Original Article

Pediatric surgery during coronavirus disease lockdown:

Multicenter experience from North India
Sandip Kumar Rahul1, Manish Kumar Gupta2, Digamber Chaubey1, Deepak Kumar3, Rupesh Keshri1,
Vijayendra Kumar1, Vijai Datta Upadhyaya4*
1
Department of Paediatric Surgery, Indira Gandhi Institute of Medical Sciences, Patna, Bihar, 2Department of Paediatric Surgery,
All India Institute of Medical Sciences, Rishikesh, Uttarakhand, 3Department of Paediatric Surgery, IMS‑BHU, Varanasi,
4
Department of Paediatric Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India

Abstract Background: Coronavirus disease Pandemic has affected the health‑care delivery at all institutions worldwide.
Analysis of multi‑institutional data would reflect the impact and challenges of this pandemic in managing
pediatric surgical cases. To assess the impact of lockdown due to coronavirus disease 2019 (COVID‑19) on
the pediatric surgical cases operated at four tertiary care institutions.
Materials and Methods: Retrospective data of all patients operated at four tertiary care centers in North
India in three different states during the imposition of lockdown due to COVID‑19 were collected and
compared to the immediate prelockdown period. The impact of following the guidelines for surgery during
this period was studied.
Results: All the institutions involved in the study showed a significant fall in the number and nature of
patients treated during the lockdown period when compared to the prelockdown data. No elective cases
were operated; 100 children were operated during this period of which neonates (56%) formed the major
group; most of them were cases of congenital anomalies which could not be deferred; solid tumours (3/100)
were operated on semi‑emergency basis; number of trauma patients fell down drastically (1/100); one
patient had bronchoscopic foreign body removal; other patients were operated for different causes of acute
abdomen. Several measures in the outpatient, intraoperative, and in‑patient care were adopted to lessen
the spread of virus to the patient and health‑care team.
Conclusion: Corona pandemic severely impacted both the number and types of patients operated.
Strict adherence to the protocol delayed emergency treatment and increased the cost of definitive
management.

Keywords: Corona virus, lockdown, pediatric surgery

Address for correspondence: Dr. Vijai Datta Upadhyaya, Department of Paediatric Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences,
Lucknow, Uttar Pradesh, India.
E‑mail: upadhyayavj@gmail.com
Submitted: 22‑Jun‑2020, Revised: 14‑Jul‑2020, Accepted: 11‑Aug‑2020, Published: 19‑Dec‑2020

This is an open access journal, and articles are distributed under the terms of the Creative
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Access this article online remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
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How to cite this article: Rahul SK, Gupta MK, Chaubey D, Kumar D,
DOI: Keshri R, Kumar V, et al. Pediatric surgery during coronavirus disease
10.4103/fjs.fjs_100_20 lockdown: Multicenter experience from North India. Formos J Surg
2020;53:216-22.

