Infectious papillomavirus in the vapor of warts treated with carbon dioxide laser or electrocoagulation: detection and protection

Hazards of surgical smoke from electrocautery: A critical review of the data

INTRODUCTION

Concerns have been voiced regarding the possibility of health risks to the operating room personnel from exposure to surgical smoke generated from electrocautery.

METHODS

Ovid Medline was queried using search terms "surgical smoke", "electrosurgery," "smoke evacuator". The NIOSH Health Hazard Evaluations Database was searched using terms, "hospital", "operating room", "Ames", "mutagen", and "salmonella".

RESULTS

Levels of pollutants in the breathable airspace within the operating room have been repeatedly shown to be very low. Absolute counts of particulate matter in the operating room are low when compared to other environments. The possibility for virus transmission with electrocautery in the operating room is unknown.

CONCLUSIONS

The risks related to the exposure to electrocautery surgical smoke have been overstated. Rigid mandates requiring smoke evacuators in all situations are not justified at this time.

Risk mitigation to healthcare workers against viral and bacterial bioaerosol load in laparoscopic surgical exhaust with a new flow mode in hollow fiber membranes-based filter

Laparoscopy of COVID-19-infected/suspected patients needs to be performed with the utmost care due to the chances of virus carryover through the pneumoperitoneum gas. In this study, polysulfone/polyvinyl-pyrrolidone hollow fiber membranes (HFMs) were fabricated by phase inversion process, and these HFMs were bundled into a module consisting of tortuous, circular-helical arrangement. Further, copper (Cu) and zinc (Zn) nanoparticles (NPs), known to have antimicrobial and antiviral properties, were flow-coated on the lumen side of the HFMs. To test functional efficiency, the modules were challenged with wet aerosol and bioaerosols. Wet aerosol removal efficiency was ∼98%. Bioaerosol-containing bacteria E. coli strain K-12, showed 2.6 log (∼99.8%), and 2.1 log (∼99.3%) removal efficiency for Cu NPs and Zn NPs coated HFMs modules, respectively, and 1.6 log (∼97%) removal for plain (uncoated) HFMs. Bioaerosols containing SARS-CoV-2 surrogate virus (MS2 bacteriophage) showed ∼5-7 log reduction of bacteriophage for plain HFMs, 3.9 log, and 2.3 log reduction for Cu and Zn coated HFMs, respectively. The flow of aerosols entirely through the HFM lumen helps in attaining a low ΔP of < 1 mm Hg, thus rendering its usefulness, particularly for exhausting pneumoperitoneum gases where high upstream pressures could lead to barotrauma. STATEMENT OF ENVIRONMENTAL IMPLICATION: Surgical smoke is generated during minimally invasive surgical (MIS) procedure such as laparoscopy when electrosurgical devices are used to cut any tissues. This smoke is a hazard as it contains toxic volatile compounds, mutagens, carcinogens, bacteria, and virus-laden aerosols. Infection to healthcare professionals through the bioaerosols containing smoke is well reported in literature. The limitation of using hypochlorite and pleated/HEPA filter, led us to design a low pressure drop bioaerosol filter, which can remove smoke, tissue fragments, and COVID-19 virus. It provides a much safer operation theatre environment during MIS procedures as well as in general for bioaerosol removal.

Estimating Air Pollution in Operation Rooms Generated from Cautery, Drills, and Other Equipment, Utilizing a Particulate Counter and Gas Analyzer

Background

Air pollution, especially indoor air pollution, is increasingly recognized as a worldwide hazard that reduces life expectancy. Pollution caused by equipment such as surgical cautery is not just a nuisance but a workplace hazard that exposes the staff to respirable particulate matter and toxic chemical agents. It has not yet received much recognition in India, nor have mitigating measures like smoke evacuators and dedicated scavenging systems become prevalent.

Methods

We aimed to do a prospective observational study of the extent of this hazard in the operation rooms in our tertiary care, Government-run hospital using a consumer-grade pollution measuring equipment (CAIR +™, Prana Air, New Delhi). We measured and compared the particulate pollutant matter (PM) levels, Total Volatile Organic Compounds (TVOC), formaldehyde, and carbon dioxide at multiple areas of interest at different time points.

Results

The particulate pollution level in PM 1.0, PM 2.5, and PM 10 and TVOCs rose many times the baseline near the surgical team during cautery use. It remained high near the anesthesia workstation. The median PM 2.5 level in µg/m3(micrograms/cubic meter) was 181 near the surgical team during cautery use, and it was 25 at the anesthesia workstation. This peak level was 30 times the basal level of 6 µg/m3 at the start of the day and was above the annual population-weighted mean PM 2·5 breakpoint of 40 μg/m3 recommended by the National Ambient Air Quality Standards in India.

Conclusions

The pollution levels increase dramatically when surgical cautery is used, potentially exposing the team to large peak elevations in particulate matter and TVOCs. We recommend the mandatory use of smoke evacuators and optimization of the air conditioning.

Surgical smoke: A hidden killer in the operating room

Surgical smoke is a byproduct of aerosols containing several components produced by energy equipment. The characteristics of surgical smoke components produced by different types of tissues or using different kinds of energy devices vary. For example, the average diameter of smoke particles produced by electrocautery is smaller, and the possibility of viable cells and pathogens in surgical smoke produced by an ultrasonic knife is higher. According to the characteristics of its composition, surgical smoke may be an important risk factor affecting the health and safety of operating room staff and patients. The use of surgical masks, suction devices and portable smoke evacuation systems can reduce this risk to some extent. However, most operating room staff members do not implement corresponding measures to protect themselves. In this paper, the characteristics of surgical smoke and the research progress in protective measures are briefly reviewed.

Human Papillomavirus Epidemiology and Prevention: Is There Still a Gender Gap?

BACKGROUND AND AIM

Human papillomavirus (HPV) is sexually transmitted, one of the three most common sexually transmitted infections (STIs) in both males and females, and the most common viral STI. A crucial public health strategy to protect people against HPV is vaccination, which has shown its effectiveness in preventing HPV-related diseases. Presently, three types of vaccines are available (bivalent, quadrivalent, and nonvalent), and they all target the two most oncogenic virus genotypes (HPV 16 and 18). In recent years, the need to implement vaccination programmes that include all genders has been discussed in order to achieve herd immunity against HPV. To date, only a few countries have included young males in their vaccination programmes. Thus, our objective with this review is to provide an overview of the epidemiology of HPV and HPV prevention strategies and report the latest findings from the scientific literature.

Existence of SARS-Cov-2 in the Peritoneal Fluid

OBJECTIVE

 To determine the existence of SARS-CoV-2 in the peritoneal fluid to assess the risk of exposure through surgical smoke and aerosolization threatening healthcare workers during abdominal surgery.

BACKGROUND

 SARS-CoV-2 is a respiratory virus and possible ways of viral transmission are respiratory droplets, close contact, and fecal-oral route. Surgeries pose risk for healthcare workers due to the close contact with patients. Aerosolized particles may be inhaled via the leaked CO₂ during laparoscopic procedures and surgical smoke produced by electrocautery.

METHODS

 All the data of 8 patients, who were tested positive for COVID-19, were collected between August 31, 2020 and April 30, 2021. Recorded clinicopathologic data included age, symptoms, radiological and laboratory findings, antiviral treatment before surgery, type of surgery and existence of the virus in the peritoneal fluid. Nasopharyngeal swab RT-PCR was used for the diagnosis. COVID-19 existence in the peritoneal fluid was determined by RT-PCR test as well.

RESULTS

 All 8 COVID-19 positive patients were pregnant, and surgeries were cesarean sections. 1 of the 8 patients was febrile during surgery. Also only 1 patient had pulmonary radiological findings specifically indicating COVID-19 infection. Laboratory findings were as follows: 4 of 8 had lymphopenia and all had elevated D-dimer levels. Peritoneal and amniotic fluid samples of all patients were negative for SARS-CoV-2.

