scientists and surgical teams decide what is needed for
1.1 COVID-19-testing and risk assessment
the protection of patients and staff during such a pandemic,
the hospital administration together with the government Each patient should undergo COVID-19-testing including a
have the obligation to provide the necessary supplies such health risk assessment. The European Centre for Disease
as filters, Personal Protective Equipment (PPE) consisting Prevention and Control (ECDC) defined discharge criteria
of gloves, fluid resistant (Type IIR) surgical face masks [18]. In Accordance to the Ministero della salute, Consiglio
(FRSM), filtering face pieces (FFPs), class 3 (FFP3 masks), Superiore di Sanità, Italy (February 28, 2020), “a COVID-
face shields, and gowns (plastic ponchos). The suggested 19 patient can be considered cured after the resolution of
Figure 2. Intercollegiate general surgery guidance on COVID-19 [17].
Figure 3. Pandemic Surgery* Guidance. *Surgery includes surgical procedures by distinct surgical disciplines such as numerous
cancer surgery disciplines, cardiothoracic surgery, ENT, eye, dermatology, emergency, endocrine surgery, general surgery, gynecology,
neurosurgery, orthopedics, pediatric surgery, reconstructive and plastic surgery, surgical critical care, transplantation surgery, trauma
surgery and urology, performing different surgeries, as well as laparoscopy, thoracoscopy and endoscopy.
symptoms and 2 negative tests for SARS-CoV-2 at 24-hour analyzed [29]. After adjusting for age and smoking status,
intervals”. In China, patients considered to be discharged, the following comorbidities with their hazard ratio (HR)
need to meet the following criteria: afebrile for >3 days, and 95% CIs were determined:
Improved respiratory symptoms, pulmonary imaging shows
obvious absorption of inflammation, and nucleic acid tests COPD (HR: 2.681, 95% CI: 1.424–5.048);
negative for respiratory tract pathogen twice consecutively Diabetes mellitus (HR: 1.59, 95% CI: 1.03–2.45);
(sampling interval 24 h). Currently, the recommendation Hypertension (HR: 1.58, 95% CI: 1.07–2.32); and
is improved clinical signs plus two 2 negative tests for Malignancy (HR: 3.50, 95% CI: 1.60–7.64).
SARS-CoV-2.
Nucleic acid amplification tests (NAAT), such as real- Patients were further stratified in accordance with com-
time polymerase chain reaction (RT-PCR) are mandatory. posite endpoints in terms of numbers of comorbidities as a
Information about specimen collection and procedures are greater number of comorbidities correlated with poorer clin-
available from the WHO [19]. At present, RT-PCR is the ical outcomes:
gold-standard performed on nasopharyngeal and/or throat
specimens in accordance to the Centers of Disease Control 1 comorbidity (HR: 1.79, 95% CI: 1.16–2.77);
(CDC) with a high specificity (low/no rate of false positive 2 comorbidities (HR: 2.59, 95% CI: 1.61–4.17).
findings) but with a low sensitivity ([20, 21] reviewed in
[22]). There is a dynamic process of development of new Clinically it is urgently necessary to stratify COVID-19
serological assays and their approval by the regulatory patients before admission and/or any surgical procedures
agencies. during the COVID-19 pandemic.
A recent study showed that negative SARS-CoV-2 Laboratory tests in COVID-19 patients often show a
nasopharyngeal testing does not mean that the individual decrease of platelets and lymphocytes with increases of lac-
is not infected as 8 out of 10 children with negative tate dehydrogenase (LDH), troponin, C-reactive protein
nasopharyngeal testing revealed persistently positive rectal (CRP), D-dimer, serum ferritin, and interleukin 6 (IL-6)
swabs testing suggesting the possibility of fecal–oral trans- [25]. A recommendation using a specimen collection kit with
mission [23]. This is concordant with the most recent instructions has been developed and is in accordance to the
findings that COVID-19 was measured in sewage provided CDC criteria [30].
3 weeks before the first case was reported in the Nether-
1.2 Pneumonia assessment e.g. by plain chest
lands [24].
X-ray/3 quadrant ultrasound/thoracic CT
Despite the need for clinicians to be aware of false nega-
tive tests, and although RT-PCR is the gold-standard, rapid Early COVID-19 infection and effects on the lungs are cru-
tests may be considered such as IgG/IgM antibody lateral cial in this pandemic, as the disease dynamics in many
flow assay or nCoV-19 Antigen in NP swabs. In Wuhan, reported patients can occur within a couple of days result-
China, “throat-swab specimens were obtained for SARS- ing in increased mortality. Pneumonia assessment can be
CoV-2 PCR re-examination every other day after clinical done alongside clinical investigation and auscultation e.g.,
remission of symptoms, including fever, cough, and dyspnea, by plain chest X-ray, 3 quadrant ultrasound, and thoracic
but only qualitative data were available” [25]. computed tomography (CT). Although controversial, chest
The WHO released early guidance for laboratory screen- CT should be considered and where indicated, an abdomi-
ing [19, 26]. Because it takes 5–10 days to make IgM anti- nal CT or an additional chest CT scan should be taken into
bodies (and IgG antibodies develop later), there will be a consideration as well.
high false negative rate for IgG/IgM tests among those Chest CT might contribute as an early diagnostic and
tested early without symptoms. Around day 10 after symp- monitoring tool for COVID-19 pneumonia. Patients with
tom onset, IgG and IgM antibodies increased with serocon- chest CT scans and signs of pneumonia could be quaran-
version within 3 weeks [27]. tined while waiting for RT-PCR test results but it needs
The ECDC released on March 25, 2020 the 7th update to be taken into account that chest CT in COVID-19
of a rapid risk assessment [28]. However, this document patients reveals a high specificity between 93 and 100%
describes the dynamics of the COVID-19 pandemic in Eur- but a moderate sensitivity of between 72 and 94% [31].
ope as rapid information but does not provide a risk assess- Additionally, chest CTs might help to stratify patients
ment for practical use. Health care employees need a risk especially in the absence of rapid access of COVID-19 test-
assessment for patient triage. To meet these needs, various ing, although a negative chest CT might not exclude
hospitals individually have developed a risk assessment to COVID-19 infections [32].
