ABSTRACT

Background

The Coronavirus Disease 2019 (COVID-19) pandemic has negatively affected global health, social welfare, and the economy at a level unprecedented in modern history. study aimed to compare surgery services in a training and research hospital in İstanbul before and after COVID-19 and evaluate these services regarding health management.

Materials and Methods

This retrospective study encompassed all surgical procedures conducted in the hospital’s operating room from 2019 to 2023. The data were analyzed using frequency, percentage and chi-square tests.

Results

The dataset encompasses 46,041 surgical procedures and 18 different disease groups. Major surgical procedures account for 66.8% of emergency surgeries and 84.2% of elective surgeries. 71.5% of the major surgeries, 88% of the moderate surgeries, and 83.4% of the minor surgeries are emergencies. Major surgical procedures are prevalent across all age demographics. 11,834 (25%) surgeries were performed in 2019, and 4,344 (9%) surgeries were performed in 2020. The pandemic significantly reduced emergency (n=3984, 11%) and elective (n=360, 3%) surgeries. There was a notable rise in the frequency of hospital visits after surgeries involving the circulatory system, ocular interventions, and operations in the middle ear as age progressed.

Conclusion

The pandemic period witnessed notable reductions in the volume of emergency, elective, major, medium, and minor surgical procedures. Surgeries experienced a decline across all disease categories, except for two: foreign body, implant, and graft surgeries, and incidents involving accidents, poisoning, contact with sharp objects, and weapons. Most surgeries can be classified as emergency procedures, with notable prevalence in cases involving the eye and middle ear, genitourinary system, skeletal structure, circulatory system, digestive tract, and respiratory ailments. Emergency, eye, and middle ear surgeries were more prevalent among individuals aged 60 and above, whereas elective surgeries were more frequently observed in the 19-30 age group. Most emergency and elective surgeries were major surgeries. The number of postoperative check-ups increased among the older age demographics.

Introduction

Surgical care has been an important component of health care for centuries. As the prevalence of cancers, cardiovascular diseases and traumatic injuries continues to increase, the impact of surgical intervention on public health will continue to grow (1). Some European Union countries performed over four million cataract surgeries and one million cesarean sections (2). As the aged population expands, cardiovascular disorders have emerged as the predominant cause of morbidity and mortality among those over 75 years of age in recent years, illustrated by the percentage of cardiac surgeries (3, 4). Advancements in health technology have led to a preference for novel uses, such as robotic surgery, over traditional open surgical methods (5).
The Coronavirus Disease 2019 (COVID-19) pandemic has negatively affected global health, social welfare, and the economy, at a level unprecedented in modern history (6). It has also led to significant changes in healthcare services. The number of patients visiting emergency services has almost halved during COVID-19 (7). Besides its detrimental impact on public health, the virus has caused the disruption and cancellation of surgical operations. Moreover, patients have had challenges receiving surgical care, prompting the formulation of a plan specifically for post-pandemic (6, 8).
Hospitals were considered high-risk environments, with intensive care units and operating rooms identified as the most hazardous regions (9). In the pre-COVID-19 period (2019), elective surgeries were four times more frequent than emergency surgeries, but during the pandemic period, they decreased to twice (10). In the first two months of the pandemic, emergency general surgery applications dropped 37.1% and 43.7%, respectively. Acute appendicitis, cholecystitis, and intestinal obstruction were the most common surgical emergencies encountered during the pandemic (11). In Türkiye, the number of surgeries conducted in 2019 was over 5 million, but it declined to 3 million in 2020, subsequently rising in the ensuing years following the conclusion of the pandemic (12).
The pandemic caused elective surgeries to be postponed, and healthcare personnel prioritized COVID-19 patients, leading to disruptions in the provision of other healthcare services (7, 13). The pandemic’s unprecedented challenges required a fundamental restructuring of global surgical care delivery. Health authorities, including the World Health Organization, Centers for Disease Control and Prevention, and European Centre for Disease Prevention and Control, along with surgical societies such as the American College of Surgeons, European Association for Endoscopic Surgery, and European Society of Coloproctology, promptly released evidence-based guidelines to reduce infection risks and conserve essential resources. The guidelines focused on several fundamental operational pillars:

Tiered Triage Systems: Elective surgeries were prioritized rigorously according to urgency and cancer risk, employing frameworks such as the Medically Necessary Time-Sensitive (MeNTS) scoring system. Surgeries were classified into tiers, including Emergency, Urgent, Semi-Urgent, and Postponable, and the classification was evaluated continuously based on the local COVID-19 burden and resource availability. This frequently resulted in considerable delays for non-urgent procedures such as bariatric and benign hernia surgeries (14).