CONCLUSION

 SARS-CoV-2 exposure due to aerosolization or surgical fumes does not seem to be likely, provided the necessary precautions are taken.

An Update on Human Papillomavirus Vaccination in the United States

Cervical cancer remains a significant disease in the United States. Although the human papillomavirus (HPV) vaccine has been approved for those aged 9-26 years and for some individuals up to age 45 years, there are many circumstances in which health care professionals may not know whether the vaccine should be recommended, such as for patients with previous infection, health care workers, and those older than age 26 years. This article highlights the evidence that the HPV vaccine is a safe and highly effective way to prevent cervical cancer, with the strongest predictor of vaccine uptake being practitioner recommendation.

Lingering SARS-CoV-2 in Gastric and Gallbladder Tissues of Patients with Previous COVID-19 Infection Undergoing Bariatric Surgery

BACKGROUND

Lingering severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in gut tissue might be a source of infection during bariatric surgery. This study aimed to confirm the presence of SARS-CoV-2 nucleocapsid in gastric and gallbladder tissues removed during bariatric surgery in individuals previously infected with coronavirus disease 2019 (COVID-19) who had negative polymerase chain reaction results prior to the surgery.

METHODS

Gastric and gallbladder specimens from 80 patients who underwent bariatric surgery between November 2021 and May 2022 and had a history of COVID-19 infection with gastrointestinal symptoms were examined for the presence of lingering SARS-CoV-2 nucleocapsid proteins using immunohistochemistry.

RESULTS

Gastric specimens from 26 (32.5%) patients and 4 (100%) cholecystectomy specimens showed positive cytoplasmic staining for the anti-SARS-CoV-2 nucleocapsid protein in surface mucosal epithelial cells. The mean age was 37.8 ± 10.3 years. The average body mass index was 44.2 ± 7.0 kg/m²; most of the patients were females (71.3%). The positive staining group was significantly younger than the negative staining group (p = 0.007). The full-dose vaccination rate was 58.8%, with a median of 91 days after the last vaccine dose. A positive serological anti-spike IgG response was observed in 99% of the patients. The median time between initial COVID-19 infection and surgery was 274 and 380 days in the positive and negative staining groups, respectively (p = 0.371).

CONCLUSION

Gastric and gallbladder tissues can retain SARS-CoV-2 particles for a long time after COVID-19 infection, handling stomach specimens from patients during an operation must be done with care, as we usually do, but now with the knowledge that in 1/3 of patients they can be present. Performing LSG on post-COVID patients did not seem to increase perioperative morbidity.

Plume Generated by Different Electrosurgical Techniques: An In Vitro Experiment on Human Skin

BACKGROUND

Plume generated by electrosurgical techniques is a health hazard to patients and dermatologists.

OBJECTIVE

To compare the particle concentration generated by various energy devices used in dermatologic surgery.

MATERIALS AND METHODS

Five surgical techniques were tested on human tissue samples in a closed chamber. A particle counter, positioned at a fixed point 20 cm away from the sample, recorded the concentrations of aerosolized particles generated over 7 particle sizes (0.3, 0.5, 0.7, 1, 2.5, 5, and 10 μm).

RESULTS

Monopolar electrocoagulation created the greatest concentration of particles followed by electrocautery, electrodesiccation, electrofulguration, and bipolar electrocoagulation. Bipolar electrocoagulation created 80 times fewer 0.3 μm particles and 98 times fewer 0.5 μm particles than monopolar electrocoagulation. Across all electrosurgical techniques, the greatest concentrations of particles generated were of the 0.3 and 0.5 μm particle size.

CONCLUSION

Bipolar electrocoagulation created the lowest concentration of particulate matter. Given the noxious and hazardous nature of surgical plume, the bipolar forceps offer surgeons a safer method of performing electrical surgery for both the surgical staff and the patient.

On the Design and Testing of an Origami Inspired Nasal Cover: Mitigating Aerosol Risks During Endoscopic Sinus Procedures

Aerosols generated during endoscopic sinus procedures present a concern to the health and safety of healthcare personnel especially with the presence of COVID-19. The purpose of this study is to describe the design and testing of a nasal cover to restrict aerosolized pathogens. The nasal cover was designed to sit overtop the nose with conformal slits for insertion of endoscopic instrumentation. Polydimethylsiloxane (PDMS) was chosen as the nasal mask material and its composition, thickness, and slit geometry were selected using a Taguchi experimental design and survey with clinical collaborators at Penn State Milton S. Hershey Medical Center. The nasal cover was designed using principles of origami engineering to be manufactured flat then folded into its operating state. Form and functionality were evaluated by surgeons, fellows, and residents in the aforementioned survey. Aerosol containment was evaluated by measuring smoke, representative of surgical aerosols, with an optical particle counter. A 25:1 composition PDMS with 3mm thickness and vertical slit geometry was chosen for the nasal cover design. Survey results demonstrated that the origami cover sat well on the nose and did not significantly impact the surgical conditions with single instrumentation. On average, this nasal cover was found to restrict more than 93% of 0.3µm aerosols, and more than 99% of all aerosols larger than 0.5µm in size. Use of a patient worn nasal cover has the potential to drastically reduce the risk to hospital personnel during endonasal surgeries by reducing aerosol generation and potential pathogen spread.

Occupational Hazards of Surgical Smoke and Achieving a Smoke Free Operating Room Environment: Asia-Pacific Consensus Statement on Practice Recommendations

Background

Surgical smoke generated through energy devices may present detrimental effects on individuals present in the operating room (OR). Despite the concerns possibly associated with surgical smoke, there may be no mandatory policies that suggest protective measures and limited firm standards are committed yet to address the same.

Aim

The aim of this paper is to present recommendations for surgeons and OR personnel by taking a consensus approach based on available literature and its interpretation by a multi-national panel of experts.

Methods

The Asia-Pacific (APAC) group was established with the aims of reviewing literature evidence, discussing key issues regarding surgical smoke and its hazards, and offering a summary of statements in achieving a smoke-free OR environment. Eleven expert surgeons from the international APAC region were gathered with the purpose of coming to a consensus on engineering, best work-practices, and administrative controls in minimizing surgical smoke exposure. A two-phase consensus method was used to obtain opinions from the expert panel of specialists. Statements with an agreement of more than 80% were accepted.

Findings

For twenty-one statements, the panel achieved consensus on 17 statements; another 5 were dropped due to lack of consensus. The consensus was obtained on statements that address the need for the implementation of administrative policies, training and awareness, standard procedure for the continued use of engineering controls, stringent work practice controls and preventive controls.

Conclusion

The statements presented may guide surgeons and OR personnel in the practical management of surgical smoke safety, mitigating the risks associated with it. The consensus statement also provides a series of recommendations that can be used with other stakeholders, such as policymakers, hospital administrators and professional societies, to highlight and motivate the implementation of meaningful policies.

Detection of SARS-CoV-2 contamination in the operating room and birthing room setting: a cross-sectional study

BACKGROUND

The exposure risks to front-line health care workers caring for patients with SARS-CoV-2 infection undergoing surgery or obstetric delivery are unclear, and an understanding of sample types that may harbour virus is important for evaluating risk. We sought to determine whether SARS-CoV-2 viral RNA from patients with SARS-CoV-2 infection undergoing surgery or obstetric delivery was present in the peritoneal cavity of male and female patients, in the female reproductive tract, in the environment of the surgery or delivery suite (surgical instruments or equipment used, air or floors), and inside the masks of the attending health care workers.

