Who Appendix 21 Summary of the Systematic Review on the Use of Surgical Gloves

Eur Urol Focus. 2020 Sep 15; 6(v): 1058–1069.

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

Nicola Pavan,^a Alessandro Crestani,^b Alberto Abrate,^c Cosimo De Nunzio,^d Francesco Esperto,^e Gianluca Giannarini,^f Antonio Galfano,^thou Andrea Gregori,^h Giovanni Liguori,^a Riccardo Bartoletti,ⁱ Francesco Porpiglia,^j Alchiede Simonato,^c, ^k Carlo Trombetta,^a Andrea Tubaro,^d Vincenzo Ficarra,^l Giacomo Novara,^m, ^⁎ and , on behalf of the Inquiry Urology Network (RUN)

Nicola Pavan

^aSection of Urology, Academy of Trieste, Cattinara Hospital, Trieste, Italian republic

Alessandro Crestani

^bUrology Unit, Veneto Institute of Oncology IOV-IRCCS, Padua, Italy

Alberto Abrate

^cUrology Section, Department of Surgical, Oncological and Oral Sciences, Academy of Palermo, Palermo, Italy

Cosimo De Nunzio

^dDepartment of Urology, Sant'Andrea Hospital, University La Sapienza, Rome, Italy

Francesco Esperto

^eSection of Urology, Campus Biomedico University of Rome, Rome, Italy

Gianluca Giannarini

^fUrology Unit, Academic Medical Centre Hospital 'Santa Maria della Misericordia', Udine, Italy

Antonio Galfano

^gUrology Unit of measurement, Niguarda Hospital, Milan, Italia

Andrea Gregori

^hUrology Unit, Ospedale Luigi Sacco, Milan, Italy

Giovanni Liguori

^aDepartment of Urology, University of Trieste, Cattinara Hospital, Trieste, Italy

Riccardo Bartoletti

ⁱDepartment of Translational Research and New Technologies, Urologic Unit, University of Pisa, Italy

Francesco Porpiglia

^jDivision of Urology, Section of Oncology, Schoolhouse of Medicine, San Luigi Hospital, University of Turin, Orbassano, Italian republic

Alchiede Simonato

^cUrology Section, Section of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy

^kUrology Unit, Section of Surgery, S. Croce eastward Carle Hospital, Cuneo, Italian republic

Carlo Trombetta

^aDepartment of Urology, University of Trieste, Cattinara Hospital, Trieste, Italy

Andrea Tubaro

^dDepartment of Urology, Sant'Andrea Hospital, University La Sapienza, Rome, Italy

Vincenzo Ficarra

^lDepartment of Human and Pediatric Pathology "Gaetano Barresi", Urologic Section, University of Messina, Messina, Italy

Giacomo Novara

^mSection Surgery, Oncology and Gastroenterology, Urologic Unit, University of Padova, Padova, Italy

Abstruse

Context

The coronavirus illness 2019 (COVID-19) pandemic raised concerns about the safety of laparoscopy due to the risk of severe acute respiratory syndrome coronavirus two (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.

Testify acquisition

Nosotros 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 process or experimental model.

Evidence synthesis

Nosotros identified 24 studies. No study was plant investigating SARS-CoV-ii or whatsoever 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 manual 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 take a high chance of transmission.

Conclusions

Although all the available data come up 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 unlike surgical procedures and its concentration. Meanwhile, adoption of all the required protective strategies, including preoperative patient nasopharyngeal swab for COVID-xix, seems mandatory.