Enhanced Preoperative Protocols: These protocols mandate universal Severe Acute Respiratory Syndrome Coronavirus 2 screening, typically conducted via reverse transcription – polymerase chain reaction, within 24-72 hours prior to surgery for all patients, including those who are asymptomatic. Preoperative isolation was recommended when feasible. Telemedicine was extensively utilized for preoperative evaluations and consent procedures to reduce hospital exposure (15).

Modifications in Operational Procedures within the Operating Room:

• Infection Control: Rigorous compliance with enhanced personal protective equipment (N95/FFP2 respirators, eye protection, gowns, gloves) is essential for all operating room personnel, particularly during aerosol-generating procedures such as intubation or laparoscopy. Operating rooms for COVID-19 equipped with negative pressure ventilation were utilized where feasible.

• Personnel and Workflow: Team sizes were reduced, and staff movement between COVID-positive and non-COVID areas was limited. Operating times were optimized, and non-essential equipment was eliminated.

• Surgical Technique: Given the evolving evidence on viral aerosolization, recommendations frequently suggested reducing the use of energy devices (such as electrocautery and ultrasonic scalpels) during laparoscopy and implementing effective smoke evacuation systems (16).

Postoperative Care Adjustments: The procedures involved modifications to pathways aimed at expediting discharge when deemed safe, such as the implementation of enhanced recovery after surgery protocols (17). Dedicated surgical wards and intensive care units free from COVID-19 were established to safeguard non-infected surgical patients. Postoperative follow-up increasingly employs telehealth.

Ethical and Safety Frameworks: These frameworks underscore the importance of equitable resource allocation, transparent communication with patients regarding risks and delays, and the ethical duty to deliver surgical care when deferral may result in substantial harm, such as cancer progression or limb threat. The regulations were primarily motivated by patient safety and the protection of healthcare workers (18).

Surgeons’ daily practices and training have been profound, enabling them to become a significant source of personnel in the fight against the virus (19). Restrictions on access to non-urgent care and elective surgeries have postponed bariatric and metabolic surgeries worldwide. Therefore, delaying surgery for patients experiencing a rapid progression of obesity and diabetes has increased the risks of morbidity and mortality (20).

The pandemic has created considerable challenges in managing healthcare services, necessitating that healthcare systems remain flexible and adaptable to these processes. Given that the pandemic yields critical insights for implementing measures against potential future pandemics, it is imperative to monitor this scenario concerning healthcare management. This study evaluates operating room practices during the pre- and post-COVID-19 periods. The study attempts to clarify the influence of the COVID-19 criterion on healthcare planning for the literature and policymakers and to provide resources.

Materials and Methods

Research Design

The retrospective research aimed to statistically evaluate the data obtained from patients who underwent surgery in a 654-bed general education and research hospital in İstanbul Türkiye between 01.01.2019 and 01.10.2023.

Population and Sample

The study universe consists of 46,041 surgeries and 18 different disease groups. All surgeries were analyzed without selecting a sample. The surgery classification was based on the medical standard of surgery; depending on their volume and complexity, surgeries may be minor, medium and major (complex). The disease definition of 46.041 surgeries was made using the International Classification of Diseases-10 (ICD-10) diagnostic codes. The current study included elective and emergency cases as a kind of surgery. Emergency cases occur unpredictably and require immediate attention on the same day. Elective cases may be scheduled for subsequent dates (21).