216 © 2020 Formosan Journal of Surgery | Published by Wolters Kluwer - Medknow

 Rahul, et al.: Pediatric surgery during COVID lockdown
INTRODUCTION
The ong oing outbreak of coronavir us disease
2019 (COVID‑2019) caused by severe acute respiratory
syndrome coronavirus‑2 (SARS‑CoV‑2) has been declared
a pandemic by the World Health Organization.[1] This
pandemic has brought unique challenges for the conduct of
surgical procedure and anesthesia in hospitals worldwide.
Considering the sudden increase in the demands of viral
diagnostic tests, personal protective equipment (PPE),
N95 masks, isolated beds, ventilators, and intensive care
units, even the most developed countries in the world
have appeared vulnerable to this pandemic. In an already
resource‑challenged country like India with such a huge
population, management of hospitals is almost impossible
if proper triage is not done between elective and emergency
cases. Although children have been found to be less affected
by the virus, they are not immune to it.[2‑4]
Pediatric surgery department caters to a set of patients
ranging from different congenital neonatal anomalies
to pediatric emergencies such as trauma and foreign
body bronchus. Each of these has its own challenges
and therefore cannot be deferred. Due to a significant
proportion of such cases, re‑organization of surgical care
in the light of COVID‑19 pandemic is a must for efficient
management. We present the surgical data and analyze the
impact of this pandemic on the management of pediatric
surgical cases at four tertiary care centers in Northern India.
MATERIALS AND METHODS
A retrospective study was conducted in the department of
pediatric surgery at four different tertiary care centers in
North India after approval from ethics committee (Approval
No. 1443/IEC/2020/IGIMS). Data of all pediatric
patients who underwent surgery for different indications
during the first three phases of lockdown (from March 23,
2020 to May 17, 2020) and from January 2020 to the start of
lockdown period was collected after consent and analyzed
retrospectively. This data included the demographic details,
detailed history, diagnosis; investigation results, COVID‑19
status, surgical details, waiting time before definitive
management postoperative stay, any complications, and
cost of management.
Standard protocol for managing surgical patients at
these institutions
Being a global pandemic with no definite drug therapy or
vaccine against it, COVID‑19 has brought an unprecedented
crisis due to its highly contagious nature. Social distancing
remains the only means to check its spread at present;
Formosan Journal of Surgery | Volume 53 | Issue 6 | November-December 2020
this has made it necessary for the law makers to enforce a
lockdown in various countries. In India, it was implemented
on March 23, 2020, for a period of 2 weeks and thereafter
extended without a break for successive phases of 2 weeks
duration. During this period, as a protocol outpatients’
clinic functioned under limitation to cater to the needs
of only serious and emergency cases; all the elective cases
were postponed and only emergency cases were operated.
Different hospitals were designated for COVID‑positive
and COVID‑negative patients; a strict rule of treating
COVID‑positive patients in COVID hospitals and
non‑COVID patients in non‑COVID hospitals was
followed once reverse transcriptase – polymerase chain
reaction (RT‑PCR) results became obvious. In doing so,
individual hospitals developed their own standard operating
protocol (SOP) which involved triaging of patients for their
symptoms, admitting all emergency patients in isolated area,
subjecting all admitted patients to RT‑PCR for COVID‑19,
transferring patients who turn negative for these tests to
the primary ward designated for the individual department
whose care is essential for the definitive management of
the patient and referring the COVID‑positive patients to
designated COVID hospitals for further treatment. The
SOP also had provision for facilities of complete protection
of all the health‑care professionals by the provision of PPE
including masks (level 2 or 3 filtering face piece depending
on the aerosol‑generating risk level), eye protecting
goggles, double nonsterile gloves, gowns, suites, caps, and
shoe‑covers. Each department was allotted a specified time
daily for telemedicine facility to advise nonemergent cases
and follow‑up cases. This further reduced the number
of patients in the outpatients’ clinic. Any health‑care
professional or supporting staff, on accidental exposure to
some COVID positive patient was quarantined for a period
of 2 weeks as a part of the institutional SOP and on turning
positive for corona virus, received treatment at an isolation
center in designated COVID positive hospital.
RESULTS
1. Table 1 shows the number of surgeries done during
this period at different institutions. When comparing
data from 55 days prior to imposition of lockdown
to that in the first 55 days of the lockdown, there was
a sharp decline in the total number of cases at these
four institutions from 596 to 100. A wide range of age
could be seen (from 1 day to 17 years) with a mean of
21.53 months. Majority were neonates, mostly due to a
variety of malformations. Male children outnumbered
females by a ratio of 4:1.
2. Table 2 enlists the different indications for which
surgery was done during the lockdown period and
217
 Rahul, et al.: Pediatric surgery during COVID lockdown

Table 1: Comparative profile of surgeries done during lockdown at different institutions