Patient summary

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

Keywords: Minimally invasive surgery, Virus, COVID-19, Surgical, fume

1. Introduction

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the illness information technology causes, coronavirus affliction 2019 (COVID-19), are causing a rapid and tragic health emergency worldwide. This is reshaping the wellness systems in several countries, due to the demand to dedicate significant medical resources to the assistance of critically ill COVID-19 patients, with substantial implications also on the medical disciplines not primarily involved in the management of COVID-xix patients. Specifically, the vast majority of the centers in the areas more severely hit past the pandemic are limiting their surgical activities, according to specific recommendations for patient triage from international societies and independent research groups [i], [2], [3], [4], [5]. Concerning surgery, Zheng et al [half dozen] recently reported recommendations for laparotomic and laparoscopic surgery to forbid the risk of aerosol dispersal containing viruses. Specifically, surgical smoke was considered to pose a risk of including active virus, and laparoscopic surgery was considered to increase the gamble of contagion due to higher particles of the surgical smoke and the risk of aerosol dispersal through pneumoperitoneum leakage. Consequently, the authors recommended special attending, including minimizing the utilise of electrocautery, reduction of pneumoperitoneum pressure, and generous employ of suction devices to remove fume and aerosol during operations, particularly before converting from laparoscopy to open surgery or any extraperitoneal maneuver [half dozen]. Although, to our knowledge, no instance of SARS-CoV-2 contamination related to those mechanisms has been reported during surgical procedures, several international surgical societies recommended caution or even discouraged the employ of a laparoscopic arroyo during the pandemic [vii], [8], [9], [ten], [xi].

The issue of the potential risk of surgical smoke has mostly been neglected in surgery in the last decades. However, it is becoming popular due to the present pandemic. Consequently, we elected to perform a systematic review of the literature evaluating the risk of virus spread due to surgical smoke for wellness intendance workers during surgical procedures (of whatsoever surgical specialties and for any clinical indications) performed on patients with a viral disease. Moreover, we as well elected to collect all the experimental studies where surgical smoke in the same clinical situations was evaluated to discover the presence of whatever virus remnants and/or its power to spread virus contagion.

2. Evidence acquisition

The asking for registration of the present systematic review was submitted on April 2, 2020 to PROSPERO (Reg. CRD42020177934). The systematic review of the literature was performed on April ii, 2020 on PubMed and Scopus databases. The PubMed search used a complex search strategy, including both medical subject heading (MeSH) and gratuitous text protocols. Specifically, the MeSH search was conducted by combining the following terms retrieved from the MeSH browser provided past PubMed: "Infectious Illness Transmission, Patient-to-Professional," "Infectious disease Transmission, Professional-to-Patient," "Health Personnel," "Viruses," "Bariatric Surgery," "Vitreoretinal Surgery," "Orthognathic Surgery," "Surgery, Plastic," "Surgery, Oral," "Colorectal Surgery," "Ambulatory Surgical Procedures," "Piezosurgery," "Dermatologic Surgical Procedures," "Urologic Surgical Procedures, Male," "Orthopedic Procedures," "Nasal Surgical Procedures," "Reconstructive Surgical Procedures," "Obstetric Surgical Procedures," "Robotic Surgical Procedures," "Minimally Invasive Surgical Procedures," "General Surgery," "Surgical Procedures, Operative," "surgery." Multiple "gratis text" searches were too performed, searching for the post-obit terms individually in all fields of the records: "surgical hazard," "surgical byproducts," "surgical fume," and "virus". Later, the search results were pooled, applying no limitations. The searches on Scopus used merely the free text protocol, with the same keywords. Subsequently, the query results were pooled without applying any limit.

Four of the authors reviewed the titles and abstracts of all the records to select the papers relevant to the review topic. Subsequently, the selected papers were assessed in full-text format by two other authors to collect all the relevant information. Specifically, we elected to collect all the clinical studies evaluating whatsoever surgical treatment for whatsoever patients with a viral disease where a risk of virus contagion was reported for the wellness workers. Moreover, we collected all the experimental studies where surgical smoke was evaluated to detect the presence of any virus remnants and/or its ability to spread virus contagion. Finally, nosotros besides included relevant studies identified from the reference listing of the papers identified in our systematic search.

An electronic spreadsheet was designed by one of the authors for data extraction, which was performed independently by ii other authors and completely double-checked by a further ane.

Hazard of bias of the available studies was estimated past questions #iv and #8–eleven for clinical studies and past questions #1, #2, and #5–eleven for preclinical studies from the National Toxicology Plan/Office of Health Assessment and Translation (NTP/OHAT) Hazard of Bias Rating Tool for Homo and Animal Studies [12]. The written report complied with the recently reported Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) argument [thirteen].