Ethical Approval

Institutional permission was obtained before the study was conducted, and ethics committee approval was obtained from the University of Health Sciences Türkiye, Hamidiye Scientific Research Ethics Committee (approval number: 1/34, dated: 25.01.2024).

Statistical Analysis

Statistical analyses were performed using the Statistical Package for the Social Sciences 25.0 for Windows (SPSS Inc., Chicago, IL, USA). Multiple limitations require attention. This single-center study conducted at a tertiary hospital in İstanbul may not accurately represent patterns observed in community hospitals or rural settings, where resource constraints vary. Secondly, variations in diagnostic coding within electronic health records (EHRs), such as the misclassification of “urgent” versus “elective”,  may impact the accuracy of disease groupings, even with the standardized application of ICD-10. Third, we did not monitor long-term outcomes of delayed surgeries, such as cancer progression in deferred biopsies, which would elucidate the clinical implications of triage decisions. Fourth, confounding factors such as local COVID-19 surges, staff shortages, and patient avoidance behaviors were not quantified, although they likely impacted surgery volumes. Ultimately, our data do not evaluate the consistent application of priority frameworks across surgical specialties, which is a recognized challenge during crises. Data were expressed as frequencies and percentages. The chi-square test was used to evaluate the frequency differences between disease groups. The significance level was accepted as p<0.05.

Results

Emergency and elective surgeries, as well as minor, medium, and major surgeries, have decreased during the pandemic (Table 1). The number of surgeries in 2020 decreased by 81% relative to 2019; albeit this reduction differs by disease group. The 34,950 emergency surgeries over a five-year span declined from 24.40% in 2019 to 11.40% in 2020, while 11,091 elective procedures fell from 29.81% to 3.25%. Similarly, there has been a reduction of 90% in the incidence of major procedures. All disease groups, exhibited a reduction in the number of procedures except for two categories: foreign body (implant and graft surgeries), and incidents involving accidents, poisoning, contact with sharp objects, and weapons (Table 1).

Most emergency surgeries involved eye and middle ear diseases (18.8%), genitourinary system diseases (18.2%), skeletal system diseases (10.6%), circulatory system diseases (9.3%), digestive system diseases (7.2%), and respiratory system diseases (5.7%) (Table 2).

Elective surgeries are performed for diseases (36.8%), digestive system diseases (8.9%), muscle-tendon injuries and fractures (8.7%), and skeletal system diseases (8.6%) (Table 2).

Between 2019 and 2023, 73.4% of all surgeries in the 0-18 age group were major, and 70.3% were urgent. These surgeries were mostly performed for respiratory system diseases (15.2%), digestive system diseases (11.7%), injuries due to contact with sharp objects (8.1%), congenital and chromosomal disorders (7.4%), skeletal system diseases (7.3%), muscle-tendon injuries and fractures (6.5%) (Table 3).

Eighty point eight percent of surgeries between the ages of 19 and 30 were major, and 51.4% were elective.
These surgeries were mainly for gynecological diseases (37.9%), the skeletal system (8.4%), the skin (8%), the respiratory system (7.3%), and the digestive system (6.3%) (Table 3).

Sixty-seven point eight percent of surgeries between the ages of 31 and 45 were major, and 73.7% were urgent. These surgeries were mainly performed on genitourinary system diseases (18.7%), gynecological diseases (15.9%), circulatory system diseases (12%), skeletal system diseases (10.2%), digestive system diseases (7.2%), and eye and middle ear diseases (5.4%) (Table 3).

Sixty-four point one percent of the surgeries between the ages of 46 and 59 were major, and 87.7% were urgent. These surgeries mainly involved the genitourinary system (22.5%), eye and middle ear (17.2%), skeletal system (12.2%), circulatory system (10%), and digestive system (8.6%) (Table 3).

Seventy-three point three percent of the surgeries performed on individuals over the age of 60 were major, and 89% were urgent. Surgeries were performed for eye and middle ear diseases (37.2%), genitourinary system diseases (14.4%), skeletal system diseases (10.3%), digestive system diseases (6.6%), neoplasms and immune system diseases (5.6%), and circulatory system diseases (4.8%) (Table 3).