try to stratify the decision-making process of where each Some have argued that the chest CT should not be part
patient should be triaged. of COVID-19 diagnostic criteria [33–37], while others favor
Recently the date providing endpoints, such as of CT scans [38–43]. One major argument for performing a
admission to intensive care units, or invasive ventilation, CT chest scan is the fact that pneumonia was radiologically
or death from 1590 laboratory-confirmed hospitalized diagnosed in some 67% of COVID-19 negative cases and in
patients in 575 hospitals in 31 province/autonomous 94% of COVID-19 positive patients [44]. In Hubei, China,
regions/provincial municipalities across mainland China CT findings were included as evidence of clinical diagnosis
between December 11, 2019 and January 31, 2020 were of COVID-19 patients [45] while this recommendation was
removed in the sixth published version [46]. Even the rates of Centers for Medicare and Medicaid Services (CMS) released
RT-PCR confirmed COVID-19 infections and synchronous on March 18, 2020 a tiered framework as potential help for
normal CT-findings vary greatly between 2% [47, 48] and hospitals and health systems to evaluate suspected
56% [49]. COVID-19 needs [55]. On March 19, 2020, the CMS
together with the CDC recommended postponing elective
1.3 Every surgery entails higher patient and staff risk surgery in a press release [56]. The United Kingdom reacted
on March 17, 2020 [57].
In general, every kind of surgery (including endoscopies and
Citing evolving evidence from China, Italy and Iran that
minimally invasive surgery, such as laparoscopy, thora-
otolaryngologists were among the highest risk group of
coscopy) is seen as entailing higher risks.
contracting the virus while performing upper airway proce-
dures and examinations, the American Academy of
(2) Planned Surgery Otolaryngology Head and Neck Surgery AAO-HNS) issued
a policy statement limiting care to time-sensitive and emer-
! COVID-19-testing and risk assessment. gent problems and the routine use of appropriate PPE
! Walking/climbing stair-test & blood gas. when treating patients in all age groups [58].
! Postpone if possible (every surgery entails higher
patient risk). 2.4 Determine planned list and execute cancelation
! Determine planned list and execute cancelation. Complex surgery which itself is associated with higher mor-
bidity and mortality should be deferred [59]. The ACS has
provided guidelines for triage to potentially determine
2 Rationale planned lists of those procedures which can be canceled
[60]. This decision is a clinical one depending on the patient,
2.1 COVID-19-testing and risk assessment (see 1.1) hospital infrastructure and actual local COVID-19 burden.
2.2 Walking/climbing stair-test and blood gas (3) Strategy

Easy, inexpensive, and almost forgotten approaches con-
sist of walking/climbing stair-test and blood gas analysis. ! Prefer Non-surgical approach
For example, the 2 stairs climbing capacity with post-test ! conservative if justifiable
pO2 > 91% has peri-operative prognostic importance [50].
! Consider Risk Reduction (for patients and staff)
2.3 Postpone if possible (every surgery entails higher ! Surgery in selected cases only
patient risk) ! Risk Laparotomy = Laparoscopy if use of
! Filtered Gas Smoke Exhaust or
The President of the Robert-Koch-Institute (RKI) sug- ! Water Lock Filters
gested postponing all elective surgical procedures and inter- ! Consider Gasless Laparoscopy
ventions in an interview on February 28, 2020 [51].
! Stoma > Anastomosis
Furthermore, surgery in general is seen at higher risk for
transmission of respiratory infections and especially poten-
tially inducing fatal patient outcome in cases where a 3 Rationale
COVID-19 diagnosis is overlooked and/or diagnosed later
[52]. Therefore, surgery is a high-risk venture for COVID-19 3.1 Prefer Non-surgical approach
patients. (conservative if justifiable)
In Germany, hospitals acted early to increased risk
posed by COVID-19 risk, followed by the German Govern- COVID-19 pneumonia carries a high mortality rate espe-
ment. On Thursday March 12, 2020 the German Govern- cially during peri- and post-operative times, which is why
ment decided that all justifiable elective admissions, any kind of surgical treatment should be scrutinized very
surgical procedures and interventions should be postponed carefully and postponed if possible. Therefore, preoperative
to increase expected capacities in terms of patient beds, check-up is of importance in terms of patient history (con-
intensive care unit (ICU) beds and ventilators [53]. Hospi- tact within the last 14 days with suspected/confirmed
tals were advised to postpone elective surgeries as infected cases).
COVID-19 capacities were judged to be increased nation- The Australian and New Zealand Hepatic, Pancreatic
wide immediately and surgical care should be limited to and Biliary Association (ANZHPBA) provided three surgi-
life-threatening diseases to minimize unnecessary resources cal COVID-19 response phases into (Phase I) Semi-Urgent
in manpower, patient beds and ICU beds, ventilators, Setting (Preparation Phase) (few COVID-19 patients, hos-
antiseptic foaming and use of PPE. pital resources not exhausted, institution still has ICU ven-
Tufts Medical Center in Massachusetts canceled all tilator capacity and COVID-19 trajectory not in rapid
planned (elective) surgery early in 2020 calendar week 2, escalation phase), (Phase II) Urgent Setting (many
which was followed by the US Surgeon General Jerome COVID-19 patients, ICU and ventilator capacity limited,
Adams’ advice on March 14, 2020 via Twitter [54]. The operating room supplies limited) and (Phase III)
“Wartime” footing (Hospital resources are all routed to to be taken into account, which explains why the stated risk
COVID-19 patients, no ventilator or ICU capacity, operat- of laparotomy compared to laparoscopy needs to be seen in
ing room supplies exhausted; only patients in whom death a much more differentiated way if available knowledge is
is likely within hours if surgery is deferred) [61]. Within this, addressed and some conditions are considered.
a complex triage scenario is provided including categoriza- At first, surgeons in Wuhan, China recommended
tion of hepato-biliary surgical procedures. highly selecting laparoscopy [75]; subsequently laparo-
Otherwise, emergency patients may be subdivided surgi- tomy was judged to be more favorable than laparoscopy
cally in an easy way into: (1) urgent surgery required (no due to the following arguments put forward by various
time delay allowed), (2) emergency operation required societies:
and (3) observation. The surgical smoke during laparoscopy using electri-
Various scoring systems and/or calculators are available cal or ultrasonic equipment for 10 minutes results in
for stratification of pre-hospital health status and comor- a significantly higher particle concentration within
bidities, physiology and outcome risk which often had not the smoke compared to laparotomy ([76] reviewed in
been explicitly validated [62]: [77]) although it is possibly the result of the smoke
concentrating in a closed space in contrast to smoke
! American Society of Anesthesiologists Physical Status that is emitted continuously during laparotomy.
