American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

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Ethics, Patient Safety, and the Business of Medicine

Ethics, Patient Safety & the Business of Medicine coverVol. 46, No. 1, 2020

Literature Overview
Editor: Lewis M. Flint, MD, FACS
Associate Editors: ;Leah Tatebe, MD, FACS; Jordan Caffe; Salman Akthar; Sydney Pekarek; Anne Stey, MD, FACS; Karl Billimoria, MD, FACS; and Heather Yeo, MD, FACS

  • Surgical Ethics
  • Patient Safety in Surgical Practice
  • The Business of Medicine

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Featured Commentary

The online formats of SRGS include access to What You Should Know (WYSK): commentaries on articles published recently in top medical journals. These commentaries, written by practicing surgeons and other medical experts, focus on the strengths and weaknesses of the research, as well as on the articles' contributions in advancing the field of surgery.

Below is a sample of one of the commentaries published in the current edition of WYSK.

Commentary by: Christopher G. DuCoin, MD, MPH, FACS

Mintz Y, Arezzo A, Boni L, et al. Minimally invasive surgery is the key to patient and operating room team safety during the COVID19 pandemic as well as in the "new normal" or chronic pandemic state to come. Br J Surg. 2020;107(11):e461-e462. doi:10.1002/bjs.11916

The COVID-19 pandemic has led to changes not only in our day-to-day lives but also in the operating room. Guidance on how to navigate operating during the COVID-19 pandemic has been conflicted and varies by geographical region and institution. The authors of this research letter endeavor to provide structure and guide safe practice for COVID-19 positive patients requiring emergency or oncologic surgery and attempt to develop a decision tree regarding the appropriate operative technique, laparoscopy vs. open surgery.

The letter begins by reinforcing the thought that elective surgery on COVID-19 positive patients should be delayed and that emergency and oncology are carried out as non-elective surgery. We suggest that transplant, cardiac, and a litany of additional surgeries fall into this urgent category regardless of COVID-19 status. The Anesthesia Quality Institute defines elective surgery as a surgical, therapeutic, or diagnostic procedure that can be performed at any time or date according to the agreement between the surgeon and patient. However, there are so many nuances and complexities to this straightforward statement. We would suggest the reader review the American College of Surgeons (ACS) statement that includes an Elective Surgery Acuity Scale (ESAS) that considers the patient's need and the impact of a surgical procedure with available resources.1 Elective surgeries need to function in a space of collaboration between surgeons, anesthesiologists, and hospital administrators, again taking into account the patient's specific needs, the resources of the intuition, and the regional impact of COVID-19. Once elective surgery is defined, we agree with the authors that this procedure should be delayed if the patient is COVID-19 positive.

Interestingly, the authors note that elective surgery should be delayed until the COVID-19 patient's status returns to negative. The return to negative status is described in Figure 1 as "Reassessment after 14 days." At our institution, the reassessment is after ten calendar days. However, the CDC has clearly defined 'negative' via either a test-based strategy or a non-test-based strategy. The test-based strategy is defined as resolution of fever without fever-reducing medications, improvement in respiratory symptoms, and a negative result from two SARS-CoV-2 tests ≥24 hours apart. While the non-test-based is defined as at least 72 hours since the resolution of fever without fever-reducing medications and improvement in respiratory symptoms and at least seven days since symptoms first appeared.2 The CDC also recommends using the test-based strategy specifically for hospitalized patients and those who are severely immunocompromised. The time between positive test and reassessment will vary based on specific instructional policies. Still, it should be recommended that how the reassessment is performed is following CDC guidelines.

The authors then describe the difference between low and high complexity cases citing differentiating variables such as possible ICU admission, laparoscopic complexity, anticipated ventilation time, hemodynamic instability, and patient positioning. However, this is not a single calculated metric (low vs. high). The list of variables could be endless: age, BMI, time of day of the procedure, renal function, cardiac function, etc. Rather, low vs. high complexity needs to be a team-based discussion with all parties, surgeon, anesthesiologist, ICU team (capacity management), and of course the patient. The authors state in Figure 1 that a highly complex emergency case necessitates an open laparotomy. Again, we feel this is a case-by-case decision, and COVID status does not affect this decision but rather the patient's physiology and ability to tolerate pneumoperitoneum. Thus, such a definitive statement cannot be recommended. For patients who are COVID-19 negative, it is recommended they undergo standard practice and laparoscopy if possible.