Sixty-six point eight percent of emergency surgeries and 84.2% of elective surgeries are major. Seventy-one point five percent of major surgeries, 88% of moderate surgeries, and 83.4% of minor surgeries are urgent. Surgeries are generally included in the major surgery group. However, it was determined that foreign body, implant, and graft surgeries (49.3%) and circulatory system diseases (31.1%) constitute the majority of the minor surgery group (Table 4).

The frequency of individuals coming to the hospital after surgery increases in older age groups. The frequency of hospital visits increases with age, especially for individuals having minor surgeries, and diseases of the circulatory system, eye, and middle ear between the ages of 19 and 59 (Table 5).

The predominant types of gynecological procedures include spontaneous vertex deliveries (n=2754) and emergency and elective cesarean deliveries (n=766). In genitourinary system disorders, procedures for abnormal uterine and vaginal hemorrhage (n=1401) and irregular menstruation (n=1252) are primarily conducted. Chronic venous insufficiency (n=2528) is predominantly conducted in circulatory system diseases, with a significant majority in the 31-45 age. The predominant types of respiratory system diseases involve issues of the nose and nasal sinuses, with procedures for nasal septum deviation (n=408) and other conditions (n=467). In surgical procedures necessitated by accidents, poisoning, and injuries from sharp objects and weapons, those resulting from bites and stings of non-poisonous insects and arthropods (n=520) are particularly prominent, significantly impacting the 0-18 age demographic. Likewise, other surgical procedures conducted across the 0-18 age demographic include foreign body removal, implant placement, and graft surgery. Many individuals undergoing surgery for eye and middle ear problems are aged 60 and above. Diabetic retinopathy procedures (n=1418) and senile cataract surgeries (n=965) are the most prominent in this group (Table 6).

In procedures for the digestive system, a substantial difference was noticed in patients aged 19 to 59. A significant difference was observed in the 19-59 age group for surgeries performed due to venous insufficiency (chronic peripheral), varicocele, and hemorrhoids in circulatory system diseases; in contrast, surgeries performed for abnormal uterine and vaginal bleeding, a significant difference was observed between all age groups, except for the 0-18 age group, in surgeries performed for abnormal uterine and vaginal bleeding. There was a substantial difference in all procedures performed for gynecological illnesses in the 19 to 45 age group. In procedures performed for soft tissue and back pain in skeletal system illnesses, there was a substantial difference within the 19-59 age group. There was a substantial difference in neoplasms and immune system diseases between the 31-60 age group and those above, regarding benign lipomatous neoplasm, trunk skin and subcutaneous tissue neoplasms, benign skin neoplasm, and malignant bladder neoplasm. Eye and middle ear surgeries among individuals aged 31-60 differ significantly from those performed on older individuals. Respiratory system procedures between 18 and 31 years old (excluding nasal septum deviation) differ significantly. All genitourinary system illnesses (excluding benign prostatic hyperplasia) show a substantial variation in the 19- to 59-year-old age group (Table 6).

Discussion

This study aimed to compare operating room services in a training and research hospital in İstanbul before and after COVID-19 and to evaluate them in terms of health management. The number of surgeries performed in 2020 varied by disease groups but decreased by 81% compared to 2019. Thirty-four thousand nine hundred fifty emergency surgeries performed in the five-year period decreased from 24.40% in 2019 to 11.40% in 2020, and 11,091 elective surgeries decreased from 29.81% to 3.25%. Similarly, the rate of major surgeries decreased by more than 90%.

