Released 3/29/2020 – this document will continue to be updated as needed.

Recently, SAGES, and/or SAGES in conjunction with EAES, published guidelines for surgeons concerning the use of laparoscopy during the current COVID-19 pandemic. We recognize that during this time of challenge to resources and personnel, every surgeon and institution is providing the very best care it can with the circumstances it finds itself in. This document represents a resource for smoke and gas evacuation based on known science, vetted publications, and potential strategies that offer the best protection to both patients and the health care team. This document is designed as a “living document” of resources and will be regularly updated when new evidence presents.

The Science of SARS-CoV-2

There is a constant influx of new information regarding the virology of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the disease, COVID-19.  What we know so far regarding the SARS-CoV-2, is the RNA virus has a size range of 0.06 to 0.14 microns³.  Along with the nasopharynx, the upper respiratory tract and lower respiratory tract, the virus has been found in the entire gastrointestinal tract from the mouth to the rectum. The virus has been found in nasal swabs, saliva, sputum, throat swabs, blood, bile, and feces.  Urine and CSF evaluations have been negative. The virus has also been found within the cells lining the respiratory tract and gastrointestinal tract. It is suspected that the virus has multiple modes of transmission.

The potential of aerosolization as a mode of transmission during endoscopy or minimally invasive surgery is the focus of this document.

Filtration

Filtration may be an effective means of protection from the release of the virus during minimally invasive surgery (MIS) and endoscopy.  Masks such as N95 respirators are designed to filter out 95% of particles that are 0.3 microns and larger. Powered Air Purifying Respirators (PAPR) may be beneficial for intubation, extubation, bronchoscopy, endoscopy, and possibly tracheostomy. Intraoperatively, filters are used to remove smoke and particulate matter including viruses. High-Efficiency Particulate Air (HEPA) filters have a minimum 99.97% efficiency rating for removing particles greater than or equal to 0.3 microns in diameter⁴.  Ultra-Low Particulate Air (ULPA) filters can remove from a minimum of 99.999% of airborne particles with a minimum particle penetration size of 0.05 microns⁵. The Association of periOperative Registered Nurses (AORN) guidelines define ULPA as filters capable of removing particles of 0.1 microns. Filtration is also essential on a larger scale in the positive pressure operative suites. HEPA filters that are placed in the ceiling provide a terminal cleaning. Clean rooms are favored over HEPA filters placed in the ductwork.

Currently, the best practice for mitigating possible infectious transmission during open, laparoscopic and endoscopic procedures is to use a multi-faceted approach, which includes proper room filtration and ventilation, appropriate PPE, and smoke evacuation devices with a suction and filtration system,⁶ as available.

Practical Measures for Use of Filtration During Laparoscopy:

1. All pneumoperitonuem should be safely evacuated from the port attached to the filtration device before closure, trocar removal, specimen extraction or conversion to open.
2. Once placed, ports should not be vented if possible. If movement of the insufflating port is required, the port should be closed prior to disconnecting the tubing and the new port should be closed until the insufflator tubing is connected. The insufflator should be “on” before the new port valve is opened to prevent gas from back-flowing into the insufflator.
3. During desufflation, all escaping CO2 gas and smoke should be captured with an ultra-filtration system and desufflation mode should be used on your insufflator if available.
4. If the insufflator being used does not have a desufflation feature, be sure to close the valve on the working port that is being used for insufflation before the flow of CO2 on the insufflator is turned off (even if there is an in-line filter in the tubing).  Without taking this precaution contaminated intra-abdominal CO2 can be pushed into the insufflator when the intraabdominal pressure is higher than the pressure within the insufflator.
5. The patient should be flat and the least dependent port should be utilized for desufflation.
6. Specimens should be removed once all the CO2 gas and smoke is evacuated.
7. Surgical drains should be utilized only if absolutely necessary.
8. Suture closure devices that allow for leakage of insufflation should be avoided. The fascia should be closed after desufflation.
9. 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. The specimen can then be removed and the closure performed.

Smoke and Gas Evacuation Products

SAGES and EAES do not endorse any of the following products. This is a working list of commercially available products that could potentially be used to filter CO2 gas or smoke evacuated during open, laparoscopic, and endoscopic procedures. Please be aware of the products your facility utilizes and contact your manufacturer’s representative or refer to the product’s instructions for use (IFU) documents for further information. We have sought information from as many companies that we are aware of, but we understand there are many other companies that may have similar products. We will do our best to add information as it becomes available to us.  In addition to smoke evacuation products, the Ultravision system may minimize aerosolized particles within pneumoperitoneum.