Grading (ASA-PS) [63]; The standard “surgical masks alone do not provide
! Charlson Comorbidity Index (CCI) [64]; adequate protection from surgical smoke” [78].
! Physiological and Operative Severity Score for the More than 600 compounds and gases or more can be
Enumeration of Mortality and Morbidity (POSSUM) identified in surgical smoke [79, 80].
[65]; This includes viruses such as human immunodefi-
! Surgical Risk Scale (SRS) [66]; ciency virus (HIV), human papillomavirus (HPV),
! Surgical Mortality Score (SMS) [67]; bovine papillomavirus (BPV) and hepatitis B virus
! Surgical Risk Score [68]; (HBV) [76, 81–89].
! Physiological Emergency Surgery Acuity Score “Human papillomavirus (HPV) types . . . seem to have
(PESAS) [69]; a predilection for infecting the upper airway mucosa,
! Surgical Apgar Score (SAS) [70]; and laser plume containing these viruses may repre-
! Perioperative Mortality Risk Score (PMRS) [71]; sent more of a hazard to the surgeon” [83]. Recurrent
! American College of Surgeons National Surgical Qual- respiratory papillomatosis (RRP) is caused by HPV-
ity Improvement Programme (ACS-NSQIP) universal type 6 (HPV-6) and HPV-type 11 (HPV-11) and asso-
surgical risk calculator [72]; ciated with exophytic lesions of the airway that are
! Surgical Outcome Risk Tool (SORT) [73];, and friable and bleed easily [90].
! Emergency Surgery Acuity Score (ESAS) [74]. “Swabs from 110 patients in nine separate treatment
sessions as well as from five pre-filter canisters, four
Although there is no Level 1 evidence, surgery in poten- fume vacuum tubes, and from the nasopharynx, eye-
tial COVID-19 patients is seen as a high-risk venture which lids, and ears of the laser surgeon before and after
is why recommendations from various international soci- laser surgery” revealed in up to 60% papillomavirus
eties favor a non-surgical approach, if justifiable. Non- DNA to be identified in swabs and even in one of five
operative conservative treatment for example includes pre-filter canisters where HPV DNA was positive [81].
cholecystotomy and drainage for acute cholecystitis, inser- In a recent study, the “concentration number of 0.3
tion of percutaneous transhepatic cholangiography drai- lm and 0.5 lm particles reached the maximum after
nage (PTCD) in cholangitis, interventional embolization 10 min of electrosurgical treatment; however, the con-
of acute gastrointestinal bleeding, antibiotic treatment for centration number of 5 lm particles began to decrease
appendicitis, or even hernia reduction under sedation for after 5-15 min of the treatment” plus “the cumulative
incarcerated hernia. particle numbers of 0.3 lm and 0.5 lm in laparoscopic
operation were higher than those of laparotomy after
3.2. Consider Risk Reduction (for patients and staff) 10 min of the treatment” suggesting that “surgical
smoke prevention should use smoke evacuator” and
3.2.1 Surgery in selected cases only that “health-care workers should also wear a highly
The general recommendation is to select surgical cases to efficient tight seal-fit mask in the OR” to avoid risk
minimize the surgical trauma as much as possible indepen- and damage [76].
dent of the size of incision for ports in laparoscopy or
laparotomy. The Royal College of Surgeons of England (RCS), Royal
College of Physicians and Surgeons of Glasgow, the Royal
3.2.2 Risk Laparotomy = Laparoscopy (includes endoscopy College of Surgeons of Edinburgh and the Royal College
and thoracoscopy) “if use of” of Surgeons of Ireland released guidance for surgeons on
3.2.2.1 Filtered Gas Smoke Exhaust or March 20, 2020 [91]. The American College of Surgeons
(ACS) released elective case triage guidelines for surgical
3.2.2.2 Water Lock Filters care on March 24, 2020 [60]. Afterwards an intercolle-
We review at first the development of how recommenda- giate general surgery guidance arrived on March 26, 2020
tions were created and point out, which knowledge needs which was updated on March 27, 2020 (Fig. 2) [17].
Figure 4. Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the European Association for Endoscopic
Surgery (EAES) recommendations regarding surgical response to COVID-19 crisis [93].
The recommendations of British and US societies had taken into account and that “protective measures are
been reviewed [17, 55–57, 60, 91]. Therefore, it had been strictly employed for OR staff safety and to maintain a func-
assumed that laparotomy was favored over laparoscopy, tioning workforce” [92].
and laparoscopy, thoracoscopy, and endoscopy should be However, it was pointed out by the SAGES that the evi-
performed on selected cases only and that although dence in terms of favoring laparotomy over laparoscopy is
COVID-19 data in terms of surgical smoke are still missing, low ([77] reviewed in [92]).
protection of viral transmission by surgical smoke would Another parameter that needs to be considered is the
need to be addressed through the use of PPE based on quicker discharge of patients following laparoscopic surgery.
earlier evidence. In this COVID-19 pandemic, hospital resources are scarce
Following publication of these guidelines, surgical soci- and hospital beds, healthcare personnel and equipment
eties around the world expressed disagreement with the should be saved for critically ill patients rather than stan-
recommendation to strictly avoid laparoscopy. Although dard post-operative care of surgical patients. Laparoscopy
laparoscopic surgery is considered an aerosol generating allows for faster discharge from hospitals and less dealing
procedure (AGP), this aerosol together with the CO2 pneu- with surgical wounds and surgical site infections (SSIs). This
moperitoneum is in a controlled cavity. is why the two largest world associations dealing with
In open surgery electrosurgical instruments produce laparoscopy, the Society of American Gastrointestinal and
smoke and aerosolization of tissue as much as in laparo- Endoscopic Surgeons (SAGES) and the European Associa-
scopy; however the dissipation of this material is to the tion for Endoscopic Surgery (EAES), quickly released their
open operating theatre space affecting all staff. Smoke evac- recommendations regarding surgical response to COVID-
uation attached to monopolar devices are helpful but have 19 (Fig. 4) [93].
limited efficacy. Moreover, glove tearing and fluid or blood Experience in laparoscopic surgery was published to dis-
splashing can cause direct contact with bodily fluids seminate knowledge and provide guidelines for minimally
whereas in laparoscopy these are avoided. invasive surgery procedures. The China and Italy experi-
The Society of American Gastrointestinal and Endo- ences are particularly helpful by providing suggestions like
scopic Surgeons (SAGES) together with the European using low pressure peritoneum, use of balloon trocars, evac-
Association for Endoscopic Surgery (EAES) stated that uating all pneumoperitoneum before trocar removal or spec-
“either open, laparoscopic or robotic” surgeries need to be imen extractions [77].
