{"paper_id":"4edee84b-74d5-41f5-9699-4fcc02692066","body_text":"www.ogscience.org 383\nIntroduction\nThe novel coronavirus disease (COVID-19) was announced \nas a pandemic by the World Health Organization (WHO) on \nMarch 11, 2020 [1]. A joint statement issued by American \nAssociation of Gynecologic Laparoscopists (AAGL), Ameri\n-\ncan College of Obstetricians & Gynaecologists (ACOG), and \nother organizations advised the suspension of elective sur\n-\ngery, shifting the focus to emergency and cancer surgery [2]. \nThe ongoing pandemic is a public health crisis that requires \nthe diversion of resources and healthcare workers towards \nGynecological laparoscopic surgeries in the era of \nCOVID-19 pandemic: a prospective study\nSushmita Saha, MS, Kallol Kumar Roy, MD, Rinchen Zangmo, MD, DNB, Anamika Das, MD, Juhi Bharti, MD, \nRakhi Rai, MS, Archana Kumari, MD, Gayatri Suresh, MBBS, Nilofar Noor, MD, Perumal Vanamail, PhD \nDepartment of Obstetrics and Gynaecology, All India Institute of Medical Science, New Delhi, India\nObjective\nThe novel coronavirus pandemic led to the suspension of elective surgeries and the diversion of resources and \nmanpower towards pandemic control. However, gynecological emergencies and malignancies must be addressed \ndespite the restricted resources and the need for protective measures against COVID-19. This study aimed to \ndetermine the types of gynecological surgeries performed, difficulties encountered, and their outcomes in the setting \nof the pandemic.\nMethods\nWe performed a prospective cohort study over 6 months at a single tertiary center, including 60 women with \ngynecological complaints, categorized as emergencies and semi-emergencies, who underwent further surgery. Their \nsurgical outcomes were measured through various parameters. \nResults\nWe found that 68.3% were emergency cases, while the rest were classified as semi-emergencies. Fibroid and \nadenomyosis with failed medical management (48.3%), followed by cervical intraepithelial neoplasia (10%), and \nmalignancies (10%) accounted for the semi-emergency cases, while ruptured ectopic pregnancies (13.3%) and torsion \nand ovarian cysts (18.4%) comprised the emergency cases. The decision to incision time between emergency and \nsemi-emergency cases varied widely due to the safety prerequisites during the pandemic, ranging from 1 hour in \nemergency cases to 48 hours in semi-emergency cases. In addition, we studied the ease of preoperative preparation, \npatient satisfaction, and the average number of personnel available to run the operation theaters at these times. No \nserious perioperative adverse events were observed in the present study. \nConclusion\nIn conclusion, gynecological surgeries could continue to be safely performed with all precautions in place against \nCOVID-19 infection and related morbidities.\nKeywords: COVID-19; Gynecologic surgical procedures; Coronavirus; Laparoscopy\nReceived: 2021.01.15.   Revised: 2021.02.28.   Accepted: 2021.03.21.\nCorresponding author: Rinchen Zangmo, MD, DNB\nDepartment of Obstetrics and Gynaecology, All India Institute of \nMedical Science, Sri Aurobindo Marg, Ansari Nagar, Ansari Nagar \nEast, New Delhi 110029, India \nE-mail: rinchhen.zn@gmail.com\nhttps://orcid.org/0000-0001-8433-9703\nArticles published in Obstet Gynecol Sci are open-access, distributed under the terms of \nthe Creative Commons Attribution Non-Commercial License (http://creativecommons.\norg/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, \nand reproduction in any medium, provided the original work is properly cited.