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CE: R.R.; ANNSURG-D-20-01577; Total nos of Pages: 8; ANNSURG-D-20-01577 REVIEW PAPER Electrocautery, Diathermy, and Surgical Energy Devices Are Surgical Teams at Risk During the COVID-19 Pandemic? à à à AQ2 Kimberley Zakka, Simon Erridge, MBBS, BSc, Swathikan Chidambaram, Michael Kynoch,y à à AQ3 James Kinross, and Sanjay Purkayastha Y, on behalf of the PanSurg collaborative group coronavirus disease-19 (COVID-19) pandemic there are understand- Objective: The aim of the study was to provide a rapid synthesis of available able concerns amongst the surgical community as to the risk of viral data to identify the risk posed by utilizing surgical energy devices intra- transmission within such surgical plumes. operatively due to the generation of surgical smoke, an aerosol. Secondarily it To date, live SARS-CoV2 has been detected in lower respira- aims to summarize methods to minimize potential risk to operating room staff. tory tract samples, saliva, feces, bile, and blood specimens.2,3 As Summary Background Data: Continuing operative practice during the such, during the perioperative process, precautions should be con- coronavirus disease-19 (COVID-19) pandemic places the health of operating sidered to minimize potential risk to the clinical team. Similar to the theatre staff at potential risk. SARS-CoV2 is transmitted through inhaled severe acute respiratory syndrome (SARS) and Middle East respira- droplets and aerosol particles, thus posing an inhalation threat even at tory syndrome outbreaks, there is a paucity of data on the potential of considerable distance. Surgical energy devices generate an aerosol of biolog- transmission of the virus intraoperatively. However, much like during ical particular matter during use. The risk to healthcare staff through use of these prior outbreaks, operating room practices must be adapted to surgical energy devices is unknown. maintain the safety of healthcare professionals.4,5 Although different Methods: This review was conducted utilizing a rapid review methodology to procedures may carry risks of viral exposure, patient care should not enable efficient generation and dissemination of information useful for be compromised, and maintenance of surgical team safety is para- concurrent clinical practice. mount. In response to this threat, surgical governing bodies and Results: There are conflicting stances on the use of energy devices and associations have therefore issued recommendations on the safe use laparoscopy by different surgical governing bodies and societies. There is no of energy devices. definitive evidence that aerosol generated by energy devices may carry active The American College of Surgeons have recommended the SARS-CoV2 virus. However, investigations of other viruses have demon- use of smoke extractors, minimizing the use of electrocautery where strated aerosolization through energy devise use. Measures to reduce potential possible.6,7 This advice is similar to the position adopted by the transmission include appropriate personal protective equipment, evacuation Royal Colleges of Surgeons in the UK, the Society of American and filtration of surgical plume, limiting energy device use if appropriate, and Gastrointestinal and Endoscopic Surgeons (SAGES) and the Euro- adjusting endoscopic and laparoscopic practice (low CO2 pressures, evacua- pean Association for Endoscopic Surgery (EAES).8–10 Their guid- tion through ultrafiltration systems). ance suggests that energy devices should be used on the lowest Conclusions: The risk of transmission of SARS-CoV2 through aerosolized reasonable setting, diathermy pencils should be used with smoke surgical smoke associated with energy device use is not fully understood, extractors where possible and filtration during laparoscopy.10 Addi- however transmission is biologically plausible. Caution and appropriate tionally, joint statements from the US and European professional measures to reduce risk to healthcare staff should be implemented when gynecological societies have recommended that minimally invasive considering intraoperative use of energy devices. and vaginal surgeries are generally safe with adequate personal Keywords: communicable diseases, COVID-19, emerging, surgery protective equipment (PPE), given the lack of evidence of SARS- CoV2 transmission in such procedures.11,12 However, the Royal Ann Surg ( 2020;xx:xxx–xxx) College of Obstetricians and Gynecologists suggests that gyneco- logical procedures with bowel involvement be performed by lapa- lectrocautery (diathermy), laser, ultrasonic scalpels, and other rotomy, as it is associated with a lower risk of generating E tissue- and vessel-sealing technologies are used across different contaminated aerosols.11 This is in direct conflict