Artículos de Revisión

Minimally invasive surgery in COVID-19 times, is it possible?

Cirugia de minima invasion en tiempos de COVID-19, es posible?

Vladimir Erik Vargas-Rocha *
Caja Nacional de Salud, Hospital Obrero Nº2, Bolivia
Patricia Segales-Rojas
Bolivian-Japanese Gastroenterology Institute, Bolivia
Brian E. Vargas-Rocha
Universidad Mayor de San Simón, Bolivia

Gaceta Médica Boliviana

Universidad Mayor de San Simón, Bolivia

ISSN: 1012-2966

ISSN-e: 2227-3662

Periodicity: Semestral

vol. 43, no. 1, 2020

Received: 09 April 2020

Accepted: 03 June 2020


Todos los derechos morales a los autores y todos los derechos patrimoniales a la Gaceta Medica Boliviana

Abstract: On March 10 the first two cases of coronavirus disease (COVID-19) are recorded in Bolivia, on March 11 it is declared a pandemic, affecting patient care at all levels, both in the public, private and insurance systems. Finding the entire health system devoid of protocols and management guidelines for this disease. Surgical services face the challenges of optimizing the care of patients with emergency pathologies, postponing elective surgeries. This delay in care will definitely have negative effects, and may even result in the late diagnosis of oncological pathologies. The surgical services adopted protocols that try to reduce the time in the operating room and the risk of postoperative complications. In this work we review the guidelines of the international associations for performing minimally invasive surgeries, making this a viable alternative to patients during the COVID-19 pandemic.

Keywords: COVID-19, general surgery, laparoscopy.

Resumen: El 10 marzo se registran los primeros dos casos de enfermedad por coronavirus (COVID-19) en Bolivia, el 11 marzo se declara como pandemia, afectando la atención de pacientes en todos sus niveles, tanto en el sistema público, privado y seguros. Encontrando a todo el sistema de salud desprovisto de protocolos, y guías de manejo ante esta enfermedad. Los servicios quirúrgicos enfrentan a los desafíos de optimizar la atención de pacientes con patologías de emergencia, posponiendo cirugías electivas. Este retraso en atención definitivamente tendrá efectos negativos, inclusive puede resultar en el diagnóstico tardío de patologías oncológicas. Los servicios quirúrgicos adoptaron protocolos que intentan reducir la cantidad de tiempo en quirófano y el riesgo de complicaciones postoperatorias, en este trabajo se realizó una revisión de las pautas de las asociaciones y guías internacionales para realizar cirugías de mínima invasión, siendo esta una alternativa viable para los pacientes durante la pandemia por COVID-19.

Palabras clave: COVID-19, cirugía general, laparoscopia.

Coronaviruses (CoVs) are a large family of viruses that can cause a range of conditions, from the common cold to more serious illnesses. A novel coronavirus is a new strain of coronavirus that has not previously been found in humans. These infections usually present with fever and respiratory symptoms (cough and dyspnea or shortness of breath). In severe cases, they can cause pneumonia, severe acute respiratory syndrome, kidney failure and even death1.

The Republic of China on 31 December 2019 reported a public health event of international concern, the outbreak in 27 patients with pneumonia of unknown etiology, with onset of symptoms on 8 December 2019 in Wuhan city. On 7 January, a virus of the coronaviridae group, a new coronavirus, was identified as the agent, and on 30 January the World Health Organisation (WHO) declared the outbreak and issued a public health emergency1.

On 26 February, a first suspected case appeared in Bolivia, whose laboratory test was negative for coronavirus. On 10 March, the first two positive cases were registered, one in Santa Cruz and the other in Oruro, imported from Italy. Finally, on 11 March, the WHO declared COVID-19 a pandemic1,2.

Through Decree 4196 of 17 March 2020, the national government declares a health emergency and quarantine throughout the state against the outbreak of the new coronavirus (COVID-19)3.


This pandemic has created an impact like no other on health systems around the world, affecting patient care at all levels, in the public, private and insurance systems. The entire health system in all countries has been deprived of protocols and management guidelines in the face of an emerging and unknown disease. All countries have adopted measures to reduce the risk of contagion, limiting health care to critical patients and true emergencies, but despite these measures, the virus continues to spread. This fact obliges health and governmental authorities to reallocate economic resources, build new infrastructure, purchase equipment and medical supplies, as well as the movement of doctors, all directed towards the care of COVID-19 patients, conditioned by these measures to the redistribution of activities in various medical areas that are not directly involved in the management and treatment of patients with COVID-194.

The recommendations for the prevention of infections transmitted by blood-borne pathogens are called “Universal (or Standard) Precautions” and were made by the Center for Diseases Control and Prevention in 1987 and remind us that these recommendations should be applied to all patients5.