\nCopyright © 2021 Korean Society of Obstetrics and Gynecology \nOriginal Article\nObstet Gynecol Sci 2021;64(4):383-389\nhttps://doi.org/10.5468/ogs.21029\neISSN 2287-8580\n\n\nwww.ogscience.org384\nVol. 64, No. 4, 2021\ncritical care. Even though elective procedures have been de -\nferred in view of the pandemic, situations requiring urgent \ngynecological or obstetric surgical interventions must still be \nperformed, and decisions should be made on a patient-by-\npatient basis. \n The severe acute respiratory syndrome coronavirus 2 \n(SARS-CoV-2) belongs to the genus Betacoronavirus and \nis transmitted between individuals through viral shedding, \nmainly spread through respiratory droplets or direct contact, \nindependent of clinical manifestations. They may also be \ntransmitted through aerosols [3]. COVID-positive patients \nmay have viral particles in their body cavity that may be dis -\nseminated through the surgical smoke generated by surgical \ninstruments [4]. Aerosols generated in an operation theater \nduring surgery may have the virus or viral particles that are \nviable for at least 3 hours and over days on surfaces [5]. \nThere are no data directly pinpointing the risk of direct surgi-\ncal exposure in infecting the surgical team [6]. \nGynecological emergencies and malignancies, if deferred, \nmay have serious consequences and should not be delayed. \nInstead, algorithms should be created, and a case-by-case \napproach should be undertaken. This study aimed to deter\n-\nmine the types of gynecological surgeries performed during \nthe COVID-19 pandemic over 6 months in our institution \nand measure the surgical outcomes in terms of various pa\n-\nrameters affected by the ongoing pandemic to improve the \nmanagement of gynecological emergencies and malignan\n-\ncies during this period. \nMaterial and methods\nThis was a single-center prospective cohort study conducted \nover 6 months in a single unit in the Division of Minimally In\n-\nvasive Gynecological Surgery of the Department of Obstetrics \nand Gynecology. Ethical approval for the study was obtained \nfrom the Institute Ethics Committee before the commence\n-\nment of the study (IEC-890/04.09.2020). A purposive sample \nof all patients fulfilling the inclusion and exclusion criteria \nand were operated by the division within the period of \n \n6 months were included in the study. Informed and written \nconsent for participation in the study was obtained from all \nparticipants. We included all patients who visited the emer\n-\ngency or outpatient department with gynecological com -\nplaints requiring surgery and all gynecological malignancies \nrequiring semi-emergency surgery. Obstetric emergencies \nother than ectopic pregnancies were excluded. All women \nwho visited the hospital with gynecological complaints un -\nderwent a questionnaire-based COVID screening followed \nby history taking and examination by the resident on call. \nUrgent blood investigations and imaging were performed, \nfollowed by conservative or surgical management. After \nproviding symptomatic treatment and resuscitation, if the \nvitals were stable, surgery was performed after COVID test\n-\ning (reverse transcriptase polymerase chain reaction [RTPCR]). \nMeanwhile, if these were unstable, the patient was taken up \nfor immediate surgery in a separate COVID-suspect opera\n-\ntion theater after performing a rapid antigen test, taking all \nprecautions required for positive patients. \nThe following measures were observed as a precaution \nduring surgery:\n· All surgeries were conducted by an experienced surgeon \nto ensure that all precautions were taken and to minimize \nthe duration of surgery.\n· Surgeons and personnel present in the operation theater \nwere in the appropriate personal protective equipment \n(PPE) (Level 1). \n· Disposable trocars were used, and the seals of trocars \nwere properly checked for any leaks.\n·  Electrosurgical and ultrasonic devices were used in a low-\npower setting, and prolonged desiccation was avoided to \nminimize plume production.\n· Laparoscopic suction was used to remove the surgical \nplume, and care was taken to prevent the spillage of \npneumoperitoneum in the room. In addition, care was \ntaken to avoid rapid desufflation or loss of pneumoperi\n-\ntoneum, particularly during instrument exchange and \nspecimen removal.\n· Surgery was conducted at a low intra-abdominal pressure \n(10-12 mmHg) as much as feasible.\n·  Before extracting the uterus through the vault, the pneu\n-\nmoperitoneum was desufflated with closed suction to \nallow the minimum escape of CO\n2 through the vault.