3. Evidence synthesis

iii.1. Results

A total of 1064 records were retrieved from PubMed and 569 from Scopus. Fig. one summarizes the literature review procedure, which allowed the identification of 24 papers, including 14 clinical studies [14], [fifteen], [16], [17], [18], [nineteen], [20], [21], [22], [23], [24], [25], [26], [27], eight preclinical studies [28], [29], [30], [31], [32], [33], [34], [35], and 2 papers reporting both clinical and preclinical information [36], [37].

Flow diagram of the systematic review.

3.1.1. Clinical studies

Kwak et al [27] reported on 11 patients who underwent a diverseness of laparoscopic and robotic procedures (including colorectal resections in five cases, gastrectomies in 3 cases, and hepatic wedge resections in another three cases). Preoperatively, all these patients had positive hepatitis B surface antigen (HBsAg), ii had detectable hepatitis B surface antibody (HBsAb), ii were positive for hepatitis B e antigen, and three patients were taking anti–hepatitis B viral medications at the fourth dimension of the written report. The surgical fume produced during the unlike laparoscopies was collected and analyzed for the presence of hepatitis B virus (HBV) DNA. The polymerase chain reaction allowed the identification of HBV Dna in 10 of the 11 patients.

All the other clinical studies were focused on human papillomavirus (HPV) infection, and most of the bachelor evidence highlighted a possible risk of contagion. Specifically, Gloster and Roenigk [19] reported a survey of 4200 laser surgeons. The prevalence and localization of their lesions were compared with those of the patients observed in two population-based cohorts (patients with warts in Olmsted County and at the Mayo Clinic from 1988 to 1992). On the whole, the overall gamble of the surgeons to acquire warts was like to that of the general population. However, the prevalence of nasopharyngeal localization was significantly higher in laser surgeons, suggesting a specific risk for the upper airway mucosa due to laser plume. In some other survey, Lobraico et al [22] reported that the overall incidence of HPV-related lesions was 3.two% amongst laser surgeons treating verrucae with the CO_two light amplification by stimulated emission of radiation, with the highest incidence existence observed for hand lesions in dermatologists (15.2%). In the vast majority of the other reports aiming at the evaluation of the presence of HPV in surgical smoke, HPV was identified in most of the dermatology and gynecology reports [xv], [25], [26], [36], [37]. Simply three small studies failed to place the virus in surgical byproducts [14], [20], [21]. Moreover, two other studies identified HPV Dna on samples from the nasolabial fold, nostrils, and conjunctiva of the surgeons as well as on the surgical gloves following light amplification by stimulated emission of radiation ablation of laryngeal papillomas and genital warts [18], [19], [20], [21], [22], [23], [24].

iii.1.2. Preclinical studies

Again, the majority of the preclinical studies were focused on HPVs and bovine papillomaviruses, with conflicting results. Specifically, some studies evaluating the presence of viral Dna in the surgical smoke after light amplification by stimulated emission of radiation treatments of infected cell cultures reconfirmed the presence of the virus [36], [37], whereas other failed to reproduce such findings [28], [29]. Nevertheless, in the nigh elegant animal model reported, Best et al [31] demonstrated recently the loftier transmissibility of the mouse papillomavirus (MmuPV1). Specifically, nude laboratory mice with established MmuPV1 tail warts were treated with scalpel excision, KTP laser ablation, and coblator treatment. Uninfected nude mice were subsequently challenged with surgical byproducts, including ablated and heated tissue, and surgical smoke products. Importantly, the study demonstrated extremely loftier penetrance of the infection in the mice exposed to all the different surgical byproducts (50% penetrance of infection at day thirteen and 100% at day 32 with byproducts of scalpel handling, 50% past twenty-four hours 35 and 100% by mean solar day 52 with byproducts of KTP laser, and 50% penetrance at day 59 and a maximum of 73% penetrance with byproducts of coblation). Similarly, the smoke feather captured during handling with the KTP laser and coblator was also highly infectious, every bit was the textile captured in a laser filter.

Apropos the studies investigating other viruses, cell cultures infected with dissimilar viruses (homo immunodeficiency virus [HIV], pseudorabies virus, varicella-zoster virus, and oral poliovirus) take been treated with dissimilar lasers to identify the ability of the byproducts to generate infected positive cultured cells, generally demonstrating negative results [32], [33], [34], [35].

three.i.three. Risk of bias cess

Supplementary Tables ane and 2 summarize the adventure of bias for clinical and preclinical studies, respectively.

