Practical Measures for the Conduct of Robotic Surgery in Pandemic Environment

There is very little evidence regarding the relative risks of Minimally Invasive Surgery (MIS) versus the conventional open approach, specific to COVID-19. Although previous research has shown that laparoscopy can lead to aerosolization of blood borne viruses, there is no evidence to indicate that this effect is seen with COVID-19, nor that it would be isolated to MIS procedures. Continued utilization of current PPE guidelines in the operating room based on patient COVID19 status is recommended. 

 

Sources of contamination (points of aerosolization, spread)

1. Intubation

2. Insufflation/desufflation

3. Smoke Evacuation

4. Specimen removal

5. Energy device use

Staff at Risk

1. Bedside assistants

2. Surgeon

3. Anesthesia

4. RN/Circulator

 

Robotic Surgery Guidelines COVID/Pandemic

Patient Testing

1. All elective emergent robotic surgical cases should receive COVID19 testing

2. Robotic surgery should not be performed on known/confirmed COVID positive patients. Other non-operative or operative (open) procedures should be utilized instead.  If patient can be delayed, they can be rescheduled after:

   1. 14 day quarantine following CDC guidelines

   2. Repeat testing completed post diagnosis day 15 and 16 with negative result

Intraoperative PPE

1. Use highest protection level III (N95, face shield, double glove) for bedside assistant, but level II for console surgeon.

2. Reduce the number of staff in the operation room to minimal effective team

   1. Surgeon

   2. Bedside assistant

   3. Scrub tech

   4. Circulator RN

   5. Anesthesiologist

Insufflation Techniques

1. CONMED AIRSEAL tri-lumen tubing on AIRSEAL mode should be utilized for insufflation which allows for 0.01 micron filtration (COVID-19 has been reported in the range of 0.06 – 0.14 μm)

2. CO2 gas and smoke should be captured with an ultra-filtration system.  Do not vent port sites to the room.

3. Minimize insufflation pressures

4. Minimize gas leakage

Surgical Procedure

1. Specimen removal should be after filtered desufflation and removal site should be covered to limit splash or aerosolization. 

2. Surgical drains should be utilized only if absolutely necessary.

3. Suture closure devices that allow for leakage of insufflation should be avoided. The fascia should be closed after desufflation.

4. Hand-assisted surgery can lead to significant leakage of insufflated CO2 and smoke from ports and should be avoided. If used to remove larger specimens and protect the wound, it can be placed after desufflation.