News

Microneurosurgery in COVID-19ePositive Patients

Pablo Ajler

Given the large-scale spreading of 2019 novel coronavirus disease
(COVID-19) around the world, the priority is to identify infected
persons and contain all possible spreading routes. Increased risk
has narrowed the window of opportunity to effectively restrain the
disease.1 The situation has also become much more complicated
and challenging as the demand for health care workers is
growing (and so is their exposure), and the extreme pressures
they face cause declining availability.
As an immediate consequence of the pandemic, many elective
neurosurgery procedures have been discontinued, though urgent
life-threatening pathologies such as cancer or acute vascular dis-
ease continue to require treatment. To curtail the potential rise of
hospital infections, it is critical to strengthen health care workers'
safety and trust in the system within which they work.2
Regarding the increasing number of patients infected with
COVID-19 who may present with pathologies that require surgery,
scientific societies have suggested the implementation of Level 3
protection for surgical procedures.3 In neurosurgery as well as in
other specialties, the use of the surgical microscope is essential
for the implementation of lighting and magnification of the
surgical field and capability to dissect the microneurovascular
structures.4 However, the use of Level 3 protection is not
compatible with the use of this device, as it is impossible to
look through the eyepieces with protective goggles.
To obtain the opinion of experts in Latin America, we carried out
a survey using Google forms among 57 referring neurosurgeons
through the networks of the sections of neuro-oncology and skull
base surgery of the Latin American Federation of Neurosurgery. We
asked a single question: “Given the situation of having to urgently
operate on a COVID-19epositive patient, where the use of a mi-
croscope is required, what would you do?” The response options
were: “do not operate”; “use the microscope looking through the
goggles”; “remove the goggles and use the microscope as usual”;
“operate without a microscope”; “use an exoscope”; “use an
endoscope”; other option (please describe).
Of the participants, 96.5% accounted for 2 options: 77.2%
answered that they would use the microscope with the goggles in
place, and 19.3% answered that they would take off the goggles.
The use of goggles under the microscope is very complex, espe-
cially in prolonged surgeries, and not wearing them is a significant
risk for the surgeon. A possible solution is the use of an exoscope,
whose main advantages include greater magnification, wider focal
distance, and better surgeon ergonomics, whereas the main
disadvantage is its nonstereoscopic vision.4,5
However, an exoscope is not available in all hospitals. How will
patients undergo surgical procedures in these cases? Although
they are different elements, they have many similarities, and in
general the focal length allows their use as exoscopes.
In our hospital, we have a simulation system to train residents,
and we are adapting our system to the present circumstances.6
Simulation programs of procedures should be generated to
minimize the risk and will play a fundamental role in the
preservation of the health of both health care workers and
patients.
CRediT AUTHORSHIP CONTRIBUTION STATEMENT
Pablo Ajler: Writing - review & editing.

department in the central epidemic area of 2019 6. Massa D, Rasmussen J, Kornfeld S, Plou P,
REFERENCES coronavirus infection. Curr Med Sci. 2020;40:281-284. Padilla F, Villaescusa M. Neurosurgical Simulation
Program [Programa de Simulación Neuro-
1. Wang Q, Yu C. The role of masks and respirator
4. Ricciardi L, Chaichana KL, Cardia A, et al. The quirúrgica]. Revista Argentina de Neurocirugía. 2020;
protection against SARS-CoV-2 [e-pub ahead of
print]. Infect Control Hosp Epidemiol https://doi.org/ exoscope in neurosurgery: an innovative “point of 34:45-54.
10.1017/ice.2020.83, accessed April 15, 2020. view.” A systematic review of the technical, surgi-
cal, and educational aspects. World Neurosurg. 2019;
2. Schwartz J, King CC, Yen MY. Protecting health 124:136-144.
Department of Neurosurgery, Hospital Italiano de Buenos
care workers during the COVID-19 coronavirus
5. Langer D, White T, Schulder M, Boockvar J, Aires, Buenos Aires, Argentina
outbreak—lessons from Taiwan’s SARS response
[e-pub ahead of print]. Clin Infect Dis https://doi.org/ Labib M, Lawton M. Advances in intraoperative 1878-8750/$ - see front matter ª 2020 Elsevier Inc. All
10.1093/cid/ciaa255, accessed April 15, 2020. optics: a brief review of current exoscope platforms rights reserved.
[e-pub ahead of print]. Oper Neurosurg. (Hagerstown) https://doi.org/10.1016/j.wneu.2020.04.251
3. Tan YT, Wang JW, Zhao K, et al. Preliminary recom- https://doi.org/10.1093/ons/opz276, accessed April
mendations for surgical practice of neurosurgery 15, 2020.

532 www.SCIENCEDIRECT.com WORLD NEUROSURGERY, https://doi.org/10.1016/j.wneu.2020.04.251