Institution Parameters
Number of Male: Neonates: Mean age and Number of Average COVID‑19 status Any COVID
cases after Female Older age range cases prior number of for surgeries related
lockdown (March children to lockdown cases done in during lockdown complication
23, 2020–May from January, 55 days prior
17, 2020) first 2020 to start of
55 days lockdown
Institution 1 45 41:4 29:16 11.5 months 295 200 23 – No test done No
(1 day–11 years) (before SOP)
22 – COVID 19
negative (after SOP)
Institution 2 14 9:5 8:6 4.43 months 46 31 All COVID negative No
(1 day-3 years)
Institution 3 19 12:7 4:15 72.84 months 148 101 3 – no test done No
(5 days-17 years) 16 – COVID negative
Institution 4 22 18:4 15:7 8.6 months (range: 388 264 8 – not done No
3 days-7 years) 1 – COVID negative
Total 100 80:20 56:44 21.53 months 877 596 All COVID negative No
(1 day-17 years)
COVID: Coronavirus disease, COVID‑19: Coronavirus disease 2019, SOP: Standard operating protocol

Table 2: Common indications of surgeries performed during lockdown

Indication Number of cases in lockdown (55 days) Number of cases just Effect of
before lockdown (55 days) lockdown
Neonatal cases 56 (ARM17+EA6+Malrotation4+HD5+JIA8+DA2+NEC5 90 ↓↓
+CDH2+PUV1+IHPS6)
Trauma cases 1 6 ↓↓
Tumours 3 7 ↓
Foreign body bronchus 1 3 ↓
Acute abdomen in older children 19 (PP6+IO8+OH+BB+appendicitis3) 29 ↓↓
Gastric outlet obstruction (secondary to 2 2 _
acid ingestion)
Infected cases 5 (Abscess3+Infected UPJO1+Emyema 9 ↓
decortication1)
Biliary atresia 4 6 ↓
Others 9 (PPC1+PD1+Urethralstricture1+Mesente 10 ↓
ric cyst1+Achalasia cardia1+CLE1+Foregut
duplication1+stoma reversal2)
Total emergency cases 100 162 ↓↓
Elective cases 0 434 ↓↓↓↓↓
Total 100 596 ↓↓↓
ARM: Anorectal malformation, EA: Esophageal atresia, HD: Hirschsprung’s disease, JIA: Jejunoileal atresia, DA: Duodenal atresia,
NEC: Necrotising enterocolitis, CDH: Congenital diaphragmatic hernia, PUV: Posterior urethral valve, IHPS: Infantile hypertrophic pyloric stenosis,
PPC: Pseudopancreatic cyst , PD: Peritoneal dialysis catheter insertion, CLE: Congenital lobar emphysema

compares it to the number of surgeries done in the
corresponding category just before lockdown. Almost
all categories showed a decrease during the lockdown
period. Congenital deformities in neonates were the
most common indication for surgery during this
period; most common among these were Anorectal
malformation, Bowel atresia, oesophageal atresia,
infantile hypertrophic pyloric stenosis; trauma cases
had lessened at all institutions; only one case of
polytrauma with pelvic and femoral fracture with
urethral injury came to the hospital during lockdown;
tumors were operated on a semi‑emergency basis.
Nonperformance of elective cases such as pelvi‑ureteric
junction obstruction, hypospadias, epispadias–
exstrophy bladder, asymptomatic renal and gallbladder
218
stones, all types of stoma closure (bowel stoma,
vesicostomy, ureterostomy), and asymptomatic
cystic lesions (thyroglossal, mesenteric, choledochal,
branchial) were the major cases which were deferred.
Delaying stoma closure increased morbidity and cost
of management. Other conditions did not cause any
specific problem for the patient in our study.
Two cases of acute appendicitis underwent laparoscopic
appendicectomy while one patient with foreign body
bronchus had bronchoscopic removal of the foreign body.
3. Table 3 shows the COVID‑specific measures taken by
these institutions to manage patients during lockdown.
All these measures had one common theme – to limit
the number of patients at registration, outpatient’s
department and indoor admission without denying
Formosan Journal of Surgery | Volume 53 | Issue 6 | November-December 2020
 Rahul, et al.: Pediatric surgery during COVID lockdown