METHODS

We conducted a cross-sectional study from November 2020 to May 2021 at 2 tertiary academic Toronto hospitals, during urgent surgeries or obstetric deliveries for patients with SARS-CoV-2 infection. The presence of SARS-CoV-2 viral RNA in patient, environmental and air samples was identified by real-time reverse transcription polymerase chain reaction (RT-PCR). Air samples were collected using both active and passive sampling techniques. The primary outcome was the proportion of health care workers' masks positive for SARS-CoV-2 RNA. We included adult patients with positive RT-PCR nasal swab undergoing obstetric delivery or urgent surgery (from across all surgical specialties).

RESULTS

A total of 32 patients (age 20-88 yr) were included. Nine patients had obstetric deliveries (6 cesarean deliveries), and 23 patients (14 male) required urgent surgery from the orthopedic or trauma, general surgery, burn, plastic surgery, cardiac surgery, neurosurgery, vascular surgery, gastroenterology and gynecologic oncology divisions. SARS-CoV-2 RNA was detected in 20 of 332 (6%) patient and environmental samples collected: 4 of 24 (17%) patient samples, 5 of 60 (8%) floor samples, 1 of 54 (2%) air samples, 10 of 23 (43%) surgical instrument or equipment samples, 0 of 24 cautery filter samples and 0 of 143 (95% confidence interval 0-0.026) inner surface of mask samples.

INTERPRETATION

During the study period of November 2020 to May 2021, we found evidence of SARS-CoV-2 RNA in a small but important number of samples obtained in the surgical and obstetric operative environment. The finding of no detectable virus inside the masks worn by the health care teams would suggest a low risk of infection for health care workers using appropriate personal protective equipment.

SARS-CoV-2 Testing of Aerosols Emitted During Pediatric Minimally Invasive Surgery: A Prospective, Case-Controlled Study

BACKGROUND

The COVID-19 pandemic has presented significant safety concerns for healthcare providers, especially those performing aerosol-generating procedures. Several surgical societies issued early warnings that aerosols generated during minimally invasive surgery (MIS) could harbor infectious quantities of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). This study tested the hypothesis that MIS-aerosols contain SARS-CoV-2.

METHODS

To evaluate SARS-CoV-2 presence in aerosols emitted during intracavitary MIS, children <18 years who required emergent MIS and were discovered to be SARS-CoV-2-positive were enrolled. Swabs were obtained from the port in-line with a filtered smoke evacuation system, the tubing adjacent to this port, the fluid collection chamber and filter, and the distal endotracheal tube (ETT). All swabs were analyzed for SARS-CoV-2 using quantitative reverse-transcription polymerase chain reaction. To evaluate viral distribution in tissues, fluorescence in situ hybridization for SARS-CoV-2 was performed on resected specimens. Outcomes were recorded, and participating healthcare workers were tracked for SARS-CoV-2 conversion.

RESULTS

From July 1, 2020, to June 30, 2021, 11 children requiring emergent MIS were discovered preoperatively to be SARS-CoV-2 positive (median age: 14 years [5-17]). SARS-CoV-2 was detected only in ETT swabs and not in surgical aerosols or specimens. Median operative time was 56.5 minutes (IQR: 46-66), and postoperative stay was 21.2 hours (IQR: 1.97-57.57). No complications or viral eruption were recorded, and none of 63 healthcare workers tested positive for SARS-CoV-2 within 6 weeks.

DISCUSSION

SARS-CoV-2 was detected only in ETT secretions and not in surgical aerosols or specimens among a pediatric cohort of asymptomatic patients having emergent MIS.

Impact of Surgical Smoke on the Surgical Team and Operating Room Nurses and Its Reduction Strategies: A Systematic Review

BACKGROUND

Surgical smoke is an integral part of surgical operations that the surgical team has been exposed to for so long. This study aimed to investigate the effects of smoke, on members of the surgical team.

METHODS

A systematic review was conducted focusing on the complexity of surgical smoke. PubMed, Scopus and web of science databases were searched until May 2020 without any time or language limitation. All documents were reviewed by title or abstract according to the search strategy. The screening process of articles was performed by two independent authors. The articles were selected according to the inclusion and exclusion criteria.

RESULTS

Overall, 37 studies in this systematic study were investigated. The effects of many surgical smokes were found in a nutshell including complications such as carcinogenic, toxicity, mutation, irritant, transmission of tumor cells, virus transmission, headaches, dizziness, sleepiness, headache, the bad odor in head hair, the tearing of the eye on the surgical team and staff.

CONCLUSION

Surgical smoke, produced during surgical operations, is one of the risks and threats to which the surgical team and operating room staff are at risk then can affect the organs of different bodies from the body of all operating room staff and surgical team.

COVID-19 infection risk by open and laparoscopic surgical smoke: A systematic review of the literature

BACKGROUND

The current COVID-19 pandemic has greatly changed the way surgery is delivered. In particular, current guidelines and policies have highlighted the need to use high level Personal Protective Equipment to reduce the risk of viral infection during open and laparoscopic surgical procedures. In particular, it was felt that the laparoscopic approach was at higher risk of viral transmission due to the chimney effect of the smoke escape from the trocars during and after the procedure. However, with this being a new and largely unknown viral agent, guidelines have been based on speculation and extrapolation from previous studies conducted in completely different situations, and led to anxiety amongst surgeons and theatre staff. We decided to conduct a systematic review of the Literature to try to clarify whether inhalation of surgical smoke can increase the risk of COVID-19 infection.

METHODS

A thorough search of the relevant Literature was performed following the PRISMA guidelines and the most relevant papers on this topic were selected for qualitative analysis. Duplicates, review, personal opinions and guidelines have been excluded. Quantitative analysis has not been performed due to the lack of homogeneous high-quality studies.

RESULTS

Literature search identified 740 papers but only 34 of them were suitable for qualitative analysis. The quality of those studies is generally quite low. We were not able to find any evidence directly linking surgical smoke with viral transmission, other than in patients with active HPV infection.

DISCUSSION

Inhalation of surgical smoke can be generally hazardous, and therefore the use of PPE during surgical operations must be recommended in any case. However, the present systematic review of the existent Literature did not identify any significant evidence of the risk of viral transmission with the surgical smoke, therefore the current guidelines restricting the use of laparoscopy and/or diathermy during the current Covid-19 pandemic may be considered excessive and non-evidence based.

Electrosurgery in dermatology

Electrosurgery applies high frequency alternating electrical currents to generate heat, thereby creating tissue damage required for cutting, hemostasis, or destruction. Electrosurgery can be delivered in a variety of different ways and can be tailored to achieve the desired clinical effect. Having a command of the underlying principles of electrosurgery will help dermatologic surgeons use the appropriate form of electrosurgery to safely achieve the desired results. We reviewed basic principles of electrosurgery, described the various techniques and devices, and delineated associated risks of electrosurgery for specific patient populations and providers. All modalities of electrosurgery present a risk of electromagnetic interference, which can negatively affect patients with implanted devices, such as pacemakers, defibrillators, cochlear implants, and deep brain stimulators. In particular, electrosurgery may create a smoke plume containing a number of volatile organic compounds potentially noxious; however, the risk of such exposure remains unknown.

Transmission Possibility of COVID-19 via Surgical Smoke Generated by the Use of Laparoscopic Approaches: A Subject of Debate During the Pandemic

Background: The smoke created by energy-based devices during surgery may have the potential to transmit viral components to operating room staff. The COVID-19 pandemic has changed staff safety regulations. However, it is not clearly understood whether it can be transmitted via surgical smoke. Laparoscopic approaches have become the standard surgical procedure in many cases, but some of previous investigations have advised to pretermit these approaches due to high risk of COVID-19 transmission. Materials and Methods: We reviewed the English literature that were indexed in the PubMed, Google Scholar, and Scopus databases by using key words including Virus, viral transmission, surgical smoke, surgical plum, laparoscopy, and COVID-19 both solely and in two-word combination. A total of 87 articles were found relevant, and after reviewing the abstract, 33 articles were shortlisted and summarized. Results: Previous studies have focused on different surgical instruments that generate smoke, methods to collect and analyze the smoke and to understand the implications of its exposure after an analysis. A total of 9 out of 11 studies on the potential transmission of human papilloma virus through surgical smoke found evidence in favor of transmission. There were studies on the possible transmission of HIV, hepatitis B virus, and Sabin poliomyelitis vaccine virus 2. Conclusion: We do not believe that laparoscopic procedures may have extra risk for COVID-19 transmission compared with the open procedures, but it is always advised that the operating room staff adhere to the safety instructions during the COVID-19 pandemic.