In alignment with the study findings, İlhan et al. (10) examined the impact of the COVID-19 pandemic on emergency and elective surgeries, revealing a decline from 947 surgeries performed in 2019 to 165 in 2020, representing a reduction of approximately 90%. They also reported a decline in the elective surgery rate from 80% in 2019 to 34.5% in 2020 (10). Previous studies indicate that the pandemic adversely affected procedures (22, 23). The effective management of patients requiring surgical intervention during the pandemic is crucial for preventing mortality from emergencies and for the ongoing, healthy treatment of cancer patients (24). During this period, surgeons experienced a reduction in elective surgical operations to mitigate virus transmission, while the postponement of these surgeries posed significant challenges (25). Due to the necessity of direct interaction between the patient and the surgeon in surgical diseases, remote healthcare services are deemed inadequate. Therefore, the surgical workforce faced greater challenges than internal medicine during the COVID-19 pandemic (26). Surgeons were instructed to make decisions regarding the prioritization and postponement of surgeries in relation to patient exposure to COVID-19 (27). Similarly, surgeries for patients infected with the virus were deferred, and it was deemed essential to perform surgeries with minimal medical staff in emergency situations (28). Consequently, a significant finding of the present research is that COVID-19 reduced the number of surgeries, which aligns with existing literature. Nonetheless, research indicates that the pandemic did not alter the incidence of certain cases, although the number of such cases studied is limited (29).

Emergency surgeries are categorized by kind as follows: eye and middle ear (18.8%), genitourinary system (18.2%), skeletal system (10.6%), circulatory system (9.3%), digestive system (7.2%), and respiratory system (5.7%). The predominant severe consequence in COVID-19 patients is acute hypoxemic respiratory failure or acute respiratory distress syndrome necessitating oxygen and ventilation interventions (30). Given that elective surgeries were predominantly suspended during the pandemic, and emergency procedures were conducted on patients diagnosed with or suspected of COVID-19 (30), it can be asserted that COVID-19-related complications (such as arrhythmias and acute cardiac damage) also influence the categories of surgeries performed.

The decline in elective surgeries corresponds with the tiered prioritization frameworks established globally during the pandemic. International guidelines categorize surgical urgency into four levels: Emergency (requiring immediate intervention within hours to avert mortality), Urgent (time-sensitive procedures necessary within the days), Semi-urgent (procedures necessary within the 1-4 weeks), and Elective (deferrable for the ≥3 months without substantial harm) (31). This stratification facilitated organized resource distribution and reduced the risks associated with COVID-19 transmission. Our data indicate an 81% overall reduction, with elective surgeries decreasing to 3.25%, which reflects strict adherence to protocols that deferred Category 3-4 procedures (32, 33). The prevalence of gynecological-obstetric surgeries, comprising 36.8% of elective procedures, highlights the prioritization of obstetric time-sensitivity and maternal-fetal health factors (34). The increased frequency of foreign body/implant surgeries may indicate their classification as Category 2 procedures, where delays pose a risk of infection or functional impairment (35). The necessity of these triage decisions may have worsened surgical backlogs for chronic conditions, highlighting a crucial aspect for future health system preparedness (36).

Most elective surgeries were performed in the 19-30 age group (35.8%), primarily due to gynecological diseases (36.8%). The incidence of cesarean deliveries is rising globally and within Türkiye. When cesarean delivery is conducted based on medical need, it significantly decreases perinatal mortality and morbidity; nevertheless, when performed electively, it may result in adverse outcomes for maternal and child health, akin to other surgical procedures (37, 38). The study’s findings indicate that while the incidence of spontaneous vertex births is elevated, elective and emergency cesarean births occur at comparable rates.

Many emergency procedures are conducted on patients aged 60 and over, accounting for 27.8%. The aging process alters the body’s structure and functioning across various dimensions. Therefore, this circumstance requires that surgical interventions on older patients be conducted with increased caution and precision (39). Aging-related physiological changes elevate the incidence of chronic diseases, as well as mortality and morbidity rates among older adults (40). The use of health services by older people is rising due to the prevalence of chronic diseases (41). Therefore, chronic disease management is a pivotal concern that necessitates emphasis on the effective and efficient delivery of health services. The research demonstrated that the incidence of hospital visits after surgery for circulatory system ailments increased with age. This condition can be linked to the rising prevalence of chronic diseases correlated with age.