Table 3: Coronavirus disease‑19 specific measures at different centers

Measures Institution
Institution 1 Institution 2 Institution 3 Institution 4
Online registration Yes Yes Yes Yes
Limiting number of patients in OPD Yes Yes Yes Yes
Triaging Yes Yes Yes Yes
Whether elective cases performed No No No No
Limiting admissions Yes Yes Yes Yes
Emergency cases Yes Yes Yes Yes
Initial admission in isolation Yes Yes Yes Yes
PCR‑test after admission and before any other intervention Yes Yes Yes Yes
Availability of PPE Kits/N‑95 masks/face shields/ Yes Yes Yes Yes
protective googles
Telemedicine OPD Yes Yes Yes Yes
Separate facilities for COVID – positive and Yes Yes Yes Yes
COVID – negative cases
Division of health‑care workers in groups to work by turn No Yes Yes No
Measures during laparoscopic surgery yes _ _ _
Lower insufflation pressure +
Desufflation by trocar suction +
Use of filters ‑
Specimen retrieval after desufflation +
Use of smoke evacuators ‑
Limited use of energy devices +
COVID: Coronavirus disease, OPD: Outpatient department, PCR: Polymerase chain reaction, PPE: Personal protective equipment

care to the needy who presents with any emergent
symptom.
Both the laparoscopic procedures during this
period were performed at Institution 1 and so
laparoscopy‑specific measures are mentioned only with
Institution 1.
4. There was an increase in the number of patients
who left against medical advice (LAMA) during this
period (seven in total), while awaiting results of PCR
for COVID‑19. At institution 1, five patients went
LAMA after admission but before the test results came.
The attendants of all these patients feared of getting
infected with the corona virus during their hospital
stay.
5. In all, there were three deaths in the patients operated
during lockdown but none of them were due to corona
virus. Among these, two patients had jejuno‑ileal
atresia (one with anastomotic leak and other with
accidental aspiration while feeding). The third
mortality was in a case of gastric pull‑up for wide gap
oesophageal atresia that had been operated prior to
lockdown; he had a pulled feeding jejunostomy tube
that resulted in a high output entero‑cutaneous fistula.
6. Four patients tested positive during this period at
Institution 1 and it being a declared “non‑COVID”
hospital they were sent to a COVID – hospital
for proper advice. Among them, a 2‑year‑old
intussusception patient died later due to her sick state;
while a child having pelvi‑ureteric junction obstruction
was operated when he turned negative for COVID‑19.
Two other positive patients (Empyema thoracis and
Formosan Journal of Surgery | Volume 53 | Issue 6 | November-December 2020
right‑sided Wilms’ tumor) were operated at another
hospital designated to operate and take care of COVID
positive patients.
7. Four nursing staff and one treating physician were found
to be corona–positive. They were kept in quarantine and
returned to work after testing negative after a couple of
weeks.
8. Following the protocol of testing for COVID‑19
before surgery delayed surgery by an average of
20 h; use of RT‑PCR, protective kits and all other
protective measures added additional cost of around
Rs. 11,500 (Indian rupees) in every patient.
DISCUSSION
The novel corona virus pandemic has necessitated a change
in the approach to health‑care delivery making “triage,” an
important step in prioritizing the management of patients.
This has affected the surgical disciplines also.[5] Recently,
the European Association of Urology Guidelines Office
suggested key points for prioritization of surgical care.[6]
This includes the impact of delay on the outcome of
surgical procedure, feasibility of alternative procedures, the
risks to the patient’s life or organ dysfunction if surgery is
delayed, presence of co‑morbidities and increased risks of
complications and the risks of progression of symptoms
or disease progression if the procedure is not performed.[6]
Therefore, a balance between the patient’s needs, available
resources and the risks of deferring surgery must be taken
into consideration when decision regarding an individual
patient is to be taken.
219
 Rahul, et al.: Pediatric surgery during COVID lockdown
Different countries and institutions have come up with their
own recommendations regarding elective and emergency
surgeries. The approach to deal with the pandemic varies
even between two departments in the same institution,
while also obeying the institutional protocol. The American
College of Surgeons have divided the operative procedures
into different tiers depending upon the urgency of surgery;
they recommend postponement of all surgeries up to tier
