Respiratory management personnel are at risk of infection when exposed to direct viral droplets. This allows you to consider delaying or limiting the procedure due to limited resources and / or patient conditions. This increases the risk of death because traditional surgical techniques produce more aerosols.
The purpose of this descriptive review is to analyze the infection risk of laparoscopic specialists in Covid-19 patients. Laparoscopic Trainer.
For many reasons use of simulators is a sensible choice like Laparoscopic Trainer.
Closed smoke evacuation circuits use to control the surgical plume, composed of suction devices connected to the electrosurgical source. Recent studies consider that the smoke evacuator decreases the average activity level between 44.1% and 99% as follows:
- With variable efficacy due to the influence of factors such as evacuator flow rate
- The angulation of the surgical device from the skin
- Distance between the evacuator outlet and the operating site
- The direction and speed of external air flow in relation to the flow of the nozzle
Use Of Filters
These filters use in portable evacuation machines, in some cases they use in the wall suction system to capture small amounts of smoke safely. Although it recommends by different professional organizations that defend its use. These measures not use very frequently due to the following:
- excessive noise,
- high cost,
- equipment maintenance problems,
- bulky devices, and
- resistance from health personnel
To Reduce the Risk of Viral Transmission
Laparoscopic procedures can create a closed environment that allows control of air entry. And exit through trocar points that are well-defined access points. And it could speculate that they could reduce the risk of viral transmission to hospital staff. The operating room through surgical smoke compared to open procedures. This due to having a closed and regulated abdominal environment that can act as a containment barrier.
However, the constant and dynamic process of insertion/extraction between the laparoscopic instruments. And the entry ports contribute to a constant leak of insufflated gas in the operating room. Any measures that can takes to reduce gas leakage from the operating room must consider the pandemic.
Use Of Smoke Evacuators
According to the recommendations of the College of Surgeons a leak mitigation strategy uses with smoke evacuators. The ultra-low particulate air filters (ULPA) with the capacity to purify 99.999% of particles larger than 0.1 µm. This is with capturing the smoke close to the emission source, reducing the exposure of the health professional.
It states that staff should routinely install ULPA filters for surgical smoke control. The most effective evacuation system is the triple filter system. This includes a prefilter that captures large particles, an ULPA filter, and a special carbon filter that captures toxics found in smoke. It has the capacity for variable suction volume to accommodate different levels of smoke production. Laparoscopic Trainer.
Use Of Balloon Ports
All minimally invasive procedure surgeons are aware that the trocar is an inadvertent escape point for CO 2pressurized pneumoperitoneum. This being a potential risk the displacement of the port due to Covid-19. The use of balloon ports recommends to reduce the inadvertent loss of pressure with leakage in the trocar exchange during instrumentation.
Use Of Direct Suction of Trocars
This makes smaller incisions or reduce the entrance of the trocar in case of being larger with forceps. This reduces the risk of exit from the pneumoperitoneum to the operating room environment. In the case of not having a smoke evacuation system, several groups suggest the use of direct suction of the laparoscopy trocars. This is to allow smoke evacuation. However, it does not guarantee high filtering efficiency. Therefore, it recommends the use of all advanced personal protection elements, including the N95 or larger mask.
Use of Intra-Abdominal Pressure
It is important to consider the insufflation and flow pressures to create a pressure gradient when two separate areas have different pressures. In the average intra-abdominal pressure used in laparoscopic surgery is 15 mmHg, compared to 12 mmHg elsewhere. Pressure management as low as 8 mmHg associated with a deep neuromuscular blockade explores with an adequate result of the procedure.
Early in vivo studies have suggested that at high intra-abdominal pressures and long procedure times they contribute to increased aerosolization rates, measured by the degree to which cellular debris spreads throughout the abdominal cavity. Given these findings, international groups recommend performing procedures with low flows (5-10 L/min of CO 2) and lower intraperitoneal pressures between 8 and 10 mmHg. Laparoscopic Trainer.
Once the procedure is over, the precautions for removing the pneumoperitoneum carries out in a careful and controlled manner. Also, aspirating the intra-abdominal CO 2, removing the piece and the trocars safely. In case of converting the surgery to open, care takes to aspirate the CO 2 previously.
When the patient is in extubating conditions, the protocol to follow bases on avoiding the aerosolization of the virus. This during the procedure and recovering the patient in rooms after transfer to the room. Medical and auxiliary personnel must remove personal protection elements with a supervised checklist to prevent contamination. And proceed to the adequate decontamination of the operating room following the cleaning and disinfection protocols established for Covid-19 patients. The use of vaporizers based on 0.5% hydrogen peroxide or 71% ethanol suggests since they effectively inactivate the virus.
Concerns For Health Workers
There is concern for health workers about the risk of contagion and death from the Covid-19 pandemic. The exposure in the different areas of care and the constant production of aerosols by patients. Minimally invasive procedures and the risk of transmission detected by surgical smoke raise doubts in surgery services. There are opposing positions that worry about the risk/benefit for the patient and the risk of exposure to health workers.
Undoubtedly, pneumoperitoneum and surgical smoke produce the aerosolization of particles within which remains of bacteria and viruses. Now there is no level of evidence that determines that SARS-CoV-2 transmits by surgical technique. However, other viruses such as human papilloma and hepatitis B initiates in the surgical environment with the ability to cause occupational diseases. So, the proper use of personal protection elements is paramount in care of all patients. Laparoscopic Trainer.
Initial Medical Management of Laparoscopy
In March 2020, the consensus of Colleges of Surgery publishes as a recommendation. The evaluation of all patients who are candidates for surgical management or initial medical management. They identify the benefits of laparoscopic as opposed to open surgery and the exposure of health personnel. Constant communication with the surgical team is important to determine the capacity of minimum personal protection elements and the suitability of the measures recommended in the operating room to minimize exposure to the virus.
Pressure Of the Pneumoperitoneum to The Minimum
In case of approaching the laparoscopic technique. It recommends to reduce the pressure of the pneumoperitoneum to the minimum possible without compromising the safety of the procedure. To reduce the power of the electrocautery and the dissection with ultrasound. Upon completion, use the laparoscopic smoke aspiration system with particulate filters. This removes the piece of tissue after completely emptying the pneumoperitoneum as well as any gauze or wick used in the procedure. And completely removes the pneumoperitoneum before removing the last trocar.
There is no scientific evidence to support the association between performing open or laparoscopic procedures. Although new information on the disease and its transmission continually reports the reduction in transmission of COVID-19. To recognize the theoretical risk of transmission as the aerosolization of the virus to a health Personnel. These are due to the flow and inadvertent loss of the pneumoperitoneum that can expose health personnel. This debate focuses on whether proper use of aerosolization prevention measures is sufficient for laparoscopic technology. Since the patient benefits by reducing hospital stay and postoperative pain. We hope conclusive research will continue to establish simplified decision making.
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