The risk of COVID-19 transmission by laparoscopic smoke may be lower than for laparotomy: a narrative review

Abstract

Background Surgical smoke is a well-recognized hazard in the operating room. At the beginning of the COVID-19 pandemic, surgical societies quickly published guidelines recommending avoiding laparoscopy or to consider open surgery because of the fear of transmission of SARS-CoV-2 through surgical smoke or aerosol. This narrative review of the literature aimed to determine whether there are any differences in the creation of surgical smoke/aerosol between laparoscopy and laparotomy and if laparoscopy may be safer than laparotomy. Methods A literature search was performed using the Pubmed, Embase and Google scholar search engines, as well as manual search of the major journals with specific COVID-19 sections for ahead-of-print publications. Results Of 1098 identified articles, we critically appraised 50. Surgical smoke created by electrosurgical and ultrasonic devices has the same composition both in laparoscopy and laparotomy. SARS-CoV-2 has never been found in surgical smoke and there is currently no data to support its virulence if ever it could be transmitted through surgical smoke/aerosol. Conclusion If laparoscopy is performed in a closed cavity enabling containment of surgical smoke/aerosol, and proper evacuation of smoke with simple measures is respected, and as long as laparoscopy is not contraindicated, we believe that this surgical approach may be safer for the operating team while the patient has the benefits of minimally invasive surgery. Evidence-based research in this field is needed for definitive determination of safety. Keywords COVID-19 • SARS-CoV-2 • Laparoscopy • Risk • Viral transmission • Safety Surgical smoke may harbor particulates of blood fragments, viable cellular material, bacteria and viruses, as well as toxic gas vapors, all of which can negatively affect surgical staff [1]. Consequently, it was feared that surgical smoke may contain viable SARS-CoV-2 [2-4] and all too quickly, major surgical learned societies published guidelines, statements and recommendations, not only to stop elective surgery but favoring laparotomy over laparoscopy [5-7]. In turn, societies [8] and surgeons [9, 10] dedicated to Minimally Invasive Surgery challenged these statements, underscoring that these risks were largely overestimated and unjustified because of the low quality of evidence [9, 10]. Even if other societies [11] progressively nuanced their initial recommendations and statements, they no longer take any clear stand for or against, only to generate more confusion among surgeons on whether laparotomy or laparoscopy was more appropriate during the pandemic. In this narrative review, we aimed to critically appraise the literature with regard to the quandary of surgical smoke

Low‐cost, safe, and effective smoke evacuation device for surgical procedures in the COVID‐19 age

“…Technical and vision-related problems: Surgical smoke can cause visual impairments during breast surgery, primarily in nipple-sparing mastectomy, soft tissue tumor surgery, liver resection, and laparoscopic surgery 3,[6][7][8] Occupational health problems: Surgical smoke can contain viruses, for which there is much evidence in the COVID-19 age, [5][6][7] thus exposing the surgical staff to infection. Chronic exposure can increase the risk of respiratory diseases, strokes, and cancer due to the harmful effects of carcinogenic volatile molecules, such as acrylonitrile, a precursor of cyanide, polycyclic aromatic hydrocarbons, and carbon monoxide.…”

“…Although the risks of surgical smoke are acknowledged, monopolar diathermy pencils with attached smoke evacuator units are not routinely used in many health care centers. [3][4][5][6][7]9,10 We developed this system to disseminate the use of electrocautery with smoke evacuators and improve the safety for the surgical team, reducing their expose to surgical smoke. In our development process, 2 mm was the best distance between the tip of the electrosurgical pen and that of the catheter, with high effectiveness of the cutting and coagulation functions and smoke evacuation.…”

“…[3][4][5] Devices that remove surgical smoke, including extractors, filters, and nonfilter devices, are necessary to improve the safety of the surgical team. [3][4][5][6][7] Electrosurgery units should be set to the lowest possible settings for the desired effect. The use of monopolar electrosurgery, ultrasonic dissectors, and advanced bipolar devices should be minimized, because they can lead to particle aerosolization.…”

“…If available, monopolar diathermy pencils with attached smoke evacuators should be used. [3][4][5][6][7] However, standard smoke evacuation devices are expensive and unavailable in many hospitals in low-income countries. 3,5,7 Thus, we developed a simple method of using the conventional surgical evacuator, coupled with an electrosurgical pen that is attached to a 14G bladder catheter for open surgery.…”

The Impact of COVID-19 on Gastric Cancer Surgery: A Single-Center Retrospective Study

“…After a rigorous analysis of the literature on surgical smoke, we conclude that there is no high level of evidence that laparoscopic surgery is routinely prohibited simply because of the risk of aerosol contamination. In particular, there is no evidence that COVID-19 is transmitted via surgical smoke generated by ultrasonic surgical instruments [20][21][22][23]. By the way, during the COVID-19 pandemic, we also use smoke evacuator which is designed with a vacuum motor.…”