Although well-nigh all the studies raised some concerns on potential biases in some of the domains of the NTP/OHAT Adventure of Bias Rating Tool for Human and Animal Studies, the overall quality of most of the clinical and preclinical reports was skillful.

3.2. Discussion

COVID-19 pandemic is significantly modifying the health systems worldwide, with major implications besides on the medical disciplines not primarily involved in the management of COVID-nineteen patients. Specifically, the vast majority of the centers in the areas more severely hit by the pandemic are limiting their surgical activities. Concerning surgery, a recent study from Zheng et al [half-dozen] highlighted the need to increase the awareness in the surgical community almost the potential risks of virus improvidence due to droplets dispersal during laparoscopic surgeries, known for several years, and several international surgical societies accept chosen for caution or even discourage the use of a laparoscopic approach during the pandemic [7], [8], [9], [10], [11]. Based on these concerns, we elected to perform a systematic review of the literature to evaluate the real risk of virus diffusion through surgical smoke. We identified a significant number of clinical and preclinical research papers on the topic (Table 1, Table ii ). In agreement with the purpose of the present review, the almost robust testify comes from the report of Kwak et al [27], where HBV Dna was demonstrated in the vast majority of the surgical fume samples collected in 11 laparoscopic and robotic procedures. Most of the reports evaluated HPV virus and related disease, and the vast majority of the literature suggested a high run a risk of infection related to HPV.

Table 1

Clinical studies evaluating the take chances of virus diffusion through surgical smoke.

