Surgery beyond coronavirus disease 2019

Abstract

Coronavirus disease 2019 (COVID-19) has changed the world as we know it and the practice of medicine forever. Past pandemics may have primed us but COVID-19 unfolded on a scale not seen in modern history with many likening it to the 1918 Spanish Flu. Fortunately, medicine has progressed since then, and the response to COVID-19 in countries such as Australia, New Zealand, Singapore, Hong Kong and Taiwan has been robust. The aggressive stance adopted by Australia and New Zealand in travel bans, social distancing and active quarantine and surveillance has flattened the curve, curtailed the spread and prevented overwhelming of healthcare systems by COVID-19 patients. This has helped keep the case fatality rate to near 1%.1 Despite healthcare systems coming under siege from the surge, inspirational stories surface each day on how healthcare workers support each other and continue to deliver excellent care. As surgeons, we pride ourselves in our kinaesthetic ability and physical stamina in service of our patients. However, this crisis has forced many of us to adapt to new roles and redefine our practices.2, 3 Proud custodians of tradition have been compelled to adopt new technology and function within the confines of lockdowns and social distancing. With the advent of a vaccine or herd immunity, we will eventually overcome this pandemic but the landscape of surgery will be transformed. How do we navigate what is to come? As countries learn to live with COVID-19, with a flattened curve and limited outbreaks that can be controlled by quarantine and case contacting, coming out of a lockdown presents equal challenge to entering one. Across the world, countries lifting restrictions are being hit by a second wave of infections and have reinstated lockdowns.4 To reduce this impact, countries such as Australia and Singapore have adopted three-phase plans to guide the reopening.5, 6 As the final line of defence, healthcare institutions are expected to unwind restrictions within the workplace slower compared to the rest of the society. This means many of our services will continue to function in a pandemic mode until the crisis within our countries is truly over. Mass testing of healthcare workers may expedite this reversal process and mitigate the risk of workplace transmission.7 Ramping back up of services will be required despite personnel still recovering from the exhaustion of such a prolonged heightened posture. Having prioritized surgeries and displaced most benign and non-emergent cases, surgeons will be faced with a backlog of anxious patients.2 We need to anticipate this by reprioritizing surgeries and progressively performing more elective cases where resources allow.8 In this globalized age, spread between countries as borders reopen may cause the pandemic to be further protracted. We cannot indefinitely postpone time-sensitive surgery like oncologic surgery. Deadlines must be established beyond which elective cases may up-triage to warrant urgent surgery. Surgeons must be prepared for the possibility of having to operate on COVID-19 patients in a prolonged pandemic.3 We may be forced to work outside our comfort zone whether in the use of additional personal protective equipment or modification of techniques to reduce transmission risk.2, 3 Yet, surgeons have and continue to show that we are adaptable professionals. Many of us have been called out of the operating theatre into the frontlines of this battle, be it helping swab patients or managing ventilators.3 This episode reminds us that behind the scalpel, we need to continually update our knowledge and maintain relevance as clinicians first. Medicine has always been slow to adapt, perhaps due to the nature of our training to be only convinced by hard evidence before adopting an idea. Surgery, where the outcomes of our patients are directly and immediately apparent from our actions, carries even higher thresholds. This pandemic has forced us to catch up with the rest of the worl