A call to arms: a perspective on safe general surgery in Singapore during the COVID-19 pandemic.

Abstract

The coronavirus disease 2019 (COVID-19) pandemic crisis has reached a critical juncture. At the time of writing, the World Health Organization has reported more than 750,800 cases and 36,405 deaths.(1) The speed of disease spread has been staggering. While it took three months to reach the first 100,000 cases, it took only 12 days to reach the next 100,000 and less than five days for the next 200,000 cases.(2) The first imported case of COVID-19 was reported in Singapore on 23 January 2020.(3) Local transmission was confirmed on 4 February 2020 and the Disease Outbreak Response System Condition (DORSCON) status was raised to Orange on 7 February 2020.(4) DORSCON is a colour-coded framework that defines the infectious disease condition as well as the measures taken to reduce disease transmission in Singapore.(5) As of 29 March 2020, there were 844 cases in Singapore and three deaths.(2) Surgical safety has fallen under the spotlight as the pandemic shifted its epicentre from China to Europe and the United States of America.(1) Surgeons are being called upon to cancel elective procedures and focus on maintaining only emergency operations and elective cancer surgeries,(6-9) as recommended by guidelines based on experiences in Italy(10) and China.(11) Decisions to persist with elective surgeries in some countries have met with opposition and criticism.(12) Concerns are mainly centred on the risk of viral transmission during surgery. To date, the evidence is clear that COVID-19 is transmitted via close contact through respiratory droplets and fomites.(13-15) The risk of airborne transmission exists and is highest during aerosol-generating clinical procedures such as intubation, extubation, laparoscopy and endoscopy. These procedures present inherent risks to anaesthesiologists, surgeons and operating nursing staff, or any unsuspecting person within the operating room (OR). Various international bodies have published recommendations. Although the evidence is not strong, the human immunodeficiency virus, Corynebacterium and human papillomavirus has been detected in surgical smoke.(16,17) The use of laparoscopic ultrasonic scalpels and diathermy also produces a far higher concentration of surgical smoke than open surgery due to low gas mobility in the pneumoperitoneum. Furthermore, viral cellular components are not deactivated effectively because of low temperatures.(10) The risk to the surgeon is thus theoretically higher, especially during the evacuation of gas, which can happen during specimen extraction, venting of smoke via trocars during surgery to improve visualisation, or unintended gas leakages due to poor seals between trocars and the abdominal wall. The second concern is the utility of valuable personal protective equipment (PPE). There have been critical shortages of PPE worldwide.(18) Graphic images of healthcare workers (HCWs) using self-made PPE from plastic or garbage bags have gone viral, as well as complaints on social media about the lack of availability of PPE or restrictions on the use of N95 respirators, some of which were posted by HCWs from respected medical systems.