Reference	Report blueprint	Cases	Specialty	Disease	Surgery performed	Energy	Methods	Endpoint	Results
HPV
Garden (1988) [36]	Prospective	7	Dermatology	Plantar or mosaic Verrucae	Ablation	CO_ii laser	Vapor was nerveless in a sleeping room in line with a vacuum system. Hybridization with HPV DNA probes revealed intact virus	To determine whether intact papillomavirus DNA exists in the plume of smoke during CO₂ light amplification by stimulated emission of radiation treatment	Viral Dna was detected in the nerveless laser vapor from ii of seven patients
Sawchuk (1989) [37]	Prospective	8	Dermatology	Plantar warts	Ablation	CO₂ light amplification by stimulated emission of radiation vs electrocoagulation	Collection of the smoke produced in the 2 procedures	HPV DNA in vapor from man plantar warts Tested whether placing a surgical mask in the vapor path could inhibit the passage of the virus onto the drove filter	Greater amount of papillomavirus Dna was usually recovered in the laser vapor than in the electrocoagulation vapor from the aforementioned wart A surgical mask was found capable of removing virtually all laser- or electrocoagulation-derived virus
Abramson (1990) [14]	Prospective	vii	Otorhinolaryngology	Laryngeal papilloma	Laser ablation	CO_ii laser	Collection of plumes and DNA extraction	To detect viral Dna in the plumes of smoke generated by CO_ii laser treatment of warts	No detection of HPV DNA in the smoke plume unless straight suction contact is made with the papilloma tissue during surgery
Andre (1990) [15]	Prospective	3	Dermatology	Big genital condyloma	Laser ablation	CO_ii laser	Collection of plumes and DNA extraction	To find viral DNA in the plumes of smoke generated by CO_two light amplification by stimulated emission of radiation treatment of warts	HPV Dna detected in ii out of 3 plume collections
Ferenczy (1990) [16]	Prospective	43	Gynecology	Condyloma acuminatum in 26 patients and depression- and high-class intraepithelial lesions in the remaining 17 patients	Laser vaporization	CO_ii laser	Swabs from lesional tissues of 43 patients equally well equally from the treated areas and from the 5 cm surrounding normal skin before and after laser vaporization	Dispersal of viral Deoxyribonucleic acid during laser therapy	65 of 110 (60%) swabs of histologically unequivocal condylomata and cervical intraepithelial neoplasia Handling fields and the surrounding 5 cm laser margins subsequently vaporization yielded similar HPV DNA positivity (16%)
Hallmo (1991) [17]	Case written report	1	Otorhinolaryngology	Laryngeal papillomatosis	Removal from each song cord with a CO_two laser	Nd:YAG laser	NA	NA	Single case of 44-yr-old laser surgeon presented with laryngeal papillomatosis after laser treatment of 55 cancers in the distal colon and rectum, but also 5 patients with anogenital condyloma sharpen
Bergbrant (1994) [eighteen]	Prospective	thirty	Dermatology	Genital warts	Genital warts	Electrocoagulation (due north = 19) vs CO_ii laser (n = xi)	Samples from nasolabial fold, nostril, and conjunctiva earlier and after the procedure PCR identification of the virus Deoxyribonucleic acid	Contamination of personnel in the operating theater	Positive samples in 9/19 (47%) medical personnel after electrocoagulation vs half dozen/11 (54%) after laser ablation Ii nasolabial fold samples were positive before electrocoagulation
Gloster (1995) [xix]	Retrospective comparative	31 surgeons vs 6124 patients	Dermatology	Warts in unlike sites	Laser vaporization	CO_ii laser	Clinical diagnosis in surgeons vs patients in population-based studies	Risks to surgeons of acquiring warts from the CO₂ laser feather vs hazard of population	CO_ii laser surgeons are no more than likely to larn nasopharynx warts than a person in the general population; less likely for other wart location
Capizzi (1998) [20]	Prospective	13	Plastic surgery	Aesthetic reasons	Light amplification by stimulated emission of radiation resurfacing in the periorbital, perioral, or total-face regions	CO₂ laser (Tru-Pulse light amplification by stimulated emission of radiation)	Collection of the laser plume smoke for cultures by a filter in the smoke evacuator	To investigate the potential bacterial and viral exposure to operating room personnel equally a result of the light amplification by stimulated emission of radiation smoke plume in CO₂ laser resurfacing Each of the 13 patients had one bacterial, one viral, and i control culture (total 39 specimens)	No viral growth