Remark (Fig. 1 in Mintz et al. Ann Surg 2020, not included here)
[100].
Knowledge which needs to addressed
3.2.2.3 Consider Gasless Laparoscopy
Screening 3363 individuals enrolling 246 individuals with
exhaled breath samples explored the value of respiratory A nearly forgotten approach is performing laparoscopic
droplets and aerosol routes of transmission with a particular 0surgery in the old-fashioned way, gasless for acute appen-
focus on coronaviruses, influenza viruses, and rhinoviruses dicitis, acute cholecystitis and as a diagnostic tool.
and showed that surgical face masks significantly reduced 3.2.2 Stoma > Anastomosis
detection of influenza virus RNA in respiratory droplets
and coronavirus RNA in aerosols, with a trend toward The Royal College of Surgeons suggested that “stoma
reduced detection of coronavirus RNA in respiratory dro- formation rather than anastomosis to reduce the need for
plets [94]. unplanned post-operative critical care for complications”
The importance of the appropriate smoke extraction be considered [17].
equipment had been pointed out earlier [95]. Although cell
particles had been found in the smoke plume, until now the (4) Operation Room (OR)
risk to the OR staff is still not defined [96] and the hazards
in terms of tumor cells in the surgical smoke from tumor dis- ! OR and Team
section by ultrasonic scalpel are unclear at present [88]. ! COVID-19-testing and risk assessment
Mintz et al. together with the Technology Committee of ! Hot and cold OR and Team (high vs. low risk)
the EAES pointed out that “Standard electrostatic filters ! Minimally required (senior) staff only
! Smoke extraction (and/or use bi-polar – smoke ;)
used for ventilation machines have the capability of filtering
known bacterial and viral loads with great efficiency and
! Anesthesia
most are certified for 99.99% effective protection against
! Consider epidural/spinal/sedation
HBV and HCV which have a diameter of 42nm and 30-60 ! In-/extubation within OR (consider aerosol box)
nm respectively” and that “SARS-CoV-2 has a larger diam- ! No positive pressure ventilation
eter of 70-90 nm” which is why “the same filtering efficiency
can be expected to apply for new virus” ([97–99] reviewed in
[100]). 4.1 OR and Team
Due to this, the capability of evacuating smoke was 4.1.1 COVID-19-testing & risk assessment
effectively shown by surgeons in Israel and Italy in five
operations without using an active suction system, which The OR team should be tested and undergo a risk assess-
was accepted for publication in Annals of Surgery on April ment. In an evolving scenario it may be possible to select
03, 2020 [100]: OR staff with proven COVID-19 exposure to man the hot
ORs. When serology tests become available all theater staff
! Cholecystectomy, should undergo serology testing.
! Inguinal hernia repair,
! Total Mesorectal Excision (TME), 4.1.1 Hot and cold OR and Team (high vs. low risk)
! Transanal Total Mesorectal Excision, and We recommend to use – if possible – a hot (H-OR) and cold
! Anterior resection of the rectum. operation room (C-OR) and designating an area to differen-
tiate between operations on confirmed/suspicious COVID-
Each surgeon reported very good efficiency of the pas- 19 positive versus negative/non-suspicious patients. As
sive smoke evacuation system during laparoscopic proce- mentioned earlier, we are aware that there are infected
dures and that “the filter system should be discarded patients with negative testing. Within the H-OR area, fil-
according to hospitals protocols for infection control ”. tering of ventilation is important and – if possible negative
The EAES technology committee provided guidance for pressure operating rooms should be used. Emergency oper-
safe use of laparoscopy, to evacuate gas and smoke from the ations, on which no time delay due to life-threatening con-
abdomen through a simple low cost adequate filter, to evac- dition occurs while to date no rapid COVID-19 test is
uate smoke and aerosol using standard ventilation machines widely available, should always be operated within the H-
filtering device and available connecting components to OR area. PPE is required for H-OR.
reduce the risk of OR staff infection [100]. This publication
4.1.3 Minimally required (senior) staff only
even includes two videos, (1) how the system can be assem-
bled with standard OR equipment and (2) the demonstra- In order to avoid any potential risk of infection for the
tion during a total mesorectal excision procedure. Despite patient and the surgical staff and to minimize further
regular instrument cleaning during surgery as well as deflat- spread of SARS-CoV-2 virus, the personnel required to per-
ing pneumoperitoneum prior to trocars as previously recom- form a necessary operation should be kept to a minimum
mended by colleagues from China and Italy [77], we [101]. This strict implementation has several advantages.
recommend adding such filters (mentioned above) to the ORs usually have positive pressure technology in the oper-
suction system both in laparoscopy and laparotomy ating area (aseptic zone) and are separated from other areas
by doors. But when the doors to the anterooms are opened, particular focus on coronaviruses, influenza viruses and rhi-
the well-directed laminar air flow will be disrupted and thus noviruses showed that surgical face masks significantly
particles and aerosols within the OR air can be swirled reduced detection of influenza virus RNA in respiratory
which provides an explanation why it should be considered droplets and coronavirus RNA in aerosols, with a trend
to not apply a positive pressure ventilation in the OR under toward reduced detection of coronavirus RNA in respira-
this specific COVID-19 situation. tory droplets [105].