2b.[7] This, however, does not apply to majority of high risk
cancer surgeries and surgical patients who are very sick to
survive without an operative procedure (Tiers 3a and 3b).[7]
National Health Survey, England, recommends to
undertake elective pediatric surgeries only if patients are low
risk for anesthesia (American Society of Anesthesiologists
Grade 1), with the exception of cancer cases.[8]
As per the guidelines of the Indian Council of Medical
Research (ICMR), all high‑risk cases who need surgery
should undergo PCR test for COVID‑19 before surgery
(all symptomatic contacts of laboratory‑confirmed cases or
asymptomatic‑direct and high‑risk contacts of a confirmed
case should be tested once between day 5 and day 14 of
coming in his/her contact).[9] Thereafter, if the patient’s
PCR test is negative, he undergoes surgery with precautions
as per surgical protocol; if positive, he is kept in isolation
meant for COVID‑19 positive patients and operated with
tertiary protection measures for anesthesia and surgery.
In the postoperative period, patient is again managed in
isolation ward. All the four institutions in this study were
guided by the protocols issued for the conduct of pediatric
surgery which is in line with that advocated by the American
College of Surgeons, ICMR and the institutional SOP.[5]
Surgical procedure being a teamwork, the conduct of a
single surgery exposes the entire health‑care team involved
in hospital registration, outpatient consultation, admission,
inpatient care, investigation and radiological workup,
anesthetic procedure, definitive surgery, postoperative care
and sanitation and disinfection measures to the risks of
this virus. Hence, strict measures must be taken at every
level to lessen the exposure; online registration, restricting
the counts of patients turning up for outdoor consultation
to only those having emergent symptoms, initial isolation
followed by PCR test for corona virus followed by all
other investigations and resorting to primary, secondary
and tertiary protection measures as per the risk group of
the patient.[10] All these steps were taken at the institutions
included in the study [Table 3].
Most of the hospitals, including the four hospitals
included in this study, have limited their outpatients’
220 Formosan Journal of Surgery | Volume 53 | Issue 6 | November-December 2020
clinics as a part of their COVID containment strategy.[8]
Only emergency and life‑threatening cases were operated.
For other patients, telemedicine sessions were used. Use
of Telemedicine or Tele‑health services has seen a surge
during this Pandemic.[11,12] Such facilities ensure delivering
health‑related advice to those in need without unnecessary
crowding in the hospital premises. These services were
available to patients treated at all four institutions and on
average 3.5 pediatric patients used to avail these services
daily. However, only medical advice can be given through
this medium; patients can only be advised to come to the
treating center, should any need for surgical intervention
arise. Also, public awareness is lacking regarding such
facilities which is reflected by the limited number of
patients availing them.
Our data demonstrates a significant fall in the number of
patients operated at each of the four institutions during the
lockdown period. This not only is due to nonperformance
of elective cases, but also due to reduction in emergency
cases (possibly due to restrictions imposed on transport
facilities).
Different subgroups of surgical patients who received
surgical care are evident on analyzing the multi‑institutional
data.
Trauma patients constitute a subgroup that needs
treatment despite their COVID‑status.[13] Fortunately,
with the imposed lockdown and restriction to unnecessary
movement and transportation, the overall number of these
patients declined considerably. In our study, trauma patients
were very few in number and they were managed following
appropriate guidelines.[14,15]
Neonatal surgical deformities formed the bulk of the
operated patients. Anorectal malformation, esophageal
atresia, Jejuno‑ileal atresia, Duodenal atresia, Malrotation
with midgut volvulus, Necrotizing enterocolitis,
Hirschsprung’s disease, Idiopathic Hypertrophic pyloric
stenosis, Congenital diaphragmatic hernia, Congenital
lung cysts, Biliary atresia and posterior urethral valves
were some common conditions for which surgery was
performed. This spectrum mimics the range of cases
found during non‑COVID times. So, with regard to
neonatal surgery no limitation was observed for any
specific condition. None of these conditions can be
