Intraoperative aerosol viral transmission in minimally invasive surgery: A scoping review and impact on clinical guidelines and practice during the onset of the COVID-19 pandemic.

Mun, Dong-Ho; Pradere, Benjamin; Shariat, Shahrokh F; Remzi, Mesut

OBJECTIVE To identify the available evidence on aerosol viral transmission risk during minimally invasive surgery (MIS) and evaluate its impact on guidelines development and clinical activity worldwide during the COVID-19 pandemic. MATERIALS AND METHODS We performed a scoping review on PubMed, Cochrane, Embase, clinical trial register, and grey literature repository databases to identify reports on viral transmission via surgical smoke or aerosolization. A systematic review of all available national and international guidelines was also performed to report their recommendations. Additionally, a worldwide transdisciplinary survey was performed to capture the actual compliance to dedicated guidelines and their impact on minimally invasive surgical activity. RESULTS Based on a selection of 17 studies, there is no evidence to support the concerns of an intraoperative viral transmission via pneumoperitoneum aerosolization. Most national surgical and urologic societies either did address this topic or referred to international guidelines. The guidelines of the American College of Surgery, the Royal College of Surgeons and the European Association of Urology Robotic Urology Section recommended an avoidance of MIS due to an increased risk of intraoperative aerosol-enhanced transmission. The results of the survey completed by 334 respondents, from different surgical abdominal specialties, suggested a lack of compliance with the guidelines. CONCLUSION There seems to be a dissonance between contemporary guidelines and ongoing surgical activity, possibly due to the perceived lack of evidence. Recommendations regarding changes in clinical practice should be based on the best available research evidence and experience. A scoping review of the evidence and an assessment of the benefits and harms together with a survey showed that laparoscopic procedures do not seem to increase the risk of viral transmission. Nevertheless, the low number of publications and low quality of existing evidence limits the validity of the review.