Recently, it was even recommended to set up a negative Furthermore, any airway procedures are now seen as
pressure in the operating theatre to reduce virus dissemina- enhancing risk to the performer: intubation and ventilation
tion beyond the OR [102]. Such an approach is recom- by anesthetists, and surgical procedures (including various
mended since a long time, but the direction of airflow in procedures by distinct surgical disciplines such as numerous
respiratory isolation rooms is often not correct [103] and cancer surgery disciplines, cardiothoracic surgery, ENT,
should be evaluated. eye, dermatology, emergency, endocrine surgery, general
Nevertheless, air-turbulences are worse the more people surgery, gynecology, neurosurgery, orthopedics, pediatric
are in the OR with or without negative air ventilation. surgery, reconstructive and plastic surgery, surgical critical
Small expert teams of lead surgeons (N = 2), mechanical care, transplantation surgery, trauma surgery and urology,
devices to provide for optimal exposure, most experienced performing different surgeries, as well as laparoscopy, tho-
surgical assistants (N = 2; one instrumentalist, one in-room racoscopy and endoscopy) and this is why protection is
OR nurse) and anesthesiologist with one anesthesia nurse mandatory. Various specialties and especially ear nose
(N = 2) act as a well-coordinated team, another reason to throat (ENT) surgeons are at high risk. The various specific
minimize human movements within the aseptic zone. The roles and responsibilities of all OR team members have been
team should perform a huddle before surgery to talk reviewed by the ACS including the in- and extubation
through the surgical and anesthesiological process and asso- within the operating room [106].
ciated risks and perform a time out at the end of surgery to
discuss postoperative risks and consequences as well as 4.1 Anaesthesia
quality of the COVID-19 risk management.
4.1.1 Consider epidural/spinal/sedation
Hospital transmission was reported being responsible for
some 41% nosocomial SARS infections [15]. Even postpon- Epidural combined spinal-epidural anesthesia was shown to
ing and/or suspending postoperative visits were reported in be safe for Cesarean delivery in parturients with COVID-
Singapore to minimize exposure and spread [102]. 19, although the incidence of hypotension appeared exces-
Protecting OR staff includes “surgeons, anesthetists, sive [107]. This approach should certainly be used for inci-
and nurses and all possible transiting persons in the OR” sion and drainage of large abscesses, strangulated femoral
[77]. Limiting medical staff in the OR results in decreased and inguinal hernia with low risk of bowel ischemia. Inade-
exposure and spread of COVID-19 with increased protec- quate sedation may result in high risk during intubation in
tion of health care teams. Only senior experienced staff case the patient gets agitated and/or has a coughing attack
and not trainees or students should be involved in surgical with further risk of pathogen transmission.
cases during this pandemic [52]. In some academic centers,
4.1.2 Intubation and extubation within OR
pathology service is included into the OR tract. We recom-
(consider aerosol box)
mend suspending this kind of pathology service during the
current outbreak. “Bag valve-mask ventilation, non-invasive ventilation,
and intubation (in spontaneously breathing patients), may
4.1.4 Smoke extraction (and/or use bi-polar – smoke ;)
create localized aerosol generation that can allow airborne
Major content has been reviewed in detail above (see transmission to those closely involved in the procedure”
3. Rationale). Any form of electrosurgery produces smoke, ([108] reviewed in [109]). Extubation is associated with
which should be minimized as much as possible decreasing increased coughing [110]. To minimize risks to health care
potential aerosolization and consecutive harming the providers, in- and extubation should only be done – if
patient and/or OR staff. If available, bi-polar diathermy possible – within the OR.
including smoke suction/evacuators should be used. An “aerosol box” consisting of a transparent plastic box
The argument of the necessity of smoke extraction and/ has been widely adapted for use in various ORs around the
or use of bi-polar tools which produce less smoke derives world “that effectively shields a provider’s face from a
from the evidence reviewed in the rationale for point (3). patient’s airway while allowing the provider to move his/
Due to the high viral load in asymptomatic patients which her arms freely to perform all necessary tasks during
is comparable to symptomatic patients, and was implicated endotracheal intubation” [111]. This aerosol box has been
that the very early transmission during the COVID-19 developed pro bono by the anesthesiologist Hsien Yung
course differs significantly in terms of strict regulations Lai from Mennonite Christian Hospital in Hua Lian,
compared to the earlier SARS-CoV epidemic between Taiwan, and registered under a Creative Commons license.
2002 and 2003 [104]. Lateral ports have been added by Philippine ENT surgeons
Screening 3363 individuals enrolling 246 individuals for tracheostomy and upper aerodigestive tract surgery.
with exhaled breath samples explored the value of respira- Virological analysis of COVID-19 patients showed
tory droplet and aerosol routes of transmission with a high pharyngeal virus shedding during the first week,
(on day 4: 7.11 108 RNA copies per throat swab) with 34 patients, of whom 11 on intensive care unit (ICU) (on ven-
confirmation of active viral replication followed by serocon- tilation), 1 on intermediate care unit (IMC), and 22 on infec-
version after day 7 in up to 50% of patients (14 days in all) tion ward; another 32 patients on another infection ward
[112]. This even serves as an argument that anaesthetists were suspicious for COVID-19 with pending test results.
only should be within the OR during intubation and/or The following information is given anonymously by
extubation. ercentages only to protect the identity of the hospital in
Germany:
4.1.3 No positive pressure ventilation
A total of 1,162 PCR test were performed, 774 in hospi-
Positive airway pressure (continuous positive airway pres- tal staff, 260 in patients and in 128 physicians, resulting
sure, CPAP/Bilevel Positive Airway Pressure, BiPAP) is into n = 19 COVID-19 positive individuals, resulting into
recommended to be avoided in procedures on COVID-19 a silent carrier (asymptomatic) rate of 1.6%. Positive tested
patients due to the potential risk of pathogen transmission individuals were isolated and the quarantine lifted.
over distances ([113] reviewed in [109]) although safe These experiences underpin the necessity to strictly
reports are available ([114] reviewed in [109]). follow the guidance of the RKI. Furthermore, it reveals,
that COVID-19 transmission can be low but it is impossible
Personal Protective Equipment (PPE) to prevent in a hospital setting even when the system is not
completely overwhelmed with COVID-19 positive patients.
