COVIDSafe thoracic surgery: Minimizing intraoperative exposure to aerosols

Abstract

Central MessageModifications to reduce viral transmission during thoracic surgery include effective screening, using a port-access surgical approach where possible, and a system of aerosol removal and filtration.See Commentaries on pages 415 and 417. Modifications to reduce viral transmission during thoracic surgery include effective screening, using a port-access surgical approach where possible, and a system of aerosol removal and filtration. See Commentaries on pages 415 and 417. The novel coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) pandemic poses unique challenges to thoracic surgery. First, the risk to postoperative thoracic patients is significant: mortality of 20% to 40% has been reported in small case series.1Cai Y. Hao Z. Gao Y. Ping W. Wang Q. Peng S. et al.Coronavirus Disease 2019 in the perioperative period of lung resection: a brief report from a single thoracic surgery department in Wuhan, People’s Republic of China.J Thorac Oncol. 2020; 15: 1065-1072Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar,2Li Y.K. Peng S. Li L.Q. Wang Q. Ping W. Zhang N. et al.Clinical and transmission characteristics of Covid-19—a retrospective study of 25 cases from a single thoracic surgery department.Curr Med Sci. 2020; 63: 364-374Google Scholar Second, the potential for aerosolization during surgery and viral transmission to the operating team has been acknowledged.3Collinson T. Hewett P. Hugh T. Padbury R. et al.Royal Australasian College of Surgeons, Clinical Expert COVID-19 Working GroupGuidelines for safe surgery: open versus laparoscopic. A rapid review commissioned by RACS.https://umbraco.surgeons.org/media/5214/2020-04-15-recommendations-on-safe-surgery-laparoscopic-vs-open.pdfDate accessed: April 9, 2020Google Scholar Although there are currently no data on intraoperative SARS-CoV-2 transmission, it is known to have similar stability and viability to severe acute respiratory syndrome coronavirus 1 in aerosols4van Doremalen N. Bushmaker T. Morris D.H. Holbrook M.G. Gamble A. Williamson B.N. et al.Aerosol and surface stability of SARS-CoV-2 as compared with SARS-CoV-1 [letter].N Engl J Med. 2020; 382: 1564-1567Crossref PubMed Scopus (6789) Google Scholar; other viruses are known to transmit through surgical smoke and aerosols5Liu Y. Song Y. Hu X. Yan L. Zhu X. Awareness of surgical smoke hazards and enhancement of surgical smoke prevention among the gynecologists.J Cancer. 2019; 10: 2788-2799Crossref PubMed Scopus (107) Google Scholar,6Tran K. Cimon K. Severn M. Pessoa-Silva C.L. Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review.PLoS One. 2012; 7: e35797Crossref PubMed Scopus (1334) Google Scholar; and there is a high incidence of coronavirus disease 2019 (COVID-19) in operators exposed to the airways.7Vukkadala N. Qian Z.J. Holsinger F.C. Patel Z.M. Rosenthal E. COVID-19 and the otolaryngologist: preliminary evidence-based review.Laryngoscope. March 26, 2020; ([Epub ahead of print])Crossref Scopus (6) Google Scholar Although many countries, including our own, have placed a temporary suspension on elective procedures, emergent/urgent thoracic patients will continue to require surgery, and relaxations of elective surgery suspensions will need to occur in the near future. We share here how we have modified our operative technique to minimize the operating team exposure to aerosols during thoracic surgery (Table 1). Informed written consent was obtained by all patients. Risk mitigation begins with effective screening. All patients undergo a nasopharyngeal swab and polymerase chain reaction testing for SARS-CoV-2 24 to 48 hours preoperatively, although this has limited sensitivity and a false-negative rate.8West C.P. Montori V.M. Sampathkumar P. COVID-19 testing: the threat of false-negative results.Mayo Clin Proc. 2020; 95: 1127-1129Abstract Full Text Full Text PDF PubMed Scopus (221) Google S