Processes for Laparoscopy in Suspected or Confirmed COVID-19 Cases

Last update: March 23, 2020

SAGES recently released recommendations for surgery during the COVID pandemic. One of their recommendations was to limit laparoscopic procedures. The statement is below:

• "For procedures deemed urgent and necessary, it is strongly recommended that consideration be given to the possibility of viral contamination during laparoscopy. Such risk should be individually weighted against the benefit of laparoscopy for a patient’s health and recovery. While it is unknown whether coronavirus shares these properties, it has been established that other viruses can be released during laparoscopy with carbon dioxide. Erring on the side of safety would warrant treating the coronavirus as exhibiting a similar property. For laparoscopic procedures, use of devices to filter released CO2 for aerosolized particles should be strongly considered."

At the current time we have two types of readily available filtration systems in the ISC that should fit our needs:

• Stryker Pneumoclear Smoke Evacuation High Flow Tube sets: this is our standard tubing for our current insufflators and each set of tubing has an in-line HEPA filter that filters particles as small as 0.08 microns with 99.98% efficiency. This has been discussed this with Parker Snow, the rep for Stryker, and while the company has not specifically addressed the use of the product for COVID-19, it in theory should filter the average sized particles generated during laparoscopic surgery. By comparison, N95 respirator masks are rated to filter 95% of particles 0.3 microns or greater. Our insufflator systems have a smoke evacuation option that needs to be activated during the case to be effective (the default is the ‘off’ setting to conserve CO2). The abdomen can also be desufflated through the in-line filter to avoid opening the other trocars and exposing the OR to particulate matter or droplets within the abdominal cavity.
• ConMed Airseal delivery system: We currently have two of these types of insufflators which we usually utilize during robotic cases but they can be used for routine laparoscopy as well – they are on the robotic towers however. It has its own type of tubing and a specialized trocar but this will filter particles down to 0.1 microns with 99.99% efficiency according to the product brochure. The abdomen can also be desufflated at the conclusion of the case through this system to minimize airborne particles in the OR. I have been in contact with the product rep and he is local and available to help us if need be.

Based on this, we are recommending that in patients with known COVID or who are suspected that any operation be delayed if possible.  If delay is not in the best interest of the patient, consider non-laparoscopic options.  If laparoscopy is in the patient's best interest or if the patient is test negative or low risk, we recommend using the smoke evacuations systems during the entire operation.  This includes desufflating the abdomen using the smoke evacuation device.  I urge every surgeon to personally double check the CO2 containers at the beginning of the operation and bring attention to monitoring levels throughout the operation.  Further avoid opening a trocar valve to clear smoke or desufflate the abdomen.

This is the protocol for the Stryker:

Run the pneumoclear insufflator on advanced mode for every procedure:

• 15mmhg for pressure and 50 l/min for flow​
• Our insufflator will not flow at 50 l/min constantly, but will react faster at that rate​
• Run smoke evac level at 4 dots (12 l/min) out​
• Desufflate mode after every procedure ​

How to get to desufflation mode​:

• Leave the inflow/outflow trocar luer lock open when case is complete​
• Hit the stop button on the pneumoclear insufflator​
• The desufflate option will appear​
• Hit the check mark​
• Pneumoclear will desufflate to 6-8mmhg​
• **Make sure trocar is clear from all tissue or organ. It will false read the pressure​.

Disclaimer

These documents and content on this website are guidelines during the COVID-19 pandemic. Because new information is released rapidly, these documents can be updated or changed at any time. These documents are in no way to be considered as a standard of care and the content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. The information in these documents is provided with no guarantees, accuracy, or timeliness. All content in these documents and website are for informational purposes only and do not constitute the providing of medical advice.