\n· Care was taken to minimize blood/fluid droplet spray or \nspread.\n· Smoke evacuation systems were used to remove the sur\n-\ngical plume and to desufflate the abdominal cavity inside \nthe operating room.\nDescriptive statistics, such as mean, median, and standard \ndeviations, were calculated. Categorical variables are pre\n-\n\nwww.ogscience.org 385\nSushmita Saha, et al. Gynaecological surgeries in COVID-19\nsented as frequency and percentage values.\nResults\nIn our study, conducted over 6 months beginning in August \n2020, a total of 60 patients underwent surgery. The baseline \ncharacteristics of the patients are presented in Table 1. The \nindications for surgery are shown in Table 2. Table 3 shows \nthe different types of surgeries performed, mean surgical \ntime and number of personnel scrubbed, and mean duration \nof hospital stay. Cases of ectopic pregnancy and torsion of \nadnexal cysts were classified as emergency cases, whereas \ncases of abnormal uterine bleeding (fibroid and adenomyosis) \nwith failed medical management and malignant gynecologi\n-\ncal cases requiring surgical intervention were categorized into \nthe semi-emergency group. Emergency cases accounted for \n31.67% of cases, whereas semi-emergency cases accounted \nfor 68.33%. Ovarian cysts and fallopian tubes with ectopic \ngestation were removed through central 10-mm ports using \nglove bags under the guidance of a 5-mm telescope inserted \nthrough the lateral port. All ports measuring ≥10 mm were \nclosed using a vicryl port closure. All patients with gyneco\n-\nlogical emergencies were tested using the rapid antigen test \nkit and operated in a separate COVID-suspect operating \nroom. Simultaneously, the RTPCR sample was sent, and the \nresult was followed up later. All semi-emergency cases tested \nnegative in the COVID RTPCR within 72 hours prior to the \nproposed surgery. The assessment of ease of preoperative \nTable 1. Baseline characteristics\nCharacteristics Value (%)\nAge (yr)\n<50 85.7\n≥50 14.3\nReligion \nHindu 91.4\nMuslim 8.6\nComorbidity \nHypertension 28.6\nMalignancy 8.7\nDiabetes 14.3\nHistory of cardiovascular disease 2.9\nHistory of respiratory disease 5.7\nTable 2. Indications of gynaecological surgeries \nIndication of surgery Value\nAUB-leiomyoma 24 (40)\nAUB-adenomyosis 5 (8.33)\nCIN III 6 (10)\nDermoid cyst 4 (6.7)\nMalignancy (endometrial cancer) 6 (10)\nRuptured ectopic pregnancy 8 (13.3)\nTwisted ovarian cyst 7 (11.7)\nValues are presented as number (%).\nAUB, abnormal uterine bleeding; CIN, cervical intraepithelial neopla-\nsia.\nTable 3. Types of surgeries and their characteristics\nType of surgery Number of \nSurgeries\nSurgical time \n(mean, min) \nNumber of per-\nsonnel scrubbed \n(mean)\nMean duration \nof hospital stay\nTotal laparoscopic hysterectomy 21 95 4 3\nMalignancy-peritoneal wash cytology with total laparoscopic \nhysterectomy with bilateral salpingooophorectomy with \npelvic lymphadenectomy\n6 135 5 5\nLaparoscopic myomectomy 9 107 4 4\nLaparoscopic salpingectomy 8 45 4 3\nHysteroscopic myomectomy 5 30 4 3\nLaparoscopic cystectomy 8 50 4 3\nLaparoscopic unliteral salpingooophorectomy (gangrenous \novary)\n3 35 4 3\n\nwww.ogscience.org386\nVol. 64, No. 4, 2021\npreparation during the pandemic using a 5-point Likert scale \nshowed a mean value of 3, indicating a neutral level of ease. \nThe mean ‘decision to incision’ time for emergency cases \nwas 1 hour, whereas it was 48 hours for semi-emergency \ncases. Among the various types of surgeries performed \n(Table 2), the mean number of personnel scrubbed, includ -\ning doctors and nursing staff, was 4. The minimum distance \nbetween the members of the surgical team was maintained \nat 1 month, which was appropriate as all procedures were \nperformed laparoscopically. The number of operation theatre \n(OT) technicians was reduced to one, increasing the duration \nof surgery. With regard to ease of operability while using \nlevel 1 PPE, a mean Likert scale score of 3 was noted, sug\n-\ngesting a neutral level of ease. The duration of hospital stay \nin all 60 cases ranged from 48 to 72 hours, with laparoscopic \nsalpingectomy cases having the shortest mean duration and \nlaparoscopic myomectomy cases having the longest mean \nduration.