Hughes (1998) [21]	Prospective	5	Dermatology	Clinically typical verrucae vulgares of the extremities	Laser ablation	Erbium:YAG lase	Laser plume was deposited on the handpiece as an abundant fluffy material and was submitted for evaluation of HPV Dna by PCR	To determine the presence or absenteeism of HPV DNA in the laser plume of erbium:YAG light amplification by stimulated emission of radiation–treated human warts	HPV Deoxyribonucleic acid was non detected in the erbium:YAG laser plume
Lobraico (1988) [22]	Retrospective	794	Multispecialty	HPV lesions	Laser ablation	CO₂ laser	Clinical survey to define the type of laser used, number of years using the laser, presence or absenteeism of lesions, and the location and biopsy confirmation of a lesion if present. If an acquired lesion was reported, a 2nd in-depth questionnaire was distributed to decide the protective measures taken After the responses to the second questionnaire were received, a telephone query was conducted with each positive respondent to substantiate the details of the questionnaire and to obtain further details	To explore both the incidence of acquired lesions amid laser users and the details predisposing to the development of such lesions	The overall incidence of HPV-related lesions was 26/794 or 3.2% of those light amplification by stimulated emission of radiation users treating verrucae with CO₂ laser The highest incidence of acquired lesions among laser users was observed in dermatologists (17/112 or xv.2%), mainly with paw lesions
Calero (2003) [23]	Case report	ane	Otorhinolaryngology	Recurrent laryngeal papillomatosis	Excision of anogenital condylomas	Electrosurgical and light amplification by stimulated emission of radiation surgical	NA	NA	Single case of a gynecology nurse who had assisted in electrosurgery and laser surgical ablation of anogenital condylomas and adult recurrent laryngeal papillomatosis
Ilmarinen (2012) [24]	Prospective	10	Otorhinolaryngology/dermatology	Laryngeal papillomas and genital warts	Surgical removal and laser vaporization	CO₂ light amplification by stimulated emission of radiation	Sample of oral mucosa, surgical gloves, and face masks of health care personnel PCR identification of the virus Dna	Risk of HPV transmission from the patient to the protective surgical masks, gloves, and oral mucosa of medical personnel	Surgical gloves positive for one surgeon and 3 nurses in 5 laryngeal papillomas Surgical gloves positive in all the operators in 5 of genital warts All oral mucosa samples tested negative All the surgical mask specimens tested negative
Neumann (2018) [25]	Prospective	4	Gynecology	Cervix uteri HPV-related lesions	Loop electrosurgical excision	Light amplification by stimulated emission of radiation ablations and loop electrosurgical excision procedures	The primary outcome was defined equally HPV subtype in resected cone and in surgical plume resulting from LEEPs of high-form squamous intraepithelial lesions of the cervix uteri	To evaluate whether surgical plumage resulting from routine LEEPs of high-course squamous intraepithelial lesions of the neck uteri might exist contaminated with the Deoxyribonucleic acid of high-gamble HPV	Four samples of surgical plume resulting from routine LEEPs indicated contamination with high-gamble HPV and showed the same HPV subtype as identified in the resected cones
Zhou (2019) [26]	Prospective	134	Gynecology	CIN Two-III lesions, persistent CIN I lesions, or chronic cervicitis with persistent high-risk HPV infections and continuous postcoital haemorrhage	Loop electrosurgical excision	Electrosurgery with loftier-frequency electrical generator and wire loop electrodes	Collection of the smoke plume generated by LEEP from the surgical site Preoperative and postoperative nasal swab specimens were collected from the surgeons for the detection of HPV DNA	To investigate the prevalence of HPV DNA in LEEP plume, to confirm whether HPV Dna in surgical smoke leads to HPV infection in surgeons' nasal cells and to demonstrate whether HPV Deoxyribonucleic acid persists in the nasopharynx of these doctors	xl/134 (29.nine%) surgical smoke samples were positive for HPV DNA 2/134 (1.v%) of the nasopharynx swab of the surgeons after functioning positive for HPV (seventy.ane% wearing ordinary mask, 29.9% a special N95 surgical mask) Genotypes detected in cervical cells and surgical smoke were identical The two operators with positive swab were wearing an ordinary mask
Other viruses
Kwak (2016) [27]	Prospective	eleven	Surgery	Various conditions in HBV-infected patients	5 lap/robotic colorectal resections 3 lap hepatic wedge resections three lap gastrectomy	Not reported	A collector was used to obtain surgical smoke in the form of hydrosol. The fume was analyzed using nested PCR	Detection of HBV in surgical smoke	HBV was detected in surgical fume in 10 of the xi cases

