Cutting back on surgeries during Covid-19

  • Wellness Premium
  • Wednesday, 03 Jun 2020

Universiti Kebangsaan Malaysia Medical centre (UKMMC) consultant ENT surgeon Prof Dr Marina Mat Baki (sitting) conducting a surgical simulation with plastic coveralls to practise preventing aerosolisation in an aerosol-generating procedure (AGP) for Covid-19 patients, assisted by the writer. — Photos: Dr HARDIP SINGH GENDEH

The spread of the SARS-CoV-2 virus that causes Covid-19 has caused a shift in the delivery of healthcare, both nationwide and across the globe.

This is especially due to the fact that this new coronavirus spreads easily through close contact with an infected person, including via the respiratory droplets generated when this person coughs or sneezes.

As healthcare institutions geared up to respond to the Covid-19 pandemic, many sacrifices and significant changes were made to cope with the anticipated overwhelming numbers of infected patients.

Frontline and critical care services are being prioritised as they are dealing directly with Covid-19 patients.

Many other healthcare services have slowed down or stopped if not urgent, including elective surgeries, in order to minimise potential exposure to Covid-19.

Indeed, many surgeons have been required to drop their scalpels and don their stethoscopes to assist in treating general medical problems during the past few months.

Many surgical officers and trainees have been sent to other departments in need, such as the Emergency Department, to help their colleagues.

However, essential or emergency surgical care is still being performed, although such operations have to be carried out in a way that minimises risk to both patient and surgeon.

Health director-general Datuk Dr Noor Hisham Abdullah, who is also a senior consultant breast and endocrine surgeon at Hospital Putrajaya, says Health Ministry (MOH) hospitals have been categorised into three types for this pandemic:

  • Covid-19 hospitals that only treat Covid-19 patients
  • Hybrid Covid-19 hospitals that treat both Covid-19 and non-Covid-19 patients, and
  • Non-Covid-19 hospitals that do not treat Covid-19 cases at all.

He notes that all emergency and semi-emergency surgeries in MOH hospitals have been proceeding as usual.

Hospitals designated for the sole treatment of Covid-19 patients had referred all their non-Covid-19 patients to nearby hybrid or non-Covid-19 hospitals as soon as they were classified as a Covid-19 hospital, and continue to do so for any non-Covid-19 patients that come their way.

Meanwhile, hybrid Covid-19 hospitals are treating all emergency surgical cases, while non-emergency surgeries are being considered on a case-by-case basis, depending how critical the condition is.

As for non-Covid-19 hospitals, it is business as usual for all emergency and non-emergency surgeries.

When to operate

The College of Surgeons, Academy of Medicine Malaysia, (CSAMM) has provided guidelines since the beginning of the movement control order (MCO) on how to conduct surgery during this time, including on triaging and prioritisation of surgeries.

Prof Hanafiah shares that the high demand for ventilators, hospital space and healthcare personnel due to Covid-19 has caused a strain on surgical services at this time.Prof Hanafiah shares that the high demand for ventilators, hospital space and healthcare personnel due to Covid-19 has caused a strain on surgical services at this time.

The principles behind the guidelines are the adequate protection of healthcare workers, maintenance of a safe surgical environment and the need to conserve resources, including personal protective equipment (PPE), given the uncertainty of how long the pandemic will last.

Elective surgeries are advised to be deferred and stable surgical conditions that respond well to medical treatment are to be considered for such treatment, e.g. stable appendicitis and cholecystitis that show improvement with antimicrobial therapy.

Cancer patients may also have their options revisited.

Chemotherapy, radiotherapy, immunotherapy and/or stereotactic radiosurgery may be considered for suitable cases if they provide similar or comparable outcomes to surgery.

CSAMM president and Universiti Malaya Medical Centre consultant colorectal surgeon Professor Dr April Camilla Roslani says that healthcare institutions should consider the following three factors in deciding which surgical cases require immediate attention and intervention:

  • Surgical case mix, which includes conditions that fit into surgical emergencies
  • Bed and manpower capacity of the hospital, and
  • Risk management based on emerging evidence.

Another factor is that anaesthesiologists are required to sedate patients for surgery.

However, many anaesthesiologists are currently being deployed to manage Covid-19 patients requiring ventilation in intensive care units (ICU), thus further straining surgical services.

In general, surgery on a Covid-19 patient should be avoided, unless its benefits outweigh the risks, such as in life-saving situations.

Preferably, such patients should have their operations delayed until they have recovered with negative confirmatory tests.

If surgery must be done, there should be a discussion among all the specialities caring for the patient to deliberate on the safety of the procedure, especially as Covid-19 patients need to be managed meticulously to limit cross-infection.

Before operation, workflow simulations are conducted to ensure a smooth procedure, ironing out any hiccups that may expose individuals to Covid-19, especially during aerosol-generating procedures (AGPs).

During operation

As a Covid-19 patient may not present with any symptoms, i.e. is asymptomatic, the MOH announced on April 4 (2020) that all patients scheduled for emergency or semi-emergency surgeries must be tested for the SARS-CoV-2 virus.

This is as certain procedures, particularly AGPs such as tracheal intubation, non-invasive ventilation, tracheotomy, CPR (cardiopulmonary resuscitation), manual ventilation before intubation and bronchoscopy, are associated with an increased risk of coronavirus transmission due to the high viral loads from the patient’s airway.