! Low risk patients (LRP) Therefore we recommend the testing as provided in Figure 3
Double gloves, booties, surgical gown out of protection reasons for patients and staff.
FFP3 (N99) or P3 (N100) face mask SARS-CoV-2 and SARS-CoV are both similar in size
Face shield (+/ googles), head cover (approximately 85 nm). Virus particles can penetrate five
surgical masks stacked together why it is recommended
! High risk patients (HRP) that health care providers wear N95 (series # 1860) and
As in LRP plus overalls under surgical gown not the usual surgical masks [119]. Decreasing the rate of
virus particles to as small as 10–80 nm size by inhalation
Gowns (plastic ponchos)
can be decreased to a 5% penetration rate simply by using
Train dressing/undressing and supervision
N95 masks (series #1860) [120]. Protection management
In general, any kind of surgical procedure should include must include eye protection (either goggles or full-face
wearing low risk PPE and as provided in Figure 3, and shield) as well [121, 122]. During the chaotic phases of
high-risk PPE in case of emergency operations (without COVID-19 spread in Asia and Italy, any kind of eye protec-
testing), positively tested patients, and negatively tested tion was used, even personal goggles (model 9302-245;
patients with a patient history of COVID-19 exposure. Uvex, Germany).
Even non-symptomatic people can spread COVID-19 PPE recommendation in treating critically ill COVID-
with high efficiency [115]. To date, there has been confusion 19 patients include using double gloves, booties, fluid-resis-
about the silent carrier transmission rate. A statistical tant surgical gown, FFP3 (N99) or P3 (N100) face masks,
modeling approach to derive the delay-adjusted asymp- and eye protection face shield (+/ googles), and a head
tomatic proportion of infections estimated a silent carrier cover ([108] reviewed in [22, 109]).
rate of 17.9% [116] but the reality seems to be worse with Furthermore, any health care provider above 65 years of
reported 46.5% non-symptomatic infected people during age with an increased co-morbidity risk (heart failure,
the outbreak on the Diamond Princess Cruise ship [117]. hypertension, lung disease, etc.) is at high risk in being part
This emphasizes the need for urgent aggressive protection of the H-OR, unless swab proven exposure to COVID-19
approaches to be implemented immediately. “The basic and a minimum 2 weeks isolation, or non-OR presence after
reproduction rate was initially 4 times higher on-board com- last symptoms.
pared to the epicentre in Wuhan, China” and it was esti- We recommend differentiating low risk patients (LRP)
mated, that evacuating all Diamond Princess Passengers with no history and/or clinical and/or laboratory sign of
and crew early during the outbreak “would have prevented COVID-19 versus high risk patients (HRP) who have a pos-
many more passengers and crew from infection” [118]. itive COVID-19 test and/or history of COVID-19 exposure.
Based on the outbreak definition in accordance to In HRP it is mandatory to wear PPE as in LRP patients
German Law – transmission of disease of two or more people plus additional gowns such as plastic ponchos. The dressing
with a common cause probable or strongly suspected, §6 and undressing should be regularly done under trained
IfGS (= Infection Protection Act, In German: Infektionss- supervision, and in real time requires a buddy system to
chutzgesetz) –, the local health department (In German: be in place (much like scuba diving).
Gesundheitsamt) ordered a shutdown of a teaching hospital Based on what we currently know, patients and health
in Germany and put it under quarantine (personal commu- care providers are at high-risk for severe COVID-19 illness if
nication). For the first time, all patients plus all employees of 65 years of age or older, are living with home care or are
one German hospital (physicians, nurses, and health care cared for in a long-term facility for the elderly. Further-
providers) were tested from Friday April 03 through more, people of all ages with certain comorbidities are at
Sunday April 05, 2020. The teaching hospital’s proven higher risk for severe illness, particularly if the underlying
COVID-19 patient load on Friday, April 03, 2020 was: medical conditions are not well controlled. Chronic lung dis-
ease or moderate to severe asthma, serious heart conditions, Step 5: Disinfect hands, wear the first layer of sterile
people in immune compromised situation, including cancer gloves, cover the cuff of protective clothing, and use
treatment, smoking, bone marrow or organ transplantation, adhesive tape to fix the cuff if necessary.
immune deficiencies, poorly controlled HIV or acquired Step 6: Wear disposable surgical cap.
immune deficiency syndrome (AIDS), and prolonged use Step 7: Wear disposable surgical mask.
of corticosteroids and other immune weakening medica- Step 8: Wear disposable surgical clothes.
tions, severe obesity (body mass index [BMI] of 40 or Step 9: Disinfect the hands, wear the second layer of
higher), diabetes mellitus, chronic kidney disease, in need sterile gloves, and cover the cuff of disposable surgical
of dialysis, and liver diseases are all such illnesses that have clothes.
Step 10: Wear a protective screen.
to be taken into account and these patients need PPE from
Step 11: Wear waterproof boot cover.
patient admission to the OR, during the operation, and
Step 12: Wear outer shoe cover.
after discharge via recovery room to the ward [22].
Step 13: Disinfect the hands, confirm the correct don-
ning of clothing with the help of others, check whether
Discussion all PPE is complete, intact and appropriate in size,
ensure that the two layers of medical personnel are
Responding to the COVID-19 pandemic, countries tightly protected and the body is not exposed, and
around the globe have increased hospital capacities, espe- enter the operating room after self-inspection in a
cially in terms of ICU beds and ventilators. Next to mirror.
patients, any health care provider needs to be protected Step 14: Disinfect surgical hands (disinfect hands and
as well. It is imperative to functionally sustained healthcare wrists with hand sanitizer, i.e. the scope of the second
capacity to avoid a worst case scenario: widespread pair of gloves), and wear disposable sterile surgical
COVID-19 transmission to OR staff increasing individual clothes.
risk to physicians and nurses and subsequent depletion of Step 15: Wear the third layer of sterile gloves, and
essential human resources. cover the cuff of sterile surgical gown.
Our comprehensive and robust recommendation serves
as Pandemic Surgery Guidance during the exponential 5. Measures to prevent aerosol transmission.