Recent literature emphasizes the necessity of guaranteeing the reliability and authenticity of medical databases in hospitals through the implementation of standardized procedures. The accuracy of EHRs is essential for clinical decision-making, healthcare operations, and research. Nonetheless, errors frequently emerge from erroneous data entry, absence of standardization, irregular updates, and similar factors. Recent studies support the implementation of standardized data entry protocols, including the utilization of consistent coding systems like Systematized Nomenclature of Medicine – Clinical Terms and ICD-10, to reduce heterogeneity in clinical documentation (42). Furthermore, routine audits and error-checking systems, including automated data validation procedures, are essential for preserving data integrity. Hospitals must develop staff training programs to ensure healthcare personnel are proficient in these requirements and the proper utilization of EHRs (43). By formalizing these standardized procedures, hospitals can reduce the risks of errors that jeopardize data integrity and patient safety.

Regarding the validity of health data, the literature recommends integrating real-time monitoring systems that can flag inconsistencies and alert clinicians to potential data inaccuracies (44). This could involve using artificial intelligence-driven tools to identify incorrect or missing information patterns, enabling timely corrections. Another recommendation is to use interoperable data exchange systems, allowing for the seamless sharing of patient data across different healthcare institutions, which can reduce redundancy and enhance data accuracy (45). These interoperable systems, combined with regular quality checks and continuous improvement processes, ensure that data remains current, relevant, and valid. Hospitals can enhance the trustworthiness and utility of their medical databases through such structured and regularized procedures, thus improving patient outcomes and supporting data-driven healthcare advancements.

Conclusion

The COVID-19 pandemic has resulted in alterations to nearly all medical procedures, particularly surgical treatments. This study analyzed 46,041 procedures conducted from January 1, 2019, to October 1, 2023, at a prominent teaching and research hospital in İstanbul province, assessing data from 18 distinct illness groups based on numerous variables.

Substantial reductions were noted during the pandemic in emergency, elective, major, medium, and minor surgical procedures. All illness groups exhibited a reduction in the number of procedures, except for two categories: foreign body, implant, and graft surgeries, as well as accidents, poisoning, and contact with sharp objects and weapons. The majority of surgeries are classified as emergency procedures, including conditions of the eye, middle ear, genitourinary system, skeletal system, circulatory system, digestive system, and respiratory system. Emergency surgeries for eye and middle ear diseases were predominantly conducted on those aged 60 and above, while elective procedures were primarily carried out on those aged 19 to 30. Most emergency and elective procedures are classified as major surgeries. The incidence of surgical follow-up visits escalates with older age demographics.

Critical care requirements for COVID-19 patients significantly diminished surgical resources, resulting in a 90% reduction in capacity for major surgeries and redirecting emergency attention towards time-sensitive conditions, such as ocular and genitourinary emergencies in the elderly. Moreover, the fear of nosocomial infection led to a decrease in hospital presentations, especially for “semi-urgent” conditions such as chronic venous insufficiency, thereby worsening age-related disparities in post-operative follow-up.

The COVID-19 pandemic revealed significant weaknesses in surgical systems, including insufficient contingency planning for aging populations, as indicated by disproportionate emergency surges among individuals aged 60 and older. The contrast between sustained obstetric volumes and the collapse of elective procedures highlighted the inflexible triage protocols for time-sensitive non-emergent care. Furthermore, unaddressed backlog risks were exemplified by delays in chronic disease management. The identified gaps require a fundamental restructuring of surgical practices to enhance resilience against pandemics. This can be achieved through the establishment of institutionalized tiered prioritization frameworks, such as MeNTS, which dynamically balance resource limitations with procedural urgency; the development of age-optimized pathways that include dedicated operating room slots and rapid discharge protocols for vulnerable elderly patients; and the implementation of real-time backlog surveillance systems aimed at high-risk deferred cases, including circulatory disorders and cancer diagnostics, to mitigate complications. Incorporating these strategies into surgical disaster planning is crucial for ensuring the continuity of essential care during future crises.

During the pandemic, isolation measures were essential for delivering a comprehensive and well-equipped health service. Planning the operating room process requires the implementation of infection control measures. Preparing crisis plans for potential outbreaks in hospital medical processes is essential, as is developing specific emergency plans for surgical and operating room procedures, which are specialized units. Effective human resource planning necessitates the organization of the surgical