Table two

Preclinical studies evaluating the risk of virus diffusion through surgical fume.

Reference	Study design	Sample size	Disease	Procedure	Energy	Methods	Endpoint	Results
HPV
Garden (1988) [36]	Prospective	4	Bovine papillomas	Ablation	CO_two laser	Vapor was nerveless in a chamber in line with a vacuum system. Hybridization with bovine papillomavirus DNA probes revealed intact bovine papillomavirus	To determine whether intact papillomavirus DNA exists in the feather of fume during CO₂ laser treatment	Bovine papillomavirus Dna was detected in the plume of smoke in 3 of the 4 treated fibropapillomas
Sawchuk (1989) [37]	Prospective	1	Bovine papillomas	Bovine wart	CO₂ laser vs electrocoagulation	Collection of the smoke produced	The prepared extracts were assayed for infectious BPV by testing their ability to induce focal transformation of mouse c127 cells	Products of the laser vapor induced foci of morphologically transformed cells and cells containing BPV-I Dna
Wisniewski (1990) [28]	Prospective	10	Cervical lesion	Ablation of cervical mucosa in patients	CO₂ light amplification by stimulated emission of radiation	Drove of the airborne particulate and culture	Southern blot testing of laser ejecta	Absence of viral organisms
Wisniewski (1990) [28]	Prospective	NR	Bovine papillomavirus	Ablation of lesion in dairy cattle mucosa in patients	CO₂ light amplification by stimulated emission of radiation	Collection of the airborne particulate and inoculation in animals	Southern blot testing of laser ejecta	No growth of lesions
Kunachak (1996) [29]	Prospective	10	Recurrent respiratory papillomatosis	Light amplification by stimulated emission of radiation ablation	CO₂ light amplification by stimulated emission of radiation	Collection of the light amplification by stimulated emission of radiation plume	To determine the potential risk of transmitting viable viral-infected cells besides as viral infectivity in prison cell line culture	Cell lines in the viral infectivity testing systems revealed no sign of viral infection
Dodhia (2018) [30]	Experimental report	12 fibers	Laryngeal papillomas	Laser ablation	KTP laser	Ten fibers were sterilized in CIDEX for 12 min, whereas two fibers were left unsterilized. HPV Dna amplification with PCR HPV genotyping detection was done using blazon-specific probes and/or Sanger sequencing	Determine if HPV tin can be detected on a light amplification by stimulated emission of radiation cobweb afterwards employ, with or without sterilization.	Over 27 strains of HPV were not detected on KTP fibers after use, with or without sterilization
Best (2020) [31]	Experimental on animal model	45	Warts	Ablation of warts in the murine model with different technique	Scalpel vs KTP laser vs coblation	Nude laboratory mice with established MmuPV1 tail warts were treated with scalpel excision KTP light amplification by stimulated emission of radiation ablation, and coblator treatment. Uninfected nude mice were challenged with surgical byproducts, including ablated and heated tissue, and surgical smoke products, surgical smoke collection, and analysis past PCR	Incidence and time course of the appearance of recurrent warts in mice	Rapid manual of virus Byproducts of scalpel treatment: l% penetrance of infection at 24-hour interval 13 and 100% at twenty-four hours 32 Byproducts of KTP laser: l% by twenty-four hours 35 and 100% past 24-hour interval 52 Byproducts of coblation: 50% penetrance at day 59 and a maximum of 73% penetrance Fume plume captured during treatment with the KTP laser and coblator was highly infectious, every bit was the material captured in a light amplification by stimulated emission of radiation filter
Other viruses
Johnson (1991) [32]	Experimental study	NA	HIV	Awarding of dissimilar free energy to infected cells	Coagulation, cutting, router, bone saw, control	Absurd vapors and aerosols produced by several mutual surgical power instruments and hot fume plumes generated with electrocautery on known HIV-ane inoculated blood were gently bubbled through sterile viral civilisation media`	HIV-i–positive cultured cells generated by the utilization of the 4 different surgical instruments	No infectious HIV-i was detected in aerosols generated past electrocautery or with a manual wound irrigation HIV-1 was cultured from absurd aerosols and vapors generated by a xxx 000 RPM spinning router tip, an musical instrument similar to the Midas Rex and the Stryker oscillating bone saw
Hagen (1997) [33]	Experimental study	20	Pseudorabies virus	Ablation of virus-infected tissue civilization plate	Excimer laser	Infected tissue civilisation plates were light amplification by stimulated emission of radiation treated in close proximity to uninfected plates	To examination the possibility of pathogenic virus transmission into the operating suite during excimer laser treatment of corneal tissue	None of the 20 uninfected plates was infected by the laser plume ascension from the ablation of infected tissue culture plates
Taravella (1997) [34]	Prospective	iv	Varicella-zooster virus	Ablation of fibroblasts infected with attenuated varicella-zoster virus	Excimer laser	PCR analysis and viral cultures were performed on the liquid in the trap. In addition, a Dacron swab, soaked in viral transport medium, was used on all ablations to test for virus in the silicone tubing used to collect the plumage and the nearest ablated cloth	Growth of varicella-zoster virus in jail cell cultures	No growth
Taravella (1999) [35]	Experimental	NA	Oral polio virus	Ablation of human embryonic lung fibroblast culture tissue	Excimer laser	Ablation plume was nerveless with suction provided by a laser smoke evacuation unit equipped with an LFS-103 filter. A chimera sleeping accommodation was used to sample the feather. X milliliters of viral culture media were placed within the trap	Positive culture from inlet tube from the smoke evacuator and liquid from the bubble trap was too cultured	Alive virus was shown in the material trapped from the laser feather.