\nThe perioperative complications are shown in Table 4. No \npatient had a history of postoperative respiratory distress, \nintensive care unit (ICU) stay, or COVID infection detected \nwithin 2 weeks of surgery. Among the hospital staff involved \nin handling patients in the operating room (OR) and wards, \n3 doctors, 1 nursing staff, and 1 OT technician were infected \nwith COVID-19 during our study period, but the source of \ninfection is unknown. On the final assessment of patient sat\n-\nisfaction, the mean Likert score was 4, suggesting that most \npatients were “very satisfied” with the treatment provided. \nAll procedures were performed laparoscopically. The mean \nhospital stay was 3.5 days. No ICU admissions were required \nafter surgery for any perioperative complications. Nine pa\n-\ntients (all semi-emergencies) tested positive for COVID-19 \nduring the initial preoperative workup, and these surgeries \nwere deferred until they tested negative. None of the pa\n-\ntients developed symptoms related to COVID-19 or yielded \npositive results in the postoperative period.\nDiscussion\nSurgery is the cornerstone in the management of most gy -\nnecological disorders. However, the ongoing pandemic has \nresulted in the diversion of healthcare workers and resources \ntowards crisis management and critical care. Simultaneously, \nwomen also present with gynecological emergencies or \nmalignancies for which surgical management cannot be de\n-\nferred. The European Society for Gynaecological Endoscopy \n(ESGE) recommends that hospitals should have alternative \narrangements for women with gynecological emergencies \nand gynecological cancers [7]. \nMany hospitals in our country have been designated as \nexclusive COVID care centers, and others have also exceeded \ntheir capacities and exhausted their resources catering to the \nhealth needs caused by this pandemic, thereby forcing them \nto cancel their surgical activities. Our institution is the top \nhealthcare center in the country, and despite the constraints \ncaused by the pandemic, gynecological surgeries with cura -\ntive intent and malignancy surgeries are being performed \nwithout compromising on COVID care. At our center, 50% \nof doctors from the clinical departments were tasked to cater \nto COVID-positive patients exclusively. As such, our depart\n-\nment is currently functioning at half of its original capacity. \nDue to these constraints and to reduce the manpower in the \nOR to promote social distancing, the number of operation \nslots provided to all surgical disciplines has been reduced \nconsiderably. In an analysis of the impact of the COVID pan\n-\ndemic on malignancies, Sud et al. [8] reported a notable in -\nterruption in cancer treatment and stated that a 3-6-months \npostponement in cancer surgery might lead to an attribut\n-\nable death ratio of 4,755/10,760.\nAs observed in our study, malignancies contributed to 6% \nof gynecological surgeries. This is much less than the malig -\nnancies operated on pre-COVID due to the presentation of \nwomen in later stages of the disease, rendering it inoperable \nand delayed in approaching healthcare facilities for gyneco\n-\nlogical complaints. However, both malignancies operated in \nour study were early-stage corpus uteri malignancies, and \nsurgery was performed with curative intent. \nBenign gynecological pathologies, particularly fibroid \nTable 4. Perioperative complications\nPeri operative parameter Frequency\nPost-operative fever 6 (10)\nBlood product transfusion 5 (8.3)\nICU stay and mechanical ventilation 0\nExposure to COVID positive patients 1 (1.7)\nCOVID infection within 2 weeks of surgery 0\nValues are presented as number (%). \nICU, intensive care unit. \n\nwww.ogscience.org 387\nSushmita Saha, et al. Gynaecological surgeries in COVID-19\nuterus, may cause abnormal uterine