As mentioned above, the authors only identify emergency or oncology surgery as the potential procedures that would necessitate deciding to operate on a COVID-19 positive patient. However, we would suggest this could be a much larger group of patients such as transplant (donor and recipient), cardiac and vascular cases, neurosurgery, ophthalmology, etc. Again, we would recommend a step-wise triage plan regarding emergency cases to prevent abuse of the system and institution, much like triaging emergency cases to the operating room during non-pandemic times. A COVID-19 positive case listed as an emergency operation should not simply be at the surgeon's discretion but should include all parties involved in the care and coordination of that patient and should include the patient as well.

The authors then draft a very well-thought-out algorithm for the decision-making process regarding performing laparoscopic vs. open surgery on COVID-19 patients based on pneumonia status. In short, if the patient has pneumonia and requires ventilation with poor respiratory compliance, they should undergo laparotomy (Figure 1). Otherwise, the authors suggest that operations are attempted with laparoscopy first. It would seem that these ventilated patients with poor lung compliance, who the authors recommend, require open laparotomy based on the physiology of abdominal insufflation during laparoscopy, not the COVID-19 positive status. It should be noted that multiple societies have put out a litany of consensus statements and guidelines regarding the safety of laparoscopy in COVID-19 patients. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) provides additional insight with excellent best practice recommendations for laparoscopic surgery. The first is to note that the CO2 should be removed from the port attached to the filtration device when evacuating pneumoperitoneum. This should be an ultra-filtration system, and the desufflation mode should be used on your insufflator if available. The next is that if the insufflator being used does not have a desufflation feature, ensure that the valve on the working port that is being used for insufflation is closed before the flow of CO2 on the insufflator is turned off (even if there is an in-line filter in the tubing). Without taking this precaution, contaminated intra-abdominal CO2 can be pushed into the insufflator with intraabdominal pressure. They also state that surgical drains should only be used if absolutely necessary, and the specimen should be removed after all of the CO2 has been evacuated.3 These are all logical precautionary steps to decrease the chance of particulate spread.

Finally, a flow diagram is provided after the letter to illustrate the author's recommendations. The authors make a final conclusory statement that "At present, aside from the potential pulmonary repercussions, there is no evidence that laparoscopy is more dangerous than laparotomy for patients with COVID-19 disease." Following this logic, COVID-19 status should not dictate the style of operation, laparoscopic vs. open, but rather the patient's physiological status should determine this decision. Thus, one could argue there is no need for this decision tree at all. What is more important is focusing on which COVID-19 patients need urgent surgery, and for those who test positive for COVID-19 but do not require emergent surgery, the institution's plan for reassessing the patient for future safe entry into the operating room.


  1. American College of Surgeons. COVID-19: guidance for triage of non-emergent surgical procedures. Published March 17, 2020.
  2. Centers for Disease Control and Prevention. Discontinuation of transmission-based precautions and disposition of patients with SARS-CoV-2 infection in healthcare settings.
  3. SAGES. Resources for smoke & gas evacuation during open, laparoscopic, and endoscopic procedures. Published May 9, 2020.



Recommended Reading

The editor has carefully selected a group of current, classic, and seminal articles for further study in certain formats of SRGS. The citations below are linked to their abstract on PubMed; free full-text is available where indicated.

SRGS has obtained permission from journal publishers to reprint these articles. Copying and distributing these reprints is a violation of our licensing agreement with these publishers and is strictly prohibited.

Friedmacher F, Puri P. Rectal Suction Biopsy for the Diagnosis of Hirschsprung's Disease: A Systematic Review of Diagnostic Accuracy and Complications. Pediatr Surg Int. 2015;31(9):821-830.

Moghadamyeghaneh Z, Sgroi MD, Chen SL, et al. Risk Factors and Outcomes of Postoperative Ischemic Colitis in Contemporary Open and Endovascular Abdominal Aortic Aneurysm Repair. J Vasc Surg. 2016;63(4):866-872.