The surgical and clinical services of health systems face the difficulties of providing the best possible treatment for patients with emergency pathologies, including certain oncological cases, postponing in all cases elective surgeries, without putting the patient or medical staff at risk, these measures aim to minimise the use of equipment and medical supplies that will be needed to deal with COVID-19, such as respirators, surgical masks, hand disinfectant, gloves and other supplies, as well as to assist in the availability of hospital beds for the care of SARS CoV-2 patients and to ensure the normal course of emergency cases requiring operating theatres and intensive care units. However, this task is very difficult, as these priorities must be correctly stratified6-9.

During this triage, it must be borne in mind that the delay in care, both in outpatient and delayed surgery programmes will have an impact on the health of patients, unfortunately, it is difficult to know how long the current crisis will last and how much it will affect the health of the general population. It is clear to note that this delay in timely care will definitely have negative effects, and may even lead to a late diagnosis of oncological diseases6.

There are a number of factors that require consideration. Regimens with a clear survival advantage should be prioritised, with curative treatments being mandatory and others requiring consideration of the risk/benefit ratio. Treatments that have only demonstrated a palliative effect for symptomatic patients require careful discussion. Delaying the initiation of therapy during periods of uncertainty or difficulty is an appropriate measure for many therapies7.

In all countries, including Bolivia, surgical protocols have been adopted that attempt to reduce the amount of time in the operating theatre, as well as the risk of postoperative complications, with the main objective that hospital stay can be minimised and recovery is immediate, avoiding repetitive physical assistance of the patient in the hospital4. In such a situation, minimally invasive surgery, such as laparoscopic and endoscopic surgery, can play a beneficial role in the treatment of pathologies that cannot be deferred.

So far, SARS-CoV-2 has been known to be found in the nasopharynx, upper respiratory tract, gastrointestinal tract, nasal swabs, saliva, throat swabs, blood, bile and faeces9. These findings have created safety and transmission risk concerns with respect to airway manipulation for administering general anaesthesia to the patient and performing laparoscopic and endoscopic procedures to a lesser extent, given that many interventions require bowel management4. Another concern is the risk of transmission through particles or aerosols generated by instruments used in surgery, such as electrical and ultrasound batteries. Although establishing and maintaining pneumoperitoneum is an essential principle in laparoscopic procedures, studies have shown that some viruses can be transmitted through carbon dioxide and aerosols during laparoscopic surgery. Examples include human papillomavirus and HIV10-12. These instruments release a higher concentration of gases into the peritoneal cavity due to the low gas mobility in the pneumoperitoneum. When trocar valves are removed, or unsealed trocar instruments are exchanged or removed, aerosol leakage from the pneumoperitoneum may increase the risk of transmission to healthcare personnel, making laparoscopic surgery riskier than an open procedure13. No study so far has identified SARS-CoV-2 in surgical smoke, nor is it known whether such viral particles would be infectious, or even if they were found in this smoke14. Therefore, routine COVID-19 testing is recommended prior to an emergency and regardless of the result, the most beneficial approach for the patient should be offered15. There is insufficient data to recommend for or against an open or laparoscopic surgical procedure21, 22. Evidence suggests that cancer patients have an increased risk of death from COVID-1923. Therefore, the risk/benefit ratio of various palliative and (neo)adjuvant treatments should be reconsidered during this pandemic. Several factors such as age and comorbidities will also influence this risk, as will the additional hospital visits associated with specific treatment24,25. According to the recommendations of the Spanish Association of Surgeons, hospital occupancy for COVID-19 patients should be a maximum of 5% in order to resume elective surgical activity26.

A review of the recommendations and guidelines of international associations and guidelines on care during surgery, to which we suggest adherence when performing minimally invasive procedures, carried out, of all these recommendations we can mention:

In summary, minimally invasive procedures remain a viable alternative for patients during the COVID-19 pandemic, provided that appropriate precautions are taken and the above recommendations are followed. The risk of SARS-CoV-2 transmission via aerosols from pneumoperitoneum has not been demonstrated nor have studies been performed to show whether there is greater transmission of the virus in laparoscopic surgery than in laparotomy14. In addition, open procedures may result in other complications, as well as prolonged hospital stay and use of beds that could be designated for patients with COVID-19.


The picture will change as the risk of infection changes and more is known about COVID-19 prevention and treatment. In addition, treatments for COVID-19, such as antiviral agents, may improve outcomes. We hope that this evidence and opinion can provide a starting point for discussions at the local level and that all surgical services can use these recommendations as a framework for creating their own specialty-specific recommendations.


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Author notes

* Correspondence to: Vladimir Erik Vargas-Rocha


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