bleeding unresponsive \nto medical management or pressure symptoms due to mass \neffect, contributing to the majority of out patient depart -\nment attendance. In our study, 74% of the operated cases \nwere categorized as semi-emergency cases, including benign \ngynecological pathologies requiring surgical solutions. Strong \net al. [9] highlighted the increased physical and mental mor -\nbidity caused by delayed surgeries for benign pathologies. \nUndue delay of surgery in these cases could also negate the \npossibility of adopting a laparoscopic surgical approach. \nThe laparoscopic approach was the preferred mode of sur\n-\ngery in our study. ESGE [7] also recommends the same for \ngynecological emergencies and cancer due to the quicker \npostoperative recovery and shorter hospital stay, which re -\nduces stress on hospital resources compared to open surger-\nies. Given the COVID-19 pandemic, the risk of exposure to \nthe operating team due to possible blood viremia in patients \nis a concern. It is believed that laparoscopic surgeries help \ncontain surgical plumes and body fluids within a closed \nspace, thereby decreasing exposure to the operating team [7]. \nKimmig et al. [10] stated that minimally invasive approaches \nminimize surgeons’ exposure to body fluids, reducing blood \ncontamination. In addition, it is associated with a shorter \npostoperative recovery period. Preoperative COVID-19 RTPCR \ntesting was performed in all cases within 72 hours of the \nproposed surgery. A rapid antigen test was also conducted, \nand surgery was performed in a separate suspect operating \nroom with all precautions. Only patients who tested negative \nwere taken up for semi-emergency surgery. Kiykaç Altinba ş \net al. [11] stated that if urgent surgery is required, preopera\n-\ntive COVID-19 screening should be performed, and surgery \nshould be performed after. In case of insufficient time for \npreoperative COVID-19 screening, surgery can be performed \nby laparoscopy with the appropriate protective measures \nin place. In case of emergencies, we performed the rapid \nantigen test, and all patients subsequently tested negative \nin the RTPCR. A mortality rate as high as 20% has been ob\n-\nserved in patients with subclinical COVID-19 infection who \nunderwent surgery, which is much higher than the adverse \noutcomes attributed to other perioperative complications, \nsuch as surgical site infections or venous thromboembolism \n[12]. Admitting untested patients for surgery creates an un\n-\nnecessary risk both for patients and all healthcare profession-\nals looking after that patient. Therefore, all over the world, \nCOVID testing prior to any surgical procedure has become a \nnew norm and is well accepted. Nine out of the 60 patients \ntested positive for COVID infection on preoperative evalua\n-\ntion, and surgery was postponed for 3 weeks until the infec-\ntion has completely resolved. These additional COVID testing \nprotocols and the division of the workforce between routine \nservices and dedicated COVID managing pools, although \nvital in current times, have increased the preoperative prepa-\nration time. In our study, we detected an average decision \nto incision interval of 1 hour in cases of ectopic pregnancy, \ntorsion, and adnexal cysts, which are classified as emergency \ncases, with preparation time being even more prolonged in \nmalignancy surgeries and other semi-emergency cases in as\n-\ncending order. Although no mortality or increased morbidity \nwas encountered in the management of emergency surger -\nies in our study, the ease of preoperative preparation has \nbeen strained with the additional requirements, as reflected \nby the ‘neutral’ average on the Likert score. Furthermore, an\n-\nother challenge in surgeries during COVID times is operating \nin a PPE, as most surgeons in the operating team reported a \nmoderate degree of difficulty while operating in a PPE. Our \noperating team used level 1 PPE in all the semi-emergency \nsurgeries and level 3 PPE in emergency cases, with a minimal \nnumber of personnel scrubbed