Airborne particulate concentration during non-thermal nano-pulse stimulation wart clearance is negligible compared to thermal modalities

Abstract

Objectives

As clinicians continue to implement safety protocols amid the global pandemic, considerations to mitigate potential viral transmission of airborne particulates (plume) generated from certain dermatologic procedures are of growing interest. This study intended to measure the change in airborne particulate matter using a non‐thermal energy modality called nano‐pulse stimulation (NPS) and compare levels of concentration to common thermal modalities (CO2 laser and electrocautery). NPS is a new non‐thermal modality that applies nanosecond pulses of electrical energy to induce regulated cell death in cellular structures while sparing the surrounding acellular structure of the dermis.

Materials and Methods

The study used a Condensation Particle Counter during four types of dermatologic procedures: (1) using non‐thermal NPS for the clearance of cutaneous, nongenital warts; (2) an electrocautery treatment of warts; (3) a CO₂ laser for facial resurfacing; and (4) an electrocautery procedure for a facelift. Four subjects and a total of 11 warts were treated with NPS while a particle counter was used to detect the average particles per cubic centimeter once per second. The same particle counter was used, for comparison, during a wart removal procedure using electrocautery for comparison, and for control, during a skin resurfacing procedure with a CO₂ laser and a facelift in which electrocautery was used.

Results

Only one of the 11 NPS wart procedures generated any detectable change in the particulate concentration and that change was negligible in comparison to the increase in particulate concentration measured during the CO₂ laser resurfacing and the electrocautery use during a facelift procedure.

Conclusions

Procedures using non‐thermal NPS technology do not generate significant plume when applied to eliminate warts, suggesting it is unlikely that this new energy modality would release viral DNA into the air.

Gaseous and Particulate Content of Laser Tattoo Removal Plume

BACKGROUND

There is increasing awareness of the potential hazards of surgical plumes. The plume associated with laser tattoo removal remains uncharacterized.

OBJECTIVE

To determine the gaseous, particulate, and microbiological content of the laser tattoo removal plume.

MATERIALS AND METHODS

Air sampling was performed during laser tattoo removal from pig skin and from patients. Measurement of metals, volatile organic compounds (VOCs), carbon monoxide (CO), hydrogen sulfide (HS), and ultrafine particulates (UPs) as well as bacterial 16S ribosomal DNA sequencing were performed.

RESULTS

Metals were identified in the plume from both pig and human skin. Volatile organic compounds were found at similar levels within and outside the treatment room. Several bacterial phyla were detected in the treatment room, but not outside. High levels of UPs were measured throughout the treatment room during tattoo removal from pig skin. Ultrafine particulates were detected at low levels in the room periphery during tattoo removal from human skin, but at higher levels in the immediate treatment zone. HS and CO were not detected.

CONCLUSION

Metals, VOCs, HS, and CO were found at levels below applicable occupational exposure limits. The presence of bacteria is of uncertain significance, but may be hazardous. High levels of UPs require further investigation.

Intraoperative Measures to Reduce the Risk of COVID-19 Transmission During Minimally Invasive Procedures: A Systematic Review and Critical Appraisal of Societies' Recommendations

BACKGROUND

The coronavirus 2019 pandemic and the hypothetical risk of virus transmission through aerosolized CO2 or surgical smoke produced during minimally invasive surgery (MIS) procedures have prompted societies to issue recommendations on measures to reduce this risk. The aim of this systematic review is to identify, summarize and critically appraise recommendations from surgical societies on intraoperative measures to reduce the risk of severe acute respiratory syndrome coronavirus 2 transmission to the operative room (OR) staff during MIS.

METHODS

Medline, Embase, and Google Scholar databases were searched using a search strategy or free terms. The search was supplemented with searches of additional relevant records on coronavirus 2019 resource websites from Surgical Associations and Societies. Recommendations published by surgical societies that reported on the intraoperative methods to reduce the risk of severe acute respiratory syndrome coronavirus 2 transmission to the OR staff during MIS were also reviewed for inclusion. Expert opinion articles were excluded. A preliminary synthesis was performed of the extracted data to categorize and itemize the different types of recommendations. The results were then summarized in a narrative synthesis.

RESULTS

Thirty-three recommendation were included in the study. Most recommendations were targeted to general surgery (13) and gynecology (8). Areas covered by the documents were recommendations on performance of laparoscopic/robotic surgery versus open approach (28 documents), selection of surgical staff (13), management of pneumoperitoneum (33), use of energy devices (20), and management of surgical smoke and pneumoperitoneum desufflation (33) with varying degree of consensus on the specific recommendations among the documents.

CONCLUSIONS

While some of the early recommendations advised against the use of MIS, they were not strictly based on the available scientific evidence. After further consideration of the literature and of the well-known benefits of laparoscopy to the patient, later recommendations shifted to encouraging the use of MIS as long as adequate precautions could be taken to protect the safety of the OR staff. The release and implementation of recommendations should be based on evidence-based practices that allows health care systems to provide safe surgical and medical assistance.

Viral Venereal Diseases of the Skin

Viral venereal diseases remain difficult to treat. Human papilloma virus (HPV) and herpes simplex virus (HSV) are two common viral venereal diseases. HPV infections are characterized by anogenital warts and less commonly by premalignant or malignant lesions. HSV infections classically present as grouped vesicles on an erythematous base with associated burning or pain; however, immunosuppressed patients may have atypical presentations with nodular or ulcerative lesions. This review discusses the epidemiology, diagnosis, and management of anogenital HPV and HSV infections with an emphasis on treatment modalities for the practicing dermatologist. Diagnosis of these diseases typically relies on clinical assessment, although multiple diagnostic techniques can be utilized and are recommended when diagnosis is uncertain or evaluating an individual with increased risk of malignancy. Management of HPV and HSV infections involves appropriate counseling, screening, and multiple treatment techniques. Particularly for HPV infections, a practitioner may need to use a combination of techniques to achieve the desired outcome.

SARS-CoV-2 During Abdominal Operations: Are Surgeons at Risk?

BACKGROUND

The safety of surgery in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-positive patients remains unclear. On the basis of data from other viral diseases, it has been assumed that coronavirus disease 2019 (COVID-19) has the potential risk of transmission during surgery. The presence of the virus within the peritoneal fluid and the peritoneal tissues is not known.

MATERIALS AND METHODS

This is a prospective cross-sectional study including adult patients with confirmed COVID-19 who underwent surgery at a single institution. Using specific real-time reverse transcriptase-polymerase chain reaction, the presence of SARS-CoV-2 was determined in abdominal fluid samples.

RESULTS

Six patients with COVID-19 underwent abdominal surgery. Five patients were asymptomatic, and 1 had severe disease. SARS-CoV-2 was tested in 20 different samples, all of which resulted negative.

CONCLUSIONS

SARS-CoV-2 was not found in the peritoneal cavity of 6 patients undergoing abdominal surgery. The risk of transmissibility of COVID-19 during surgery is still unclear.