Apart from standard universal precautions, healthcare workers must also adhere to airborne precautions when performing AGPs.

Prof April notes that the CSAMM has provided guidelines on how and when to conduct surgeries during the current pandemic. — FilepicProf April notes that the CSAMM has provided guidelines on how and when to conduct surgeries during the current pandemic. — FilepicGuidelines recommend the use of N95 face masks, head and neck covers, eye protection, long-sleeved water repellent gowns, plastic aprons, double gloves and shoe covers for AGPs, even if Covid-19 screening is negative.

Imaging such as CT (computed tomography) scans of the chest could provide a clearer picture in patients who are at risk for Covid-19 (e.g. recent contact with a Covid-19 patient or having an ongoing chest infection), but require emergency surgery, as testing for Covid-19 should not delay any emergency surgeries.

However, certain cases are so urgent that there is no time at all for Covid-19 testing first, e.g. in cases of emergency airway obstruction, ruptured appendix with a full-blown infection and trauma cases due to road traffic collisions.

When the Covid-19 status is unknown, the surgical team consisting of the anaesthesiologist, surgeon, operation theatre nurse and healthcare assistants, are required to act as if the patient has Covid-19 and don the appropriate PPE.

This is the same for high-risk patients (e.g. with a history of exposure) without any symptoms and Persons Under Investigation (PUIs) with symptoms.

Says Hospital Canselor Tuanku Muhriz (HCTM) director and consultant vascular surgeon Prof Datuk Dr Hanafiah Harunarashid: “Their safety is our priority and the hospital ensures that there is adequate PPE available to keep our doctors safe.”

In confirmed Covid-19 cases, powered air-purifying respirators (PAPRs) and medical coverall suits should be considered for emergency surgical procedures.

After surgery, patients need to be admitted to designated Covid-19 wards or ICUs where healthcare workers are required to be in full PPE.

With limited stock of PPE, many healthcare institutions have limited the number of surgeons and staff in the operation theatres.

Only the most senior available surgeon, and in certain cases, an assistant surgeon with the next most experience, are encouraged to perform the procedure.

Surgical associations have also advised against the use of powered instruments such as electrocautery, surgical drills, ultrasonic scalpels, lasers and several others on Covid-19 patients, as these instruments spread aerosol droplets to the environment.

Therefore, many surgeons will have to use conventional surgical instruments with limited technological assistance.

However, recent evidence has suggested that the microdebrider, previously thought to cause aerosolisation, is now deemed safe as it is often attached to an inbuilt suctioning system.

This instrument is particularly useful for airway and nasal surgeries.

Negative pressure operating theatres are preferred for Covid-19 cases, but not all healthcare facilities have them.

After surgery on a confirmed or suspected Covid-19 patient, the operating theatre, anaesthetic equipment and surgical instruments will all require thorough decontamination.

A recovery plan

Planning a surgical exit strategy is challenging as the future of this pandemic is vague.

Many healthcare institutions have gradually increased surgical services with the recent decrease in Covid-19 patients, catering for not only emergency cases, but also semi-emergency ones.A trainee surgeon practises with a laparoscopic surgical simulation to develop his skills. Most trainee surgeons have been sent to help out in other departments during this pandemic.A trainee surgeon practises with a laparoscopic surgical simulation to develop his skills. Most trainee surgeons have been sent to help out in other departments during this pandemic.

The deferment of elective surgeries has created a backlog of cases.

Dr Noor Hisham says that the MOH is planning to overcome any potential surgical backlogs by extending clinical hours, increasing operating room time for surgeries, “uberisation” of services and employing virtual clinics for stable patients.

The ministry is also looking into enhancing daycare surgery and the Global Surgery Initiative.

He notes that the new normal will include staggering outpatient clinic appointments to avoid overcrowding and to ensure adequate social distancing, especially in patient waiting areas and pharmacies.

Covid-19 testing will still be required for patients undergoing surgery as per the current protocol.

The reduction in elective surgeries also means that trainee surgeons may have their training extended as they are unable to participate in many surgeries to practise their skills.

Training with surgical simulations may mitigate the loss of surgery time to some extent, although this method needs to be validated.

Therefore, hospitals may have a delay in receiving new surgical specialists in the near future.

Prof Hanafiah, who is also the international adviser of the Royal College of Surgeons, Edinburgh, adds: “During the Covid-19 pandemic, the extreme demand for ventilators, hospital space and personnel is depriving surgical capacity to a point where essential surgical delivery is severely strained.

“This certainly has an effect on millions of surgical patients worldwide, both short and long term.

“We must therefore find long-term solutions to anticipate future pandemics of this scale, by planning for a new surgical ecosystem that includes a robust infrastructure, workforce, care delivery, financing and artificial intelligence to cater for both service and training needs.”

It is still too early to predict when Covid-19 hospitals will resume full surgical services, but the number of new cases in the upcoming weeks will be a good guide.

There will soon be more conversations between surgical specialities and hospital administrators on when to return to top gear!

Dr Hardip Singh Gendeh is a ear, nose and throat (ENT) surgeon and lecturer at HCTM. For more information, email The information provided is for educational purposes only and should not be considered as medical advice. The Star does not give any warranty on accuracy, completeness, functionality, usefulness or other assurances as to the content appearing in this column. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

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