The smoke generated by the use of the electrosurgical
spread of the COVID-19 or future similar outbreaks
throughout the world (Fig. 3). equipment will form aerosols. During the operation,
an aspirator can be used to absorb the smoke, but
Protective procedures in the operation room at Shang-
the suction operation can also cause the generation
hai East Hospital, Tongji University, were provided in an
of aerosols. Therefore, it is recommended to reduce
interview with Xiaohu Jiang, MD, PhD, Professor of Sur- the negative pressure suction operation during the
gery [75]. We review them here as each single step has operation, and use the electrosurgical smoking device
sound practical value: to reduce the diffusion of aerosols.
Closed negative pressure suction system shall be used.
1. Operations should be done in a negative pressure The disposable negative pressure suction bag shall be
OR with separate passage. Operation observation added with effective chlorine containing disinfectant
is forbidden. of 5000 mg/L – 10,000 mg/L before operation, and
2. Operation sheets should be waterproof. sealed after operation, and treated as infectious med-
3. PPE shall be in accordance with level III protection ical waste.
standards. Endoscopic surgery should be minimized, because
there is no evidence to rule out whether the leakage
4. The wearing process of personnel on the operating of pneumoperitoneum pressure in endoscopic surgery
table (wearing two-layer surgical caps, three-layer contributes to aerosol transmission pathways, or
sterile gloves, two masks, two pairs of shoe covers, whether there is the possibility of increasing the risk
two disposable surgical gowns, one medical protec- of infection of the operating personnel.
tive clothing, one goggles, one protective screen and
one boot cover).
Step 1: Enter the OR, disinfect hands, change protec- Summary
tive slippers, and enter the dressing room. Wash
hands in seven steps, change personal clothes, wear A consortium of scientists and clinicians from various
hand washing clothes, remove personal articles such specialties provided a compact Pandemic Surgery Guidance
as jewelry, watches, mobile phones, etc., and wear dis- to serve as more practical guide during the exponential pan-
posable surgical caps. demic COVID-19 spread (Fig. 3). The guidance is relevant
Step 2: Wear medical protective mask and do a tight- for surgical procedures by distinct surgical disciplines such
ness test. as numerous cancer surgery disciplines, cardiothoracic
Step 3: Wear goggles, shoe covers and disinfect hands. surgery, ENT, eye, dermatology, emergency, endocrine
Step 4: Enter the buffer zone after self-inspection. surgery, general surgery, gynecology, neurosurgery, ortho-
Hand disinfection, inspection of medical protective pedics, pediatric surgery, reconstructive and plastic surgery,
clothing (model, integrity, etc.), wearing disposable surgical critical care, transplantation surgery, trauma
medical protective clothing. surgery and urology, performing different surgeries, as well
as laparoscopy, thoracoscopy and endoscopy. The present PESAS Physiological Emergency Surgery Acuity
Pandemic Surgery Guidance could even serve as the basis Score (PESAS)
for other future potential pathogen crises yet to come. PMRS Perioperative Mortality Risk Score
Suggestions and corrections from colleagues will be wel- POSSUM Physiological and Operative Severity
comed as we are all involved in a dynamically developing Score for the Enumeration of Mortality
process to increase our collective COVID-19 knowledge. and Morbidity
PPE Personal Protective Equipment
Nomenclature PTCD Percutaneous transhepatic cholangiogra-
phy drainage
AAO-HNS American Academy of Otolaryngology RCS Royal College of Surgeons of England
Head and Neck Surgery RKI Robert-Koch-Institute
ACS American College of Surgeons RT-PCR Real-Time Polymerase Chain Reaction
ACS-NSQIP American College of Surgeons National SAGES Society of American Gastrointestinal and
Surgical Quality Improvement Pro- Endoscopic Surgeons
gramme universal surgical risk calculator SARS-CoV Severe Acute Respiratory Syndrome
AIDS Acquired immune deficiency syndrome Coronavirus
ANZHPBA Australian and New Zealand Hepatic, SARS-CoV-2 Severe Acute Respiratory Syndrome Coro-
Pancreatic and Biliary Association na Virus 2
ASA-PS American Society of Anesthesiologists SAS Surgical Apgar Score
Physical Status Grading SMS Surgical Mortality Score
BiPAP Bilevel Positive Airway Pressure SORT Surgical Outcome Risk Tool
BMI Body mass index SRS Surgical Risk Scale
BPV Bovine papillomavirus WHO World Health Organization
CCI Charlson Comorbidity Index
CDC Center of Disease Control
CFR Case-fatality rate
Supplementary material
CMS Centers for Medicare & Medicaid Services
C-OR Cold (low risk) operation room (OR) Supplementary Material is available at https://www.
COVID-19 Coronavirus disease 2019 4open-sciences.org/10.1051/fopen/2020002/olm
CPAP Continuous positive airway pressure
CRP C-reactive protein
CT Computed tomography Acknowledgments
EAES European Association for Endoscopic Sur-
gery The manuscript was created in very focused and fast
EASA Emergency Surgery Acuity Score way (4 days). By this, we used a new way of a social med-
ECDC European Centre for Disease Prevention ium to receive and exchange material fast for review and
and Control points of criticism. None of the colleagues was used to it,
FFP3 Filtering Face Pieces, class 3 but anyone who accepted that logistical way made it hap-
FRSM Fluid resistant (Type IIR) surgical face pen, to review, edit and change content fast (< 24 h). The
masks manuscript was supported by the Theodor-Billroth-
HBV Hepatitis B virus AcademyÒ (TBAÒ) and INCORE, (International Consor-
HIV Human Immunodeficiency Virus tium of Research Excellence) of the (TBAÒ). We express
HPV Human papillomavirus our gratitude to the discussions on the web group of the
Theodor-Billroth-AcademyÒ (TBAÒ) on LinkedIn, the ex-
HPV-6 Human papillomavirus type 6
change with scientists at Researchgate.com, as well as per-
HPV-11 Human papillomavirus type 11
sonal exchanges with distinguished colleagues who
H-OR Hot (high risk) operation room (OR)
stimulated our thinking – we thank each one. The authors
HR Hazard ratio highly acknowledge the extreme helpful and professional
ICU Intensive care unit fast peer-review process of the handling Editor as well as
IL-6 Interleukin 6 of the excellent peer-reviewers.