with the Associa- surgical specialties. These devices are used for precise dissection, tion of Laparoscopic Surgeons of Great Britain and Ireland who hemostasis and tissue mobilization. Each of them is associated with advocate for continued laparoscopic surgery, particularly in post 1 the production of a surgical plume. Within the context of the pancreatitis cholecystectomy and obstructing hiatal hernia repair.13 A statement by the Journal of Minimal Invasive Gynecology further endorses laparoscopy as the preferred surgical approach for gyneco- From the ÃDepartment of Surgery and Cancer, Imperial College London, London, logic patients.14 A significant challenge for practitioners is the UK; and yDepartment of Anesthesia, Imperial College NHS Healthcare Trust, changing nature of the guidance across organizations and time, London, UK. despite little evidence underpinning the differing stances. A sum- AQ4 [email protected]. This research was supported by the NIHR Imperial Biomedical Research Centre mary of stakeholder recommendations for operative practice during (BRC). The views expressed are those of the authors and not necessarily those the COVID-19 pandemic is detailed in Supplementary Table 1, http:// of the NIHR or the Department of Health and Social Care. links.lww.com/SLA/C263. AQ5 JK: Advisory board for Ethicon. Grant award from Intuitive robotics. NIHR funding for iEndoscope. The current recommendations attempt to take a pragmatic Supplemental digital content is available for this article. Direct URL citations approach, as no current published research has sought to identify the appear in the printed text and are provided in the HTML and PDF versions of presence of SARS-CoV2 particles within surgical smoke from any this article on the journal’s Web site (www.annalsofsurgery.com). energy device intraoperatively. Conflicting guidance between orga- Copyright ß 2020 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0003-4932/16/XXXX-0001 nizations may lead to confusion and anxiety amongst healthcare DOI: 10.1097/SLA.0000000000004112 staff. Here, we review the evidence that informs these guidelines in Annals of Surgery Volume XX, Number XX, Month 2020 www.annalsofsurgery.com | 1 CE: R.R.; ANNSURG-D-20-01577; Total nos of Pages: 8; ANNSURG-D-20-01577 Zakka et al Annals of Surgery Volume XX, Number XX, Month 2020 respect to utilization of energy devices, and critically appraise the Whilst individual cases may vary, without adequate ventila- quality of recommendations made. tion and PPE surgeons may typically be exposed to very high concentrations to these ultrafine particles during use of energy devices.18 There are suggestions that a high initial viral dose may SURGICAL SMOKE AND ULTRAFINE PARTICLES be associated with more significant disease burden,26 however the The composition of surgical plume varies widely, with the quality, retrospective nature and systemic bias inherent within them nature and size of its components depending on the tissue dissected, makes it hard to prove a definitive causality. However, for surgical and the energy method involved. Numerous investigations have team safety, these should be considered until disproven. shown that electrocautery (diathermy) creates the smallest particles, with a mean aerodynamic size of 0.07 mm, whereas the largest COMPONENTS OF SURGICAL PLUMES 15–18 particles (0.35–6.5 mm) are generated by ultrasonic scalpels. Surgical plumes are a byproduct of the use of energy devices Laser tissue coagulation creates particles of about 0.31 mmin intraoperatively. The contents of the plumes are derived from 2 15–18 size. Furthermore, the concentration or number of particles separate products. Firstly, the heat produced results in rupture of cell produced depends on the tissue dissected, with the highest emissions membranes, releasing water vapor (making up 95% of the contents of originating from cauterization of organ parenchyma and fat, and the surgical plumes).27 The other 5% of surgical plumes are made up of lowest from muscle tissue. In fact, of 10 different tissue types tested, combustion by-products (non-biological) and cellular debris in the liver has been demonstrated to have the highest mass concentration form of particulate material.27 This includes bacteria, viral particles 19 of particles in surgical smoke. and malignant cells.27,28 Particles with a diameter smaller than 10 mm are shown to be Lower temperature vapor from ultrasonic scalpels has a higher inhalable. Those with a diameter smaller than 2.5 mm are often risk of carrying viable infectious particles as compared to higher referred to as ‘‘lung-damaging dust’’ as they are more likely to settle temperature aerosols from electrocautery.17 The composition of in the alveoli rather than the upper airways (Fig. 1). For reference,