American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

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SRGS Volume 45 Number 5 Hernia CoverVol. 45, No. 5, 2019

Literature Overview
Editor: Lewis M. Flint, MD, FACS
Associate Editors: Mark Malangoni, MD, FACS; and Mustafa Hussain, MD, FACS

  • Inguinal Hernias
  • Umbilical Hernia Repair
  • Incisional Hernia
  • Incisional Hernia Prevention
  • Operative Management of Incisional and Ventral Hernias    

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Featured Commentary

The online formats of SRGS include access to What You Should Know (WYSK): commentaries on articles published recently in top medical journals. These commentaries, written by practicing surgeons and other medical experts, focus on the strengths and weaknesses of the research, as well as on the articles' contributions in advancing the field of surgery.

Below is a sample of one of the commentaries published in the current edition of WYSK.

COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet. 2020;396(10243):27-38. doi:10.1016/S0140-6736(20)31182-X

Commentary by: Brian G. Harbrecht, MD, FACS

The COVID-19 pandemic has altered society, health care delivery, and surgical care in ways that are unprecedented in our lifetimes. The importance of understanding how to manage this pandemic has emphasized the need to disseminate information rapidly and collaborative efforts have become common.  The current multi-institutional study enrolled 1,128 patients undergoing surgery from 235 hospitals worldwide to evaluate the effect of SARS-CoV-2 infection on outcomes.1 This work demonstrates that mortality after elective and emergency surgery is increased with SARS-CoV-2 infection primarily associated with increased pulmonary complications.

Patients were accrued from January through March 2020 and 86 percent had laboratory confirmation with polymerase chain reaction-based testing for the virus. The amount of effort to collect, analyze, and rapidly report the data is massive, and the investigators are to be commended on a timely report. This timeframe represents the early phase of the pandemic in many parts of the world. Policies to mitigate spread of SARS-CoV-2 infection, such as limitations on elective surgery, were beginning but not uniform—this factor likely accounts for the finding that 25 percent of surgeries were elective. The fact that mortality for elective surgery was 19 percent, however, emphasizes the clinical impact of this disease since elective surgery mortality should be a fraction of that.

Methodological considerations for this study are important. Subjects could be enrolled if they tested positive for SARS-CoV-2 from seven days before to 30 days after surgery. While the number of patients who underwent preoperative testing is not reported, only 26 percent of subjects were positive preoperatively. It is not clear how many of the remaining patients were infected with SARS-CoV-2 and asymptomatic at the time of surgery as opposed to how many contracted the virus during the post-operative hospitalization. It appears as if the majority of subjects either contracted SARS-CoV-2 in the postoperative hospital setting or became symptomatic enough at that time to prompt testing. Notably, the seven-day postoperative mortality was only 5.2 percent, which suggests that the mortality increased with increasing duration of hospitalization, a finding unlikely to be due to the direct effects of surgery. The median length of hospital stay after minor surgery was 10 days and after elective surgery, 13 days—both of which seem long for routine surgery. One could speculate that the majority of the hospitalization was dealing with the ramifications of contracting SARS-CoV-2 rather than the effects of surgery. Is this high mortality rate related to surgery being performed or is it an effect of surgery being the entry into the hospital setting where the patients were exposed to, contracted, or became symptomatic from SARS-CoV-2? Would the mortality rate be similar for patients admitted with diabetic ketoacidosis who develop symptoms of SARS-CoV-2 after being hospitalized? Whether routine pre-op testing and avoidance of elective surgery for positive patients would have altered these findings is not known. Answers to these questions will hopefully be forthcoming.

It seems reasonable to conclude that developing symptoms of SARS-CoV-2 infection complicates recovery from surgery regardless of whether infection was present preoperatively or contracted as a consequence of being hospitalized and exposed in the health care setting. The authors’ recommendation of considering ways to triage need for surgery in this pandemic is prudent. Since many patients have deferred needed health care due to concerns of contracting SARS-CoV-2 from exposure in a health care setting or have had important health issues disrupted due to the COVID-19 pandemic,2,3 the health consequences of COVID-19 may take years to be fully known. Careful decision-making will be essential to mitigate the risks of SARS-CoV-2 infection versus the risks of deferring treatment of conditions requiring surgical therapy while this pandemic evolves.


  1. COVIDSurg Collaborative. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet. 2020;396(10243):27-38. doi:10.1016/S0140-6736(20)31182-X
  2. Mehrotra, A. (2020, May 19). What Impact Has COVID-19 Had on Outpatient Visits?
  3. Rosenbaum L. The Untold Toll - The Pandemic's Effects on Patients without Covid-19. N Engl J Med. 2020 Jun 11;382(24):2368-2371. doi: 10.1056/NEJMms2009984



Recommended Reading

The editor has carefully selected a group of current, classic, and seminal articles for further study in certain formats of SRGS. The citations below are linked to their abstract on PubMed; free full-text is available where indicated.

SRGS has obtained permission from journal publishers to reprint these articles. Copying and distributing these reprints is a violation of our licensing agreement with these publishers and is strictly prohibited.

Friedmacher F, Puri P.Rectal Suction Biopsy for the Diagnosis of Hirschsprung's Disease: A Systematic Review of Diagnostic Accuracy and Complications. Pediatr Surg Int. 2015;31(9):821-830.

Moghadamyeghaneh Z, Sgroi MD, Chen SL, et al.Risk Factors and Outcomes of Postoperative Ischemic Colitis in Contemporary Open and Endovascular Abdominal Aortic Aneurysm Repair. J Vasc Surg. 2016;63(4):866-872.