in to avoid crowding in oper\n-\nating rooms. Yánez Benítez et al. [13] found that more than \nhalf of their study participants stated that a PPE significantly \naffected surgical performance, decreased comfort, impeded \ncommunication, and impaired vision significantly during sur\n-\ngery. In a study by Agarwal et al. [14], additional issues such \nas contact dermatitis, nasal bridge pain, pain over the pinna, \nand risk of self-contamination due to self-readjustment of \nmasks were noted. In our center, a teaching hospital, the \naverage number of surgeons scrubbed in for the emergency \nand semi-emergency cases during COVID times was 4, less \nthan the pre-COVID number of 5-6 surgeons per case. This \nmay have contributed to the slight prolongation of the surgi\n-\ncal duration. Apart from this, only one laparoscopy technical \nstaff member was available in all cases during the pandemic. \nSetting up the paraphernalia for laparoscopic surgeries re\n-\nsulted in a decrease in the availability of technical staff and \nprolonged surgical time. Difficulty in dealing with technical \nissues associated with the laparoscopic instruments and ex\n-\nhaustion due to reduced staff also led to frequent interrup -\ntions in the surgeries, prolonging the surgical duration. All \npatients transitioned smoothly into the postoperative period \nwith no major adverse events. Postoperative complications \n\nwww.ogscience.org388\nVol. 64, No. 4, 2021\nwere confined to fever (n=5), blood product transfusion \n(n=6), and inadvertent exposure (n=1) of patients with CO -\nVID. No cases of respiratory distress requiring intensive care \nor mortality were observed. This reinforces that with ad\n-\nequate precautions in place, properly screened patients could \nundergo surgical interventions with routine risks even during \nthis pandemic.\nAnother obstacle encountered during this study was the \nexposure of tested COVID-negative patients to untested \npatient attendants. Stringent measures, such as allowing a \nsingle attendant with each patient after appropriate screen\n-\ning and limited meeting times, were put in place. Though \ninconvenient, these were later appreciated by the patients.\nWorldwide, healthcare professionals dealing with the pan-\ndemic are being infected by this virus. In our study, despite \nmaintaining all precautions, 5 healthcare workers tested \npositive for coronavirus during the study, though the source \nof infection is unknown. There is a high probability that they \nmay have acquired the infection from the community.\nOverall, most of our patients were very satisfied with the \nsurgical team and staff members, their behavior and commu\n-\nnication, and management skills during their entire hospital \nstay. This may because the extent of care provided in these \ndifficult times exceeded their expectations, and many refused \nsurgery in other healthcare setups in the country due to the \nlack of facilities for semi-emergent gynecological procedures. \nIn addition, stringent policies were implemented in the hos\n-\npital, both in the wards and in the operating room, for infec-\ntion control, a major factor for improved patient satisfaction. \nThese findings also corroborate Bin Traiki et al.’s, [15] who \nconducted a patient satisfaction survey that demonstrated a \nhigh level of patient satisfaction after surgery in the COVID \nera. \nThe present study found that surgical operations could \ncontinue during the COVID‐19 pandemic in a tertiary care \ncenter, and elective surgeries with curative intent need \nnot be deferred. With all appropriate precautions for both \nhealthcare workers and patients’ safety, a tertiary care center \ncan cater to both the COVID and non-COVID needs of the \npopulation.  \nIn conclusion, with appropriate screening measures in \nplace, gynecological emergency and semi-emergency surger\n-\nies can be performed in a tertiary care center, despite the \nconstraints caused by the ongoing pandemic. Although the \nsurgical time was slightly prolonged due to the minimal num\n-\nber of staff, surgeries can be performed with equal efficacy. \nGiven the advantages of laparoscopy, including safety, it can \nbe the preferred mode of surgery compared to laparotomy in \nCOVID areas.