Surgery in the era of COVID-19: implications for laparoscopy and natural-orifice endoscopic surgery: a narrative review

Controversy exists regarding the use of minimally invasive surgery (MIS) during the corona virus disease 2019 (COVID-19) pandemic. Several surgical societies have issued recommendations regarding precaution measures during MIS, nonetheless these recommendations were conflicting with respect to the use of laparoscopy with little or no inference to natural-orifice endoscopic surgery. A comprehensive literature search was performed to explore the available evidence pertinent to the novel coronavirus 2 (SARS-CoV-2) transmission dynamics in MIS, and benefits of MIS procedures in patients with transmissible viral diseases. According to the current evidence, SARS-CoV-2 has a multi-route transmission, including fecal-oral transmission. Evidence on airborne transmission in the operative setting are however limited. In addition to nasopharyngeal screening, it would seem prudent to perform routine fecal testing for SARS-CoV-2 in patients undergoing positive-pressure transanal minimally invasive procedures. This is particularly relevant to regions with high level of epidemicity. In patients with confirmed SARS-CoV-2 infection, conventional laparoscopic and robotic approaches, and atmospheric transanal surgery with high volume smoke evacuation may be safer alternatives. Considering the high rates of postoperative pulmonary complications and mortality associated with SARS-CoV-2 infection, use of laparoscopy is advised in suspected or confirmed COVID-19 patients who require abdominal surgery, particularly older patients and those with comorbidities. Laparoscopy may decrease the probability of postoperative disease exacerbation, and provide earlier recovery, less morbidity and mortality, and shorter hospital stay with subsequent decreased risk of in-hospital secondary transmission. High index of suspicion in postoperative patients with fever or respiratory symptoms is necessary to timely diagnose COVID-19. Chest computed tomography scan has a higher sensitivity compared to real-time PCR and can potentially be used to assist in the diagnosis, particularly in elderly patients.