Since the present systematic review adopted a standardized methodology to identify all the available evidence in the field, the nowadays paper represents the ideal background to estimate the risk of diffusion of the novel SARS-CoV-2 virus for health professionals, for whom no clinical study is available. On the whole, although all the available data come from viruses that are very dissimilar from the novel coronavirus, because that the SARS-CoV-ii virus has been shown in blood and stools [38], [39], the theoretical run a risk of virus improvidence through surgical fume cannot exist excluded. Although specific clinical studies are needed to sympathise the constructive presence of the virus in the surgical fume of dissimilar surgical procedures and its concentration, adoption of all the required protective strategies seems mandatory. In this regard, all the measures suggested past Zheng et al [6] can exist considered appropriate (eg, minimizing the use of electrocautery, reduction of pneumoperitoneum pressure, and generous use of suction devices to remove smoke and aerosol during operations, specially before converting from laparoscopy to open surgery or any extraperitoneal maneuver). On top of this, a preoperative nasopharyngeal sample for COVID-19 can be considered wise [40]. Having said that, the available pieces of evidence do not seem to be sufficient to recommend consummate interruption of all the laparoscopic and robot-assisted surgical programs. This is clearly of value wherever the medical and economical resources available during this pandemic are sufficient to treat medical and surgical conditions other than COVID-19 patients.

The present study is not devoid of limitations. Start, we were non able to place any newspaper focused on the novel or other coronavirus, and almost of the bachelor studies were indeed focused on HPV, which is a very different kind of virus. This highlights the demand for specific studies on the topic. 2d, only a unmarried study evaluated the presence of a virus in the smoke from laparoscopic procedures on patients infected with HBV [27]. The study assesses exactly the kind of surgical setting that is nether discussion now. Obliviously, viruses with large differences in construction may take unlike behavior in this regard, and the presence of a virus in the surgical smoke does not automatically imply an airborne contamination. Nevertheless, some reports on HPV support such a possibility. Other studies are needed on SARS-CoV-2 and other viruses (eg, HBV, hepatitis C virus, and HIV) and other surgical procedures (eg, cholecystectomy, colectomy, radical prostatectomy, and radical hysterectomy, which are among the most frequently performed laparoscopic procedures worldwide). Moreover, it should too be considered that surgical smoke is also produced during open up surgery. Li et al [41] recently reported on xxx open and laparoscopic surgical procedures in the obstetrics and gynecology operating rooms of 3 dissimilar hospitals from Taiwan, demonstrating that the cumulative number of particles of 0.3 and 0.five μm in laparoscopic operation was higher than that in laparotomy afterwards 10 min of using an electronic pocketknife. Withal, the cumulative number of particles of 5 μm after 10 min of using the electronic pocketknife was numerically higher in open cases. Although all the reported differences were non statistically significant, these warrant some caution also for open up surgery, where surgical smoke evacuation and filtration should be amend studied and implemented [42]. Third, although the nowadays systematic review followed a strict methodology, the overall quality of the findings is mainly related to the quality of the available bear witness. Nonetheless, our cess of the methodological quality of the reports through the NTP/OHAT Hazard of Bias Rating Tool for Human and Animal Studies identified a large number of good methodological reports.

iv. Conclusions

Although all the available data come up from viruses that are very unlike from the novel coronavirus, considering that the SARS-CoV-2 virus has been shown in blood and stools, the theoretical risk of virus improvidence through surgical smoke cannot be excluded. Although specific clinical studies are needed to understand the effective presence of the virus in the surgical smoke of different surgical procedures and its concentration, adoption of all the required protective strategies, including preoperative patient nasopharyngeal swab for COVID-19, seems mandatory. The available pieces of evidence do non seem to be sufficient to recommend complete intermission of all the laparoscopic and robot-assisted surgical programs.

Author contributions: Nicola Pavan had full access to all the information in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Pavan, Novara, Ficarra.

Acquisition of data: Pavan, Crestani, Abrate, De Nunzio, Esperto.

Assay and estimation of data: Novara, Giannarini, Galfano, Gregori.

Drafting of the manuscript: Novara, Pavan.

Critical revision of the manuscript for of import intellectual content: Liguori, Bartoletti, Porpiglia, Simonato, Trombetta, Tubaro.

Statistical analysis: None.

Obtaining funding: None.

Administrative, technical, or material back up: None.

Supervision: Liguori, Bartoletti, Porpiglia, Simonato, Trombetta, Tubaro.

Other: None.

Financial disclosures: Nicola Pavan certifies that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject field matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, adept testimony, royalties, or patents filed, received, or awaiting), are the following: None.

Funding/Support and function of the sponsor: None.

Footnotes

Appendix A. Supplementary data

The following are Supplementary data to this article:

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7274598/