Current wall suction devices do not use ultrafiltration.

Summary of Commercially Available Smoke Evacuation Systems

Please see our SAGES Medical Device Repository document for the summary.

References

1. Surgical smoke and infection control. Alp E, Bijl D, Bleichrodt RP, Hansson B, Voss A. J Hosp Infect. 2006 Jan;62(1):1-5.
2. Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery. Kwak HD, Kim SH, Seo YS, Song KJ. Occup Environ Med. 2016 Dec;73(12):857-863.
3. China Novel Coronavirus Investigating and Research Team. Zhu N, Zhang D, Wang W1, Li X, Yang B, Song J, Zhao X, Huang B, Shi W, Lu R, Niu P, Zhan F, Ma X, Wang D, Xu W, Wu G, Gao GF, Tan W. N Engl J Med. 2020 Feb 20;382(8):727-733.
4. Medical Advisory Secretariat. Air cleaning technologies: an evidence-based analysis. Ont Health Technol Assess Ser. 2005;5(17):1–52.
5. SO 29463-1:2017 High Efficiency Filters And Filter Media For Removing Particles From Air – Part 1: Classification, Performance, Testing, And Marking.https://www.iso.org/obp/ui/#iso:std:iso:29463:-1:ed-2:v1:en.
6. Surgical Smoke and the Orthopedic Implications. The Internet Journal of Orthopedic Surgery. Parsa RS, Dirig NF, Eck IN, Payne III WK. 2015, Volume 24 Number 1.
7. Practical recommendations for critical care and anesthesiology teams caring for novel coronavirus (2019-nCoV) patients. Wax RS, Christian MD. Can J Anaesth. 2020 Feb 12 [Epub ahead of print].
8. Risk of acquiring human papilloma-virus from the plume produced by the carbon dioxide laser in the treatment of warts. Gloster HM Jr, Roenigk RK. J Am Acad Dermatol. 1995, 32:436–41.
9. Surgical smoke may be a biohazard to surgeons performing laparoscopic surgery. Choi SH, Kwon TG, Chung SK, Kim TH. Surg Endosc. 2014, 28 (8): 2374-80.
10. Experimental study of the potential hazards of surgical smoke from powered instruments. In SM, Park DY, Sohn IK, et al. Br J Surg. 2015, 102:1581––1586
11. Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery. Kwak HD, Kim SH, Seo YS, et al. Occup Environ Med. 2016, 73:857––863
12. Papillomavirus in the vapor of carbon dioxide laser-treated verrucae. Garden JM, O‘Banion MK, Shelnitz LS, et al. JAMA. 1988, 259:1199––1202
13. Human papillomavirus DNA in CO2 laser-generated plume of smoke and its consequences to the surgeon. Ferenczy A, Bergeron C, Richart RM. Obstet Gynecol. 1990, 75:114-118
14. Presence of human immunodeficiency virus DNA in laser smoke. Baggish MS, Poiesz BJ, Joret D, Williamson P, Refai A. Lasers Surg Med. 1991;11:197–203
15. Studies on the transmission of viral disease via the CO2 laser plume and ejecta. Wisniewski PM, Warhol MJ, Rando RF, Sedlacek TV, Kemp JE, Fisher JC. J Reprod Med. 1990, 35:1117–23
16. Interim Infection Prevention and Control Recommendations for Hospitalized Patients with Middle East Respiratory Syndrome Coronavirus (MERS-CoV). https://www.cdc.gov/coronavirus/mers/infection-prevention-control.html
17. inimally invasive surgery and the novel coronavirus outbreak: lessons learned from Italy. Zheng MH, Boni L, Fingerhut A. Annals of Surgery. 2020. [Accepted for Publication].
18. COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission. Gu J, Han B, Wang J. Gastroenterology. March 3 2020 [Epub ahead of print].
19. ASGE | JOINT GI SOCIETY MESSAGE- COVID-19 Clinical insights for our community of gastroenterologists and gastroenterology care providers. https://www.asge.org/home/joint-gi-society-message-covid-19
20. AORN J. 2017 May;105(5):488-497.
21. COVID 19 AP 50 30 Information March 30 Lexion Medical
22. AlwaysPneumo Brochure 8 page 2019 Lexion Medical
23. Symmetry Surgical Smoke Evacuation Systems

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