\nConflict of interest\nNo potential conflict of interest relevant to this article was \nreported.\nEthical approval\nEthical approval for the study was obtained from the Institute \nEthics Committee before the commencement of the study \n(IEC-890/04.09.2020). The study was performed in accor\n-\ndance with the principles of the Declaration of Helsinki.\nPatient consent\nWritten informed consent and the use of images from pa -\ntients are not required for the publication.\nFunding information\nNone.\nReferences \n  1.  World Health Organization. Coronavirus disease (CO -\nVID-19) situation dashboard [Internet]. Geneva (CH): \nWorld Health Organization; c2020 [cited 2020 Apr 20]. \nAvailable from: https://who. sprinklr.com.\n  2.  American Association of Gynecologic Laparoscopists. \nCOVID-19: joint statement on elective surgeries [Inter\n-\nnet]. Cypress (CA): American Association of Gynecologic \nLaparoscopists; c2020 [cited 2020 Mar 16]. Available \nfrom: https://www.aagl.org/covid-19/covid-19-joint-\nstatement-on-elective-surgeries/.\n  3.  Mohapatra RK, Pintilie L, Kandi V, Sarangi AK, Das D, \nSahu R, et al. The recent challenges of highly contagious \n\nwww.ogscience.org 389\nSushmita Saha, et al. Gynaecological surgeries in COVID-19\nCOVID-19, causing respiratory infections: symptoms, \ndiagnosis, transmission, possible vaccines, animal mod -\nels, and immunotherapy. Chem Biol Drug Des 2020;  \n96:1187-208.\n  4.  Chiofalo B, Baiocco E, Mancini E, Vocaturo G, Cutillo G, \nVincenzoni C, et al. Practical recommendations for gy -\nnecologic surgery during the COVID‐19 pandemic. Int J \nGynecol Obstet 2020;150:146-50.\n  5.  van Doremalen N, Bushmaker T, Morris DH, Holbrook \nMG, Gamble A, Williamson BN, et al. Aerosol and sur\n-\nface stability of SARS-CoV-2 as compared with SARS-\nCoV-1. N Engl J Med 2020;382:1564-7.\n  6.  Cohen SL, Liu G, Abrao M, Smart N, Heniford T. Per\n-\nspectives on surgery in the time of COVID-19: safety \nfirst. J Minim Invasive Gynecol 2020;27:792-3. \n  7.  ESGE recommendations for gynaecological endoscopic \nsurgery for COVID-19 outbreak. Facts Views Vis Obgyn \n2020;12:5. \n  8.  Sud A, Jones ME, Broggio J, Loveday C, Torr B, Garrett A, \net al. Collateral damage: the impact on outcomes from \ncancer surgery of the COVID-19 pandemic. Ann Oncol \n2020;31:1065-74.\n  9.  Strong SM, Magama Z, Mallick R, Sideris M, Odejinmi \nF. Waiting for myomectomy during the COVID-19 pan\n-\ndemic: the vicious cycle of psychological and physical \ntrauma associated with increased wait times. Int J Gyne\n-\ncol Obstet 2020;151:303-5.  \n10.  Kimmig R, Verheijen RHM, Rudnicki M; for SERGS \nCouncil. Robot assisted surgery during the COVID-19 \npandemic, especially for gynecological cancer: a state -\nment of the Society of European Robotic Gynaecological \nSurgery (SERGS). J Gynecol Oncol 2020;31:e59.\n11.  Kiykaç Altinbaş Ş, Tapisiz ÖL, Üstün Y. Gynecological \nlaparoscopic surgery in the shade of COVID-19 pandem\n-\nic. Turk J Med Sci 2020;50:659-63.\n12.  Lei S, Jiang F, Su W, Chen C, Chen J, Mei W, et al. Clini-\ncal characteristics and outcomes of patients undergoing \nsurgeries during the incubation period of COVID-19 in\n-\nfection. EClinicalMedicine 2020;21:100331.\n13.  Yánez Benítez C, Güemes A, Aranda J, Ribeiro M,  \nOttolino P , Di Saverio S, et al. Impact of personal protec-\ntive equipment on surgical performance during the CO -\nVID-19 pandemic. World J Surg 2020;44:2842-7.\n14.  Agarwal A, Agarwal S, Motiani P . Difficulties encoun -\ntered while using PPE kits and how to overcome them: \nan Indian perspective. Cureus 2020;12:11652. \n15.  Bin Traiki TA, AlShammari SA, AlAli MN, Aljomah NA, \nAlhassan NS, Alkhayal KA, et al. Impact of COVID-19 \npandemic on patient satisfaction and surgical outcomes: \na retrospective and cross sectional study. Ann Med Surg \n(Lond) 2020;58:14-9.","source_license":"CC0","license_restricted":false}