A knowledge gap unmasked: viral transmission in surgical smoke: a systematic review

BACKGROUND

Concerns regarding the aerosolized transmission of SARS-CoV-2 via SS have caused significant apprehension among surgeons related to the use of minimally invasive surgery (MIS) during the COVID19 pandemic. While a limited number of studies have previously demonstrated the presence of viral material in SS, no comprehensive systematic review exists on the subject of viral transmission in SS. Methods A systematic review of the literature was conducted as per PRISMA guidelines. MEDLINE, EMBASE, and CENTRAL databases were searched for publications reporting the primary outcome of the presence of viral particles in SS and secondary outcomes of indices suggesting transmission of viable virus particles in SS producing clinically important infection. All human, animal, and in vitro studies which used accepted analytic techniques for viral detection were included. A meta-analysis was not complete due to methodologic heterogeneity and inconsistent reporting of outcomes of interest.

RESULTS

23 publications addressed the presence of viral components in SS, and 19 (83%) found the presence of viral particles in SS. 21 publications additionally studied the ability of SS to induce clinically relevant infection in host cells, with 9 (43%) demonstrating potential for viral transmission.

CONCLUSION

Evidence exists for viral transmission via SS. However, HPV remains the only virus with documented transmission to humans via SS. While meaningful translation into practical guidelines during the COVID pandemic remains challenging, no evidence exists to suggest increased risk in MIS.

Safety and Efficacy of Nano-Pulse Stimulation Treatment of Non-Genital, Cutaneous Warts (Verrucae)

BACKGROUND AND OBJECTIVES

This study describes the effects of nano-pulse stimulation (NPS) technology on the common verruca with the objectives of demonstrating efficacy and safety. NPS technology applies nanosecond pulses of non-thermal electrical energy to induce highly localized regulated cell death in the cellular structures of the targeted zone with negligible effects on surrounding non-cellular structures. Previous clinical studies applying NPS to common, benign skin lesions have demonstrated safety and efficacy in clearing seborrheic keratoses and sebaceous hyperplasia.

STUDY DESIGN/MATERIALS AND METHODS

Sixty-two subjects were enrolled at a total of five sites. One hundred and ninety-five study verrucae up to 10 mm wide were treated with NPS delivered by a console-based handheld applicator (CellFX® System; Pulse Biosciences) and follow-ups occurred every 30 days with the option to retreat at 30, 60, and 90 days. There were 62 untreated controls and 46% of the treated verrucae were recalcitrant.

RESULTS

Overall, 75.3% (70/93) of the common verrucae, 72.7% (8/11) of the flat verrucae, and 43.8% (14/32) of the plantar verrucae treated with NPS were completely clear by 60 days following the last treatment and did not recur within the 120-day observation period. The majority (54%) of verrucae cleared with a single NPS procedure. The most common treatment site reactions were erythema (50.5%) and eschar formation (23.4%) on Day 30 and on Day 120 mild erythema was present in 14% of the cases and hyperpigmentation in 18.5%. No serious adverse events were reported. A particle counter was used during 11 NPS procedures on verrucae and no significant plume generation was detected during these procedures.

CONCLUSIONS

NPS is a safe and effective procedure for removing non-genital, cutaneous verrucae. Lasers Surg. Med. © 2021 The Authors. Lasers in Surgery and Medicine published by Wiley Periodicals LLC.

Consistency of global recommendations regarding open versus laparoscopic surgery during the COVID-19 pandemic: a systematic review

Background

Throughout the COVID‐19 pandemic, there has been worldwide debate regarding whether open surgery should be performed in preference to laparoscopic surgery due to the theoretical higher risk of viral aerosolization by the release of pneumoperitoneum. We aimed to assess the consistency of national and international surgical society recommendations regarding the choice of surgical approach; assess the quality of evidence of viral emission in surgical aerosol; and assess the quality of evidence comparing aerosol generation by different surgical energy devices.

Methods

A systematic review of PubMed, Medline, Embase and Cochrane databases was performed. Three search strategies were employed. Twenty‐eight studies were included in the final analysis and quality appraised. Confidence in review findings was assessed using the GRADE‐CERQual (Confidence in Evidence from Reviews of Qualitative research) tool.

Results

Worldwide recommendations regarding open versus laparoscopic surgery are consistent, with a majority recommending that surgical approach is decided on a case‐by‐case, risk minimization approach. There is limited, low‐quality evidence that viral particles can be emitted in surgical aerosol. There is a paucity of literature on the quantity of aerosol produced by different surgical energy devices, and no evidence to support the use of certain surgical instruments to minimize aerosol production.

Conclusions

There is considerable consistency among worldwide recommendations regarding the choice of surgical approach, although the evidence base is lacking. To inform clinical recommendations, further research examining viral emission, transmission, infectivity and amount of surgical aerosol produced is required.

Coronavirus disease 2019 pandemic and identifying insufflators with desufflation mode and surgical smoke evacuators for safe CO2 removal

INTRODUCTION

Given the propensity of severe acute respiratory syndrome coronavirus 2 to spread, it is imperative that those continuing to perform surgery take precautions to limit the potential generation of contaminated aerosols in smoke from energy-based instruments. The aim of this study was to report current data regarding insufflators with desufflation mode and similar options to safely remove CO₂ in minimal access surgery.

METHODS

A non-systematic review of the scientific literature was conducted using the PubMed database, and the main companies that provide surgical devices were contacted for information.

RESULTS

Most commercially available smoke evacuators use a combination of suction and mechanical filtering. There are also electrostatic precipitators that charge surgical smoke and retain the particles via electrostatic attraction. The search identified three insufflators with desufflation mode, four modular smoke evacuators using mechanical filtration, and only one device using electrostatic precipitation. However, none of these devices has been tested with viruses.

CONCLUSION

This review identified commercially available equipment that employs mechanical filtering and electrostatic attraction principles that can be used for pneumoperitoneum evacuation during the present coronavirus disease 2019 pandemic. This pandemic should assist in raising awareness regarding protection measures and the risk of occupational exposure in surgery.

Occupational Skin Disease in Physicians: A Review of the Literature

OBJECTIVES

Occupational skin disease (OSD) arises from work-related activity. However, there is a paucity of literature on OSD in physicians. The aim of the this review was therefore to examine and summarize what types of symptomatic OSD physicians experience.

METHODS

We conducted a systematic literature search on Cochrane Library, Embase, and Pubmed.

RESULTS

Contact dermatitis from formaldehyde and glutaraldehyde were found in 11.5 and 13.5% of cases, respectively. In total 2.4-14.9% had latex allergy. The reported standardized incidence ratio of squamous cell carcinoma and melanoma was up to 2.15 [95% confidence interval (CI) 1.57-1.95] and 3.2 (95% CI 1.38-6.31). Transmission of human papilloma virus (HPV) particles during carbon dioxide laser wart ablation were found in 70% of samples collected from protective gloves and in 52% of samples from vapors.

CONCLUSIONS

The most frequently reported OSD in physicians is contact dermatitis from allergens in disinfectants and rubber gloves. There is also a risk of cutaneous reactions to latex. The incidence of skin cancer was higher in physicians than in the general population, and the reason for this remains unexplained and potentially biased. There are no reports of transmission of patient HPV to surgeons during wart ablation, possibly because of proper use of protective equipment.

Laparoscopic surgery during the COVID-19 pandemic: detection of SARS-COV-2 in abdominal tissues, fluids, and surgical smoke

Background

There are still concerns over the safety of laparoscopic surgery in coronavirus disease 2019 (COVID-19) patients due to the potential risk of viral transmission through surgical smoke/laparoscopic pneumoperitoneum.

Methods

We performed a systematic review of currently available literature to determine the presence of severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) in abdominal tissues or fluids and in surgical smoke.

Results

A total of 19 studies (15 case reports and 4 case series) comprising 29 COVID-19 patients were included. The viral RNA was positively identified in 11 patients (37.9%). The samples that tested positive include the peritoneal fluid, bile, ascitic fluid, peritoneal dialysate, duodenal wall, and appendix. Similar samples, together with the omentum and abdominal subcutaneous fat, tested negative in the other patients. Only one study investigated SARS-COV-2 RNA in surgical smoke generated during laparoscopy, reporting negative findings.