IMC Intermediate care unit
LDH Lactate dehydrogenase
LRP Low risk patients Dedication
HRP High risk patients
MERS-CoV Middle East respiratory syndrome coron- The authors dedicate the publication to all COVID-19
avirus victims as well as to all physicians, nurses and health care
NAAT Nucleic acid amplification test providers who gave everything they had and lost for the
OR Operation room benefit of their patients.
Conflict of Interest dynamics in Wuhan, China, of novel coronavirus-infected

pneumonia. N Engl J Med 382, 1199–1207. https://doi.org/
The author reports the following conflict of interest: 10.1056/NEJMoa2001316.
Björn LDM Brücher is Editor-in-Chief in Life Sciences- 4. Lu R, Zhao X, Li J, Niu P, Yang B, Wu H, Wang W, Song
H, Huang B, Zhu N, Bi Y, Ma X, Zhan F, Wang L, Hu T,
Medicine of 4open by EDP Sciences. Ijaz S Jamall, Marjan Zhou H, Hu Z, Zhou W, Zhao L, Chen J, Meng Y, Wang J,
Slak Rupnik, Ray Perkins and Bruno Zilberstein are Senior Lin Y, Yuan J, Xie Z, Ma J, Liu WJ, Wang D, Xu W,
Editorial Board members. The following colleagues are Edi- Holmes EC, Gao GF, Wu G, Chen W, Shi W, Tan W
torial members in Life Sciences-Medicine of 4open by EDP (2020), Genomic characterisation and epidemiology of 2019
Sciences: Jochen Salber, Avraham Rivkind, Jose Florencio novel coronavirus: implications for virus origins and recep-
F Lapeña Jr., Rainer Kube, Michael Scherer, Jose da Costa, tor binding. Lancet 395, 565–574. https://doi.org/10.1016/
Rainer Lück, Mesut Tez, Selman Sökmen, Edouard Mat- S0140-6736(20)30251-8.
5. Zhu N, Zhang D, Wang W, Li X, Yang B, Song J, Zhao X,
evossian, Nelson Elias, Grzegorz Wallner, and Mohammad Huang B, Shi W, Lu R, Niu P, Zhan F, Ma X, Wang D, Xu
Kermansaravi. The authors, of their own initiative, sug- W, Wu G, Gao GF, Tan W, China Novel Coronavirus
gested publishing the manuscript as a Rapid Publication Investigating and Research Team (2020), A novel
with online reviewing including to the Managing Editorial coronavirus from patients with pneumonia in China, 2019.
to perform a transparent peer-review of their submittals. N Engl J Med 382, 727–733. https://doi.org/10.1056/
No author took any action to influence the standard sub- NEJMoa2001017.
6. Yeager A (2020), Coronavirus’s genetics hint at its cryptic
mission and peer-review process, and all report no conflict
spread in communities – Contact tracing and genetic testing
of interest. The authors alone are responsible for the con- reveal how SARS-CoV-2 circulated among individuals for
tent and writing of the manuscript. This manuscript con- weeks, especially in the US, before being detected. The
tains original material that has not previously been Scientist, Mar 6, 2020. Available from https://www.the-
published. The idea for this manuscript came from the first scientist.com/news-opinion/coronaviruss-genetics-hint-at-
author. After a structure was created, INCORE members, its-cryptic-spread-in-communities-67233. (Accessed March
such as Björn LDM Brücher, Ijaz S Jamall, and Marjan 2020)
7. Scales DC, Green K, Chan AK, Poutanen SM, Foster D,
Slak Rupnik revised it and the body text was created. Each Nowak K, Raboud JM, Saskin R, Lapinsky SE, Stewart TE
single author contributed to acquisition and/or analysis and (2003), Illness in intensive care staff after brief exposure to
interpretation of data. Every single author read, reviewed severe acute respiratory syndrome. Emerg Infect Dis 9,
and edited the manuscript. All authors contributed to the 1205–1210. https://doi.org/10.3201/eid0910.030525.
manuscript and its discussion and summary and approved 8. Christian MD, Loutfy M, McDonald LC, Martinez KF,
the final manuscript. Each author agrees to be accountable Ofner M, Wong T, Wallington T, Gold WL, Mederski B,
for all aspects of the work. The Uniformed Services Univer- Green K, Low DE, SARS Investigation Team (2004),
Possible SARS coronavirus transmission during cardiopul-
sity of the Health Sciences author reported no proprietary monary resuscitation. Emerg Infect Dis 10, 287–293.
or commercial interest in any product mentioned or concept https://doi.org/10.3201/eid1002.030700.
discussed in this article. The opinions or assertions con- 9. Luo C, Yao L, Zhang L, Yao M, Chen X, Wang Q, Shen H
tained herein are the private ones of the author and are (2020), Possible transmission of Severe Acute Respiratory
not to be construed as official or reflecting the views of Syndrome Coronavirus 2 (SARS-CoV-2) in a Public Bath
the Department of Defense, the Uniformed Services Univer- Center in Huai’an, Jiangsu Province, China. JAMA Netw
Open 3, e204583. https://doi.org/10.1001/jamanetworkopen.
sity of the Health Sciences or any other agency of the U.S.
2020.4583.
Government. 10. American Academy of Otolaryngology Head and Neck
Surgery (AAO-HNS) (2020), Anosmia, Hyposmia, and
Dysgeusia Symptoms of Coronavirus Disease. March 22,
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Cite this article as: Brücher B.L.D.M, Nigri G, Tinelli A, Lape~

na Jr J.F.F, Espin-Basany E, et al. 2020. COVID-19: Pandemic
surgery guidance. 4open, 3, 1.

COVID-19: Pandemic Surgery Guidance

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Ó B.L.D.M. Brücher et al., Published by EDP Sciences, 2020

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COVID-19: Pandemic surgery guidance

*Corresponding author: [email protected]

Keywords: Anesthesia, Cancer, Cardiothoracic surgery, China, Coronavirus, COVID-19, Dermatology,

Figure 2. Intercollegiate general surgery guidance on COVID-19 [17].

2.2 Walking/climbing stair-test and blood gas (3) Strategy

Conﬂict of Interest dynamics in Wuhan, China, of novel coronavirus-infected

Cite this article as: Brücher B.L.D.M, Nigri G, Tinelli A, Lape~

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