Laparotomy represents the safest option during COVID-19 outbreak: Authors' response to: "The COVID-19 pandemic should not take us back to the prelaparoscopic era" by Botteri et al. and "Emergency laparoscopic surgery during COVID-19: what can we do and how to do it safely" by Bonapasta et al.

Abstract

Dear Editor, We thank both Botteri et al. and Bonapasta et al. for their interest in our article.1 Despite their comments supporting a wider use of laparoscopy during COVID-19 outbreak, we think that the current lack of evidence mandates a swing toward a more prudent approach.2 Recently, viral RNA was detected in the peritoneal fluid of a COVID-19 patient who had undergone a laparotomy for a small bowel volvulus.3 No ischemia or perforation was present, thereby, excluding the possibility of contamination due to spillage from the gastrointestinal tract. Several filtration systems have been described to filtrate pneumoperitoneum and vapor during laparoscopy,4 but they add to the workload of an already stretched staff. Furthermore, these tools may be not available everywhere, and concurring with other authors,5 we recommend laparotomy as the safest option. With the current reduction of surgical caseload, performing a reduced number of emergency laparotomies is reasonable. The same evidences taken to support the benefits of laparoscopy, such as reduced surgical site infection rate and length of stay, confirm that no difference exists in main outcomes, such as mortality, major complications, or reoperation rate.6,7 Botteri et al. state that laparoscopy offers a greater chance of protecting operators because all gases and vapors are confined to the abdominal cavity. We want to stress that pneumoperitoneum is the main source of aerosolization and with a minimized use of electrocautery by an experienced surgeon, a laparotomy may be a gasless procedure. Furthermore, the mandatory step of removing the trocars under vision at the end of any laparoscopy may not be possible without gas leakage. Bonapasta states that “immediate conversion to laparotomy should be considered after assessment of the intra-abdominal status and at any time during operation, if a significant electrosurgical use is necessary.” However, in case of an intraoperative complication, such as major bleeding requiring a rapid conversion, a controlled and safe gas exsufflation before incision may be suboptimal, representing a great risk for all operating room staff. With the current shortage of surgical personnel, surgeons, and trainees reallocated in intensive therapy units (ITU) and medical wards to face the overwhelming number of COVID-19 patients, preventing a SARS-CoV-2 transmission among health-care workers and patients remains a priority.8–10 Botteri et al. point out that negative appendectomies “are not so common anymore,” but in the RIFT (Right Iliac Fossa Pain Treatment) study,11 (in patients aged 16–45 years) the negative appendectomy rate (NAR) was 20% in the United Kingdom and 6.2% in the other European countries. Regarding the access, we agree that midline may be appropriate for complex cases (e.g., acute diffuse peritonitis), although a McBurney incision, enlarged superiorly if needed as pararectal, may allow to perform safely even an ileocecal resection in the majority of cases. The same authors claim the potential advantages of stenting malignant colonic obstruction, hence, lowering surgical complications and stoma rate, and delaying anesthesia. We support this opinion in normal times, but during the pandemic, endoscopic services may be centralized, and transporting a patient with COVID-19 (or suspected) in an endoscopic unit for stent placement may imply a further risk of diffusion and an increased length of stay due to a delayed surgery. We agree that the risk of a permanent stoma after Hartmann operation may exist. However, in areas with a high incidence of COVID-19, all patients are considered infected until proven otherwise. Several reports suggest that SARS-CoV-2 may produce hypercoagulability, endothelitis, and intestinal ischemia.12 Thus, we prefer to err on the side of safety and avoid a potential anastomotic leak, with the additional associated morbidity, ITU admission, and mortality. We think that, under the current exceptional circumstances, a wider perspective, taking into account resource availability, staff protection, and risks reductions must be adopted. With 156 medical doctors, died “on the field” as of May 8, 2020, we do not want to go backward but safely move into the future. Francesco Pata, MD General Surgery Unit, Nicola Giannettasio Hospital, Corigliano-Rossano, Italy. [email protected] La Sapienza University, Rome, ItalyMansoor Khan, MD, FACS, FRCS Digestive Diseases Department, Brighton and Sussex University Hospitals, Brighton, United Kingdom Royal College of Surgeons of England, DSTS Faculty, London, United KingdomDomenico Iovino, MDSalomone Di Saverio, MD, FACS, FRCS Department of General Surgery, University of Insubria, University Hospital of Varese, ASST Sette Laghi, Regione Lombardia, Italy