Review Article Global Surgery Glob Surg, 2020 doi: 10.15761/GOS.1000219 Volume 6: 1-8 ISSN: 2396-7307 Use of ultrasonic devices in laparoscopic surgery and risk of COVID-19 contamination: What does the evidence say? Giovanni A Tommaselli, Crystal D Ricketts*, Jeffrey W Clymer and Raymond S Fryrear II Medical Affairs – Ethicon Endo-Surgery - 4545 Creek Rd, Cincinnati, OH 45242, USA Abstract With the emergence and spread of Coronavirus Disease 2019 (COVID-19), surgical care of patients has been disrupted for surgeons across the world. Recently several surgical societies are raising concerns about using ultrasonic devices during laparoscopic surgery due to questions regarding a proposed risk of viral transmission of COVID-19. In this review, we will provide an overview of COVID-19’s transmission, evaluate available evidence on surgical smoke production and possible risk of viral contamination and discuss the optimization of ultrasonic device use during the ongoing COVID-19 global pandemic. Introduction A pneumonia of unknown cause detected in Wuhan, China, on December 27th was frst reported to the World Health Organization (WHO) Country Ofce in China on December 31st, 2019 [1]. Early in January, it was determined that these pneumonia cases were due to a novel coronavirus, named SARS-CoV-2, causing a disease called COVID-19. SARS-CoV-2 is a positive-sense single-stranded RNA virus, whose virion is 60–140 nm in diameter [2]. SARS-CoV-2 has four structural proteins: proteins E (envelope), M (membrane), and S (spike) which create the viral envelope and, through protein S, attach to and fuse with the membrane of a host cell. Protein N (nucleocapsid) holds the RNA genome [2]. SARS-CoV-2 is responsible for a worldwide epidemic, which was declared as a pandemic by the WHO on March 11th, 2020. Tis pandemic severely limited elective surgical activity throughout the world, as well as triggered multiple surgical societies (e.g., SAGES/ EAES, ESGE, AAGL) [3-5] to issue “recommendations” on ways to reduce the risk of virus transmission to the operating room (OR) personnel caring for COVID-19 patients or patients with unknown COVID-19 status. Most of the recommendations are focused on ways to reduce potential exposure via personal protective equipment (PPE), smoke evacuation and potential aerosolization of SARS-CoV-2 by electrosurgical devices or CO 2 insufation of the pneumoperitoneum. Tese recommendations include setting electrosurgical units to the lowest possible settings for the desired tissue efect and minimizing the use of monopolar electrosurgery, ultrasonic dissectors, and advanced bipolar devices, as they can lead to particle formation in the resulting surgical smoke. Tese recommendations were initially focused on laparoscopic surgery, where the risk of viral aerosolization from CO 2 insufation was considered, along with the potential concentration of aerosol created from the use of energy devices. Concerns have been raised regarding the use of ultrasonic devices where several authors speculated these devices may produce a low- *Correspondence to: Crystal D Ricketts, Medical Afairs – Ethicon Endo- Surgery, Cincinnati OH USA, E-mail: cricket9@its.jnj.com Key words: COVID-19, surgical smoke, ultrasonic, laparoscopic, surgical care, surgery, aerosol formation, virus Received: June 08, 2020; Accepted: June 18, 2020; Published: June 25, 2020 temperature aerosol which do not efectively deactivate the cellular components of virus in patients [6] or may cause more aerosol formation [7]. Even though there is no evidence supporting these theories, diferent surgical societies, as well as some published literature, are suggesting not to use ultrasonic energy, in favour of electrosurgery. Te aim of this review is to analyse available evidence related to the surgical smoke created by ultrasonic devices as it relates to the risk of COVID-19 transmission during laparoscopic surgery. Modes of transmission of COVID-19 Te current available evidence suggests the main source of transmission of SARS-CoV-2 is through respiratory droplets (particles > 5-10 μm in diameter) [8] from infected people and through contact with contaminated surfaces [1,9-13]. Te detection of viable SARS-CoV-2 in stools of COVID-19 patients, who can shed the virus in the feces for days afer respiratory symptoms have disappeared [14,15] and virus RNA has been found in sewage [16,17]. Tis evidence raises the possibility of fecal-oral transmission, even though there is no data available to support this hypothesis. Other means of transmission of the virus have not been confrmed. Some studies found the presence of SARS-CoV-2 RNA in blood, but in a very limited number of cases (10-11%) [18,19]. Data on the presence or absence of the infectious virus in blood, plasma or serum has not been reported, as well as blood-borne transmission of COVID-19 disease. Vertical transmission of the virus from an afected mother to her child seems to be unlikely, even though 4 afected children out of