Covid and surgery: Doctors tweak process, adopt methods to minimise risk of infection | Mumbai news - Hindustan Times
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Covid and surgery: Doctors tweak process, adopt methods to minimise risk of infection

ByJyoti Shelar, Mumbai
Sep 11, 2021 11:57 PM IST

When doctors set out for surgery in special cases, they introduced some tweaks and changes on the operation table to reduce the risk of Covid infection inside the theatre

Early this year, when a 65-year-old Covid positive woman admitted to a hospital in Nagothane suffered from a sudden heart blockage, she was rushed to the Fortis Hospital in Vashi for an emergency intervention. Her heart rate had fallen to 30, much below the normal range of 60 to 100. Doctors took her into the hospital’s fifth-floor catheterisation laboratory to implant a pacemaker, a small device that sends electrical impulses to the heart muscle. But a surgical procedure on a patient with an active Covid-19 infection would mean risking the medical staff with the infection too. To minimise the risk, the medical team decided to limit the use of cautery- an electrosurgical machine commonly used to burn and seal a bleeding blood vessel, that produces smoke during the process. This surgical smoke could potentially be carrying the virus and thus be a huge threat to the medical staff in closed operation theatre.

Doctors opt to delay the invasive interventions by at least two weeks if patients have active Covid infection and if the surgery can wait. (Shutterstock)
Doctors opt to delay the invasive interventions by at least two weeks if patients have active Covid infection and if the surgery can wait. (Shutterstock)

“To fit in the pacemaker in the chest wall, we needed an incision of about the breadth of four fingers,” said interventional cardiologist Dr Brajesh Kanwar. “We opted for other techniques like pressing the bleed with gauze and using mosquito forceps- a type of forceps used to control bleeding. But eventually, we had to give in to the cautery machine to burn one bleeder that wouldn’t stop easily,” he said.

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As the pandemic unfolded in March 2020, surgical procedures came to a complete halt except for emergencies like the case of this 65-year-old woman. When doctors set out to operate on such special cases, they introduced some tweaks and changes on the operation table to reduce the risk of infection inside the theatre. While surgical work has now resumed to a large extent, doctors have stuck to these techniques as a precaution amidst the fear of breakthrough infections and reinfections.

“Every patient can be infective at any given point of time,” said Kanwar. “The infection control norms and the personal protection norms are here to stay for a long time. Certain shortcuts that can save time in the operation theatre are also going to be widely used. For instance, a surgeon may opt to use a stapler instead of a suture to save time and limit the exposure in the theatre, especially if the patient has an active infection. Instead of cutting the tissue, doctors may opt for dissecting with the use of closed forceps. This reduces bleeding and in turn, reduces the use of smoke-producing cautery machine. These decisions have to be balanced with the kind of case one is handling,” said Kanwar who has carried out nearly 20 pacemaker implantations and over 150 angioplasties in active Covid patients since last year.

Doctors opt to delay the invasive interventions by at least two weeks if patients have active Covid infection and if the surgery can wait. “But there are some cases in which waiting is not an option at all,” said Dr Manmohan Kamat, head of general and minimal invasive surgery at the Nanavati Max Super Speciality Hospital. He cited an example of a 64-year-old Covid positive woman who was shifted from a nursing home with acute abdominal pain. Investigations revealed that she had bowel gangrene which had to be operated out immediately before the infection spread. However, such a surgery would involve heavy spillage of digestive chyme- the partially digested food and secretions of the gastrointestinal tract- which may be highly contagious.

“The procedure involved making a cut on the abdomen and removing at least five feet of the small intestine,” said Kamat who has operated on nearly 15 patients with an active Covid infection. “We managed to minimise the spillage by using a stapler cutting method, instead of a clamp and cut method,” he said adding that he preferred carrying out open surgeries on such patients instead of laparoscopic procedures.

Among the surgical emergencies, gynaecologists were perhaps the first to jump in the operation theatres amidst the raging pandemic to conduct normal deliveries and cesarean sections of Covid positive women. The Lokmanya Tilak Municipal General Hospital in Sion has carried out nearly 500 deliveries of Covid positive women, more than half of them are C-sections. In the process, the gynaecology department adopted several protocols including the use of a knife to cut open the lower abdomen instead of using the cutting probe in the cautery machine, which cuts and helps reduce the bleeding, but produces excessive smoke. “To control bleeding, we opted for ligating the blood vessel by suturing,” said Dr Arun Nayak, the head of the gynaecology department. “The ligating process takes longer time, but we have stuck to it. In cases where use cautery was unavoidable, we used a suction machine to trap the smoke,” he said.

According to Nayak, they have also started using an acrylic box while intubating a patient and administering anaesthesia. “The acrylic box creates a transparent barrier between the patient and the anaesthetist and reduces the direct flow of aerosols from patient’s breath or cough on the doctor,” he said.

Protocols outside the operation theatre include micro- coordination in terms of sanitising the trail of Covid patients when they are brought into the hospital and moved from one department to another within the premises for investigations. Interventional cardiologist Kanwar said that Fortis Hospital, Vashi has a mic system that announces the movement of Covid patients so that the staff can promptly follow the trail and spray the area with disinfectant as a precaution.

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