considered non life-threatening or not capable of causing
any organ damage. Children with bowel atresia had a
prolonged hospital stay, often exceeding 2 weeks, thereby
making them at risk for exposure.
 Rahul, et al.: Pediatric surgery during COVID lockdown
Cancer surgeries, on most occasions, cannot be deferred
fearing tumor growth, its spread (metastases) and risk to
life. These points must be carefully balanced against the
risks of viral transmission to these patients (due to their
immune‑compromised state).[16] All tumor surgeries were
done on semi‑emergency basis and their hospital stay
was kept as short as possible by allowing early feeds and
mobility, lessening their overall exposure.[17] Wherever
applicable, they were also sent for chemotherapy and
radiotherapy after discussion in online Institutional tumor
board to provide comprehensive cancer care.
The number of emergencies in grown up children were
fewer and their number had declined compared to the
non‑COVID period. Some of these included foreign
body bronchus, Acute Appendicitis, Empyema Thoracis,
Intestinal obstruction, perforation peritonitis and tumors.
We followed the guidelines whereby a diversion stoma is
preferred over an anastomosis if a choice has to be made
between the two. This lessens the chances of a second
surgery, should an anastomotic leak occur.[18] SARS‑CoV‑2
has been found in many fecal specimens and this implies
precaution during bowel surgeries.[19‑21]
The advantages and disadvantages of laparoscopic surgery
during COVID period have often been compared.[22,23]
Less trauma, faster recovery and discharge, contained
surgical field limiting exposure to fumes and fluids,
wider spacing between persons involved in surgery and
anesthesia are some direct advantages of laparoscopic
procedure;[24] however, energy devices, surgical plume and
smoke have been regarded as potential risk factors for viral
transmission.[20,22] These risks are not well substantiated
by available data. Using filters and safe smoke evacuator
for the released carbon dioxide during surgery, creating
a closed circuit for insufflation preventing any release of
free gas during the procedure, limiting the use of energy
devices to minimum and lessening the insufflation pressure
to decrease the risks of aerosolization of the virus are a
few described measures.[22,25] In case, smoke evacuators
are not available, direct application of suction device to
the laparoscopic trocars facilitates safe disposal of the
smoke.[22] Also, any surgical specimen should always be
removed when the abdomen in desufflated.[22] We had
only two laparoscopic procedures during this period and
both these patients were discharged the next day. We used
lower insufflations pressures, applied suction to the trocar
to achieve safe evacuation of gas and smoke and retrieved
the surgical specimen after desufflation.
Number of males who had surgery during this period was
four times the number of females who were operated. If
Formosan Journal of Surgery | Volume 53 | Issue 6 | November-December 2020
not due to social discrimination for the female child, this
implies that males are more affected with anomalies and
emergencies, which necessitate hospital admission in a crisis
situation like lockdown.
A disturbing trend was the increase in the number of
patients who LAMA, while awaiting the results of PCR
for corona before surgery. In all, there were seven such
patients; they left due to fear of getting infected.
There were no COVID – related deaths in the department
of pediatric surgery in any of these four institutions.
Three children who died during this period were all due to
non‑COVID related causes. At institution one, four nursing
staff and one doctor were positive for corona virus and
were safely quarantined to re‑return to work on testing
negative for COVID‑19.
Following the protocol (intervening only after testing) led to
unnecessary delay in instituting definite care to needy patients.
This global pandemic has changed the dynamics of the
hospitals and the number, nature and expenses of the cases
which are now subjected to surgery. All the four hospitals
involved in the study have high volume pediatric surgery
units which have been limited by the lockdown and the
SOP in their functioning and patient care.
CONCLUSION
COVID‑19 has severely impacted the functioning of hospitals
and health‑care delivery by decreasing the number and types
of patients getting treatment; following the recent protocol
often delays treatment and adds to the cost of management.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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