Conclusions

There are conflicting results regarding the presence of SARS-COV-2 in abdominal tissues and fluids. No currently available evidence supports the hypothesis that SARS-COV-2 can be aerosolized and transmitted through surgical smoke. Larger studies are urgently needed to corroborate these findings.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00423-021-02142-8.

The impact of COVID-19 in medical practice. A review focused on Urology

COVID-19 pandemic is a rapidly spreading virus that is changing the World and the way doctors are practicing medicine. The huge number of patients searching for medical care and needing intensive care beds led the health care system to a burnout status especially in places where the care system was already overloaded. In this setting, and also due to the absence of a specific treatment for the disease, health authorities had to opt for recommending or imposing social distancing to relieve the health system and reduce deaths. All other medical specialties non-directly related to the treatment of COVID-19 had to interrupt or strongly reduce their activities in order to give room to seriously ill patients, since no one knows so far the real extent of the virus damage on human body and the consequences of doing non deferrable procedures in this pandemic era. Despite not been a urological disease, the urologist needs to be updated on how to deal with these patients and how to take care of himself and of the medical team he works with. The aim of this article is to review briefly some practical aspects of COVID-19 and its implications in the urological practice in our country.

Airborne Aerosolized Mouse Cytomegalovirus From Common Otolaryngology Procedures: Implications for COVID-19 Infection

OBJECTIVES

To determine whether common otolaryngology procedures generate viable aerosolized virus through a murine cytomegalovirus (mCMV) model for infection.

STUDY DESIGN

mCMV model of infection.

SETTING

University of Utah laboratory.

METHODS

Three-day-old BALB/c mice were inoculated with mCMV or saline. Five days later, each mouse underwent drilling, microdebrider, coblation, and electrocautery procedures. Particle size distribution and PM2.5 (particulate matter <2.5 µm) concentration were determined with a scanning mobility particle sizer and an aerosol particle sizer in the range of 15 nm to 32 µm. Aerosolized samples from these procedures were collected with an Aerosol Devices BioSpot sampler for viral titer based on polymerase chain reaction and for viable virus through viral culture.

RESULTS

As compared with the background aerosol concentrations, coblation and electrocautery showed statistically significant increases in airborne aerosols (Tukey-adjusted P value <.040), while microdebrider and drilling at 30,000 rpm did not (.870 < Tukey-adjusted P value < .930). We identified viral DNA in samples from coblation and drilling procedures, although we did not identify viable viruses in aerosol samples from any of the 4 procedures.

CONCLUSION

Coblation and electrocautery procedures generate >100-fold increases in aerosol concentrations over background; only coblation and drilling produce aerosolized viral DNA. The high concentration of aerosols from coblation and electrocautery suggests the need for appropriate safeguards against particle exposure to health care workers. The presence of viral DNA from drilling and coblation procedures warrants the need for appropriate protection against droplet and aerosol exposure.

Are Smoke and Aerosols Generated During Laparoscopic Surgery a Biohazard? A Systematic Evidence-Based Review

Background. Laparoscopic surgery generates end products that can have potentially harmful effects for the surgical team from short- or long-time exposure. In view of the current SARS-CoV-2 circumstances, controversy has risen concerning the safety of surgical smoke (SS) and aerosols and the perception of an increased risk of exposure during laparoscopic surgery. Methods. The present qualitative systematic review was conducted according to Meta-Analyses and Systematic Reviews of Observational Studies (MOOSE). A literature search was performed from March 2020 up to May 10, 2020, using the PubMed database, Cochrane, and Google Scholar to assess the risk of airborne transmission of viruses and the potential health risk of surgical smoke- and aerosol-generating procedures produced during laparoscopic surgery. The keywords were introduced in combination to obtain better search results. Application of the inclusion and exclusion criteria identified 44 relevant articles. Results. Genetic material from certain viruses, or the virus itself, has been detected in SS and aerosols. However, in the current SARS-CoV-2, as in other coronavirus situations, studies analyzing the presence of airborne transmission of viruses in surgical smoke are lacking. Conclusion. Despite the lack of clear evidence regarding the risk of diseases as the result of smoke- and aerosol-generating procedures during laparoscopic surgery, further investigation is needed. Meanwhile, all available precautions must be taken.

Impact of the COVID-19 pandemic on oncological and functional robotic-assisted surgical procedures

The COVID-19 pandemic led to a decrease in surgical activity to avoid nosocomial contamination. Robotic-assisted surgery safety is uncertain, since viral dissemination could be facilitated by gas environment. We assessed the impact and safety of the COVID-19 pandemic on robotic-assisted surgery. Data were collected prospectively during lockdown (March 16th–April 30th 2020) in 10 academic centres with robotic surgical activity and was compared to a reference period of similar length. After surgery, patients with suspected COVID-19 were tested by RT-PCR. During the COVID-19 lockdown we evidenced a 60% decrease in activity and a 49% decrease in oncological procedures. However, the overall proportion of oncological surgeries was significantly higher during the pandemic (p < 0.001). Thirteen (7.2%) patients had suspected COVID-19 contamination, but only three (1.6%) were confirmed by RT-PCR. The COVID-19 pandemic resulted in a significant decrease in robotic-assisted surgery. Robotic approach was safe with a low rate of postoperative COVID-19 contamination.

Preventing and managing complications in dermatologic surgery: Procedural and postsurgical concerns

The second article in this continuing medical education series reviews the evidence regarding the intraoperative and postoperative risks for patients and health care workers. We share the most up-to-date recommendations for risk management and postoperative complication management to ensure optimal surgical efficacy and patient safety.

Laser Plume From Human Papillomavirus-Infected Tissue: A Systematic Review

BACKGROUND

Laser procedures are becoming more prevalent across multiple medical specialties for a variety of indications. The plumes created by these lasers have raised concern for the dissemination of an infectious material.

OBJECTIVE

To review and summarize the information on viral dissemination in laser plumes available in the literature.

MATERIALS AND METHODS

Data Sources A systematic review was performed on English and non-English articles using the PubMed and the Cochrane databases. A manual search of bibliographies from relevant articles was also performed to collect additional studies.

STUDY SELECTION

Only articles in the English language with full texts available that pertained to viral particles in laser plumes were included. Data Extraction Two authors performed independent article selections using predefined inclusion and exclusion criteria.

RESULTS

There have been case reports of possible transmission of human papillomavirus (HPV) by inhalation of laser-produced aerosols. Multiple investigators have attempted to recreate this scenario in the laboratory to qualify this risk. Others have conducted clinical experiments to determine the presence of HPV in laser plumes.

CONCLUSION

The current body of the literature suggests that laser surgeons are at a risk for HPV exposure by inhalation of laser-derived aerosols. We offer best practice recommendations for laser operators.

A device category economic model of electrosurgery technologies across procedure types: a U.S. hospital budget impact analysis

AIMS

The electrosurgical technology category is used widely, with a diverse spectrum of devices designed for different surgical needs. Historically, hospitals are supplied with electrosurgical devices from several manufacturers, and those devices are often evaluated separately; it may be more efficient to evaluate the category holistically. This study assessed the health economic impact of adopting an electrosurgical device-category from a single manufacturer.

METHODS

A budget impact model was developed from a U.S. hospital perspective. The uptake of electrosurgical devices from EES (Ethicon Electrosurgery), including ultrasonic, advanced bipolar, smoke evacuators, and reusable dispersive electrodes were compared with similar MED (Medical Energy Devices) from multiple manufacturers. It was assumed that an average hospital performed 10,000 annual procedures 80% of which involved electrosurgery. Current utilization assumed 100% MED use, including advanced energy, conventional smoke mitigation options (e.g. ventilation, masks), and single-use disposable dispersive electrode devices. Future utilization assumed 100% EES use, including advanced energy devices, smoke evacuators (i.e. 80% uptake), and reusable dispersive electrodes. Surgical specialties included colorectal, bariatric, gynecology, thoracic and general surgery. Systematic reviews, network meta-analyses, and meta-regressions informed operating room (OR) time, hospital stay, and transfusion model inputs. Costs were assigned to model parameters, and price parity was assumed for advanced energy devices. The costs of disposables for dispersive electrodes and smoke-evacuators were included.

RESULTS

The base-case analysis, which assessed the adoption of EES instead of MED for an average U.S. hospital predicted an annual savings of $824,760 ($101 per procedure). Savings were attributable to associated reductions with EES in OR time, days of hospital stay, and volume of disposable electrodes. Sensitivity analyses were consistent with these base-case findings.

CONCLUSIONS

Category-wide adoption of electrosurgical devices from a single manufacturer demonstrated economic advantages compared with disaggregated product uptake. Future research should focus on informing comparisons of innovative electrosurgical devices.

Airborne human papillomavirus (HPV) transmission risk during ablation procedures: A systematic review and meta-analysis

BACKGROUND

Human Papillomavirus (HPV) is associated with development of oropharyngeal cancer. Aim of this review was to assess airborne transmission risk of infectious particles from HPV lesions to airway mucosa of medical staff during established ablation procedures.

METHODS

A systematic review of human and animal studies, published before 09/2020, relevant to airborne HPV transmission. Controlled studies reporting prevalence of HPV-associated upper airway (nasal/oral/pharyngeal) disease in staff performing ablation procedures (laser, loop electrosurgical excision [LEEP], cryosurgery) on HPV lesions were included in meta-analysis. Additionally, we aimed for a comprehensive systematic overview of studies regarding occupational risk of airborne HPV transmission and safety measures during ablation procedures.

RESULTS

A total of n = 30 original studies report outcomes related to HPV transmission risk in medical staff conducting ablation procedures. HPV DNA detection in ablation smoke (n = 7), matching HPV genotypes on ablated HPV lesions and face/airways of medical staff after ablation (n = 2), and evidence for infectivity of papillomavirus in ablation smoke (n = 3, animal models only) were reported. Three case reports describe occupational HPV disease of upper airway mucosa. Three controlled studies assessed warts (in CO₂ laser-users only); when pooling all controls (general population, non-laser users), nasal/oral/pharyngeal lesion sites were more common amongst laser-users (OR = 5.75; 95%CI[1.55, 21.38]; p < .001).

DISCUSSION

Airborne HPV dispersal with matching "high-risk" HPV-genotypes in airways of medical staff after ablations (LEEP and CO₂-laser) and cases of HPV-associated upper airways neoplasms based on exposure to laser and LEEP smoke are documented. Upper airway mucosa is a more common anatomical site for warts in CO₂ laser users compared to controls. Simple safety measures greatly reduce HPV contamination and transmission risk.

CSO (Canadian Society of Otolaryngology - Head & Neck Surgery) position paper on rhinologic and skull base surgery during the COVID-19 pandemic

Healthcare services in many countries have been partially or completely disrupted by the Coronavirus (COVID-19) pandemic since its onset in the end of 2019. Amongst the most impacted are the elective medical and surgical services in order to conserve resources to care for COVID-19 patients. As the number of infected patients decrease across Canada, elective surgeries are being restarted in a staged manner. Since Otolaryngologists - Head & Neck Surgeons manage surgical diseases of the upper aerodigestive tract where the highest viral load reside, it is imperative that these surgeries resume in a safe manner. The aim of this document is to compile the current best evidence available and provide expert consensus on the safe restart of rhinologic and skull base surgeries while discussing the pre-operative, intra-operative, and post-operative care and tips. Risk assessment, patient selection, case triage, and pre-operative COVID-19 testing will be analyzed and discussed. These guidelines will also consider the optimal use of personal protective equipment for specific cases, general and specific operative room precautions, and practical tips of intra-operative maneuvers to optimize patient and provider safety. Given that the literature surrounding COVID-19 is rapidly evolving, these recommendations will serve to start our specialty back into elective rhinologic surgeries over the next months and they may change as we learn more about this disease.

Could Interventional Radiological Therapies Offer a Safer Alternative as We Emerge from COVID-19 Pandemic?

The ongoing SARS-CoV-2 (COVID-19) pandemic poses a major risk to health care delivery all around the world and also poses significant risks to the public and health care workers (HCWs). Surgical procedures, particularly elective procedures, have been cancelled or deferred due to increased risks associated with surgery and anesthesia both to the patient and the HCWs as well as to allocate resources to treat infected patients. This is particularly true for patients with comorbidities and cancer. As countries emerge from this pandemic, a phased return to conventional surgical procedures is being proposed, with emphasis on procedures performed in ambulatory settings and avoiding endotracheal intubation, where possible. Interventional radiological (IR) procedures offer a unique advantage in this setting, as these procedures are often performed with local or regional anesthesia with shorter hospital stay. In this brief communication, we outline the current opinion on surgical risks and guidelines and suggest areas where interventional therapies may offer an advantage to the multidisciplinary team and patient.

Eradication of Benign Skin Lesions of the Face by Voltaic Arc Dermabrasion (Atmospheric Plasma): Postoperative Pain Assessment by Thermal Infrared Imaging

Objectives

The face aging processes are associated with physiologic and biochemical alteration that produces wrinkles, skin pigmentation and benign growths. The aim of this study was to evaluate the clinical efficacy of voltaic arc dermabrasion with plasma to remove benign facial skin lesions.

Study Design

Voltaic arc dermabrasion plasma technique was used to remove the facial benign skin lesions. The study involved 45 patients (26 females;19 males) treated for benign facial skin lesions with voltaic arc dermabrasion also called plasma exeresis technique. The subjects age ranged between 43 and 65 years. The clinical observations and comparison of pretreatment and post-treatment photographs of the treated regions were performed by a joint examiner at each follow-up visit.

Results

During plasma irradiation, the average temperature of the skin was 290.3 ± 21.7 °C, while immediately after it was 90.6 ± 21.8 °C. Overall clinical improvement was 100% in six lesions with complete resolution of all lesions. Three patients observed a transient post-inflammatory pigmentation with a peak at 1 month after VAD treatment, gradually fading spontaneously over 2 to 3 months.

Conclusions

The voltaic arc dermabrasion technique (atmospheric plasma) should be considered for lesions, especially relatively superficial ones, and small lesions that are located on the face.

Level of Evidence IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The clinical and translational research activities at the INT - IRCCS "Fondazione Pascale" cancer center (Naples, Italy) during the COVID-19 pandemic

COVID-19 pandemic following the outbreak in China and Western Europe, where it finally lost the momentum, is now devastating North and South America. It has not been identified the reason and the molecular mechanisms of the two different patterns of the pulmonary host responses to the virus from a minimal disease in young subjects to a severe distress syndrome (ARDS) in older subjects, particularly those with previous chronic diseases (including diabetes) and cancer. The Management of the Istituto Nazionale Tumori - IRCCS "Fondazione Pascale" in Naples (INT-Pascale), along with all Health professionals decided not to interrupt the treatment of those hospitalized and to continue, even if after a careful triage in order not to allow SARS-CoV-2 positive subjects to access, to take care of cancer patients with serious conditions. Although very few (n = 3) patients developed a symptomatic COVID-19 and required the transfer to a COVID-19 area of the Institute, no patients died during the hospitalization and completed their oncology treatment. Besides monitoring of the patients, all employees of the Institute (physicians, nurses, researchers, lawyers, accountants, gatekeepers, guardians, janitors) have been tested for a possible exposure. Personnel identified as positive, has been promptly subjected to home quarantine and subdued to health surveillance. One severe case of respiratory distress has been reported in a positive employees and one death of a family member. Further steps to home monitoring of COVID-19 clinical course have been taken with the development of remote Wi-Fi connected digital devices for the detection of early signs of respiratory distress, including heart rate and oxygen saturation.In conclusion cancer care has been performed and continued safely also during COVID-19 pandemic and further remote home strategies are in progress to ensure the appropriate monitoring of cancer patients.

Metagenomic analysis of the dust particles collected from the suction tube and the suction funnel of a dermatological laser smoke evacuator system

In the last few decades, there has essentially been an explosion in the use of lasers in medicine, especially in the area of cosmetic dermatology. Potentially harmful substances are liberated when tissues are vaporized with laser. This creates numerous risks, including the spread of infectious disease. Smoke evacuators are devices that capture and filter laser plume, thereby maintaining a safe environment for the surgical team and patient. Our aim was to characterize the microbial community structure within the suction tube and funnel of the smoke evacuator system, identify their origin, and evaluate pathogenicity. Dust particles were collected from the instruments with a cotton swab. DNA was extracted from the swabs and the transport media, and sequencing was performed using the Illumina HiSeq Xplatform. Metagenomic analysis was conducted using the Empowering the Development of Genomics Expertise (EDGE) Bioinformatics pipeline and custom Python scripts. The most abundant bacterial species were Micrococcus luteus and Brevibacterium casei in the suction tube, and Dermacoccus sp. Ellin 185 and Janibacter hoylei in the suction funnel. A total of 15 medium- to high-quality metagenome-assembled genomes (MAGs) were constructed where we found 104 antibiotic-resistant genes (ARGs) and 741 virulence factors. Findings indicate that the suction tube and funnel are likely a reservoir of virulence factor genes and ARGs, which can possibly be passed on to other bacteria via horizontal gene transfer. We would like to emphasize the health risk these microorganisms pose and the need to reevaluate the current hygiene standards with regard to the smoke evacuator system.

Cost-Effective Filtrating Suction to Evacuate Surgical Smoke in Laparoscopic and Robotic Surgery During the COVID-19 Pandemic

The wide and fast spread of COVID-19 around the world has led to a dramatic increase in the need for protection products both for carers and for populations. Surgical team protection includes a systematic screening of patients, wearing protection devices by all the operating staff, and adequate management of aerosols. The risk of aerosol dispersal is particularly high during laparoscopic and robotic surgeries due to the interaction between circulating CO2 and surgical smoke that may contain small viral particles. To decrease the risk of virus transmission, many recommendations have been implemented including the use of integrated insufflation devices comprising smoke evacuation and filtration mode. Such devices are lacking in many centers around the world and to overcome this urgent unmet need, we designed a cost-effective filtrating suction as a more readily available alternative.

Assessing the risk of viral infection from gases and plumes during intra-abdominal surgery: a systematic scoping review

BACKGROUND

The aim of this study was to identify the current evidence regarding the risk of acquiring viral infections from gases or plumes during intra-abdominal surgery. Peritoneal fluids may contain cellular material and virus particles. Electrocautery smoke and plumes from energy devices may aerosolize harmful substances and viral particles. Insufflation and desufflation during laparoscopic surgery may also aerosolize and distribute biological material. A systematic scoping review was performed to assess the evidence and inform safe surgical practice.

METHODS

A systematic search of the PubMed and Medline databases was undertaken until June 2020, observing Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology, to identify articles associating viral infection of operating room staff from surgical gases and plumes. All evidence levels were included. The search strategy utilized the search terms 'surgery', 'laparoscopy', 'laparoscopic' 'virus', 'smoke', 'risk', 'infection'.

RESULTS

The literature search identified 74 articles. Eight articles relevant to the subject of this review were included in the analysis, two of which specifically related to intra-abdominal surgery. Of the remaining six, four involved gynaecological surgery and two were in-vitro studies. No evidence that intra-abdominal surgery was associated with an increased risk of acquiring viral infections from exsufflated gas or smoke plumes was identified.

CONCLUSION

There is currently no evidence that respiratory viruses can be found in the peritoneal fluid. Whilst there is currently no evidence that desufflated carbon dioxide or surgical smoke plumes present a significant infectious risk, there is not a wealth of literature to inform current practice. Further clinical research in this area is required.

Postoperative assessment of nosocomial transmission of COVID-19 after robotic surgical procedures during the pandemic

OBJECTIVES

To assess potential nosocomial coronavirus disease-2019 (COVID-19) transmission in patients who underwent robot-assisted laparoscopic procedures during the pandemic.

MATERIAL AND METHODS

Prospective study in patients undergoing robot-assisted laparoscopy in urology or gynaecology within 2 academic hospitals. Patients underwent local preoperative COVID-19 screening using a symptoms questionnaire. Patients with suspicious screening underwent coronavirus real time-polymerase chain reaction (RT-PCR) and were excluded from robotic surgery if positive. Patients with symptoms postsurgery were systematically tested for coronavirus by RT-PCR. One-month postsurgery, all patients had a telephone consultation to evaluate COVID-19 symptoms.

RESULTS

Sixty-eight patients underwent robotic surgery during the study period (median age: 63-years [IQR: 53-70], 1.8 male: female ratio). Oncology was the main indication for robotic surgery (n = 62, 91.2%) and 26 patients (38.2%) received a chest CT-scan prior to surgery. Eleven patients (16.2%) were symptomatic after surgery of whom only 1 tested positive for coronavirus by RT-PCR (1.5%) and was transferred to COVID-19 unit with no life-threatening condition. No attending surgeon was diagnosed with COVID-19 during the study.

CONCLUSIONS

Robot-assisted laparoscopic surgery seemed safe in the era of COVID-19 as long as all recommended precautions are followed. The rate of nosocomial COVID-19 transmission was extremely low despite the fact that we only used RT-PCR testing in symptomatic patients during the preoperative work-up. Larger cohort is needed to validate these results.

Risk of Virus Contamination Through Surgical Smoke During Minimally Invasive Surgery: A Systematic Review of the Literature on a Neglected Issue Revived in the COVID-19 Pandemic Era

CONTEXT

The coronavirus disease 2019 (COVID-19) pandemic raised concerns about the safety of laparoscopy due to the risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) diffusion in surgical smoke. Although no case of SARS-CoV-2 contagion related to surgical smoke has been reported, several international surgical societies recommended caution or even discouraged the use of a laparoscopic approach.

OBJECTIVE

To evaluate the risk of virus spread due to surgical smoke during surgical procedures.

EVIDENCE ACQUISITION

We searched PubMed and Scopus for eligible studies, including clinical and preclinical studies assessing the presence of any virus in the surgical smoke from any surgical procedure or experimental model.

EVIDENCE SYNTHESIS

We identified 24 studies. No study was found investigating SARS-CoV-2 or any other coronavirus. About other viruses, hepatitis B virus was identified in the surgical smoke collected during different laparoscopic surgeries (colorectal resections, gastrectomies, and hepatic wedge resections). Other clinical studies suggested a consistent risk of transmission for human papillomavirus (HPV) in the surgical treatments of HPV-related disease (mainly genital warts, laryngeal papillomas, or cutaneous lesions). Preclinical studies showed conflicting results, but HPV was shown to have a high risk of transmission.

CONCLUSIONS

Although all the available data come from different viruses, considering that the SARS-CoV-2 virus has been shown in blood and stools, the theoretical risk of virus diffusion through surgical smoke cannot be excluded. Specific clinical studies are needed to understand the effective presence of the virus in the surgical smoke of different surgical procedures and its concentration. Meanwhile, adoption of all the required protective strategies, including preoperative patient nasopharyngeal swab for COVID-19, seems mandatory.

PATIENT SUMMARY

In this systematic review, we looked at the risk of virus spread from surgical smoke exposure during surgery. Although no study was found investigating severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or any other coronavirus, we found that the theoretical risk of virus diffusion through surgical smoke cannot be excluded.