Surgery on patients with suspected or confirmed COVID-19. Management and treatment recommendations

In anticipation of the expected COVID-19 infected patients increase and the need to rationally use Personal Protective Equipment (PPE) while continuing to provide surgical procedures, we developed institutional guidelines, for surgical team members precaution during COVID-19 pandemic. Although the majority of the evidence suggests that COVID-19 spreads through droplets, some literature supports aerosols propagation [7,8]. Among infectious diseases experts from our institution, we developed our guidelines based on potential spreading patterns, exposure risk and PPE conservation.

Disease transmission was in exponential magnitude, reporting 332,930 confi rmed cases worldwide and 14,510 deaths on March 23, 2020 due to the new virus [3].
By July 12, 2020, there have been reported 12,945,505 confi rmed cases of COVID-19 and 571,444 deaths worldwide.
With an overall fatality rate of 7 %. During the last 14 days, the number of new reported cases represents 76% of the total cumulative cases [4,5].
The fi rst registered case in Mexico was reported on February 28, 2020, related to a 35-year-old male with a travel history to Italy. Declaring a Health Emergency on March 30, 2020. Currently (July 13, 2020), 299,750 confi rmed cases and 35,006 deaths caused by COVID-19 have been reported in our Country [6].
In anticipation of the expected COVID-19 infected patients increase and the need to rationally use Personal Protective Equipment (PPE) while continuing to provide surgical procedures, we developed institutional guidelines, for surgical team members precaution during COVID-19 pandemic.
Although the majority of the evidence suggests that COVID-19 spreads through droplets, some literature supports aerosols propagation [7,8]. Among infectious diseases experts from our institution, we developed our guidelines based on potential

Results
A fl ow diagram algorithm was created (Figure 1). We relied on the assumption that every patient could be a COVID-19 infected patient until proven otherwise. This assumption is based on the growing community transmission of COVID-19.
Patients who do not meet the criteria for COVID-19 testing (Table 1), may be operated using traditional techniques, taking standard safety measures.
In patients who meet the criteria for COVID-19 testing, the procedure will be postponed until the testing results are known. Those patients requiring urgent procedures, will be categorized into two categories, patients with confi rmatory COVID-19 test and patients without test. In patients with confi rmed COVID-19, urgent surgical procedures will be performed following the safety recommendations for SARS-CoV-2 patients (Table 2); such as using N95 respirators, surgical face shields and opting for open surgery techniques. Patients with negative COVID-19 testing results may be operated using traditional techniques.
Patients who do not meet the criteria for COVID-19 testing (Table 1), may be operated using traditional techniques, taking standard safety measures.
In patients who meet the criteria for COVID-19 testing, the procedure will be postponed until the testing results are known. Those patients requiring urgent procedures, will be categorized into two categories, patients with confi rmatory COVID-19 test and patients without test. In patients with confi rmed COVID-19, urgent surgical procedures will be performed following the safety recommendations for SARS-CoV-2 patients ( Table 2); such as using N95 respirators, surgical face shields and opting for open surgery techniques. Patients with negative COVID-19 testing results may be operated using traditional techniques. + Consider those instruments in contact with body fl uids contaminated.
In patients who require emergency procedures but have not been tested for COVID-19, the safety measures for probable SARS-CoV-2 infected patients should be taken (Table 3).
Rapid testing for COVID-19 virus will not be possible in case of emergency procedures. We assumed that all patients

Conclusions
The current COVID-19 pandemic has required the prompt development of new hospital guidelines for clinical facilities.
Although COVID-19 is a new threat, we have shown that by developing an easy-to-follow algorithm for surgical and intervention teams, we can guarantee optimal safety for health care providers. This algorithm prioritizes patients according to disease severity, tests results and symptomatology, while ensuring rational use of PPE in limited resources environments.   In case of opting for laparoscopic surgery: · Limit pneumoperitoneum to 10-12mmhg · Avoid incisions larger than the diameter of the trocar to avoid pneumoperitoneum leakage · Do not open the trocars to evacuate the smoke generated by high energy devices · At the end of the procedure; use an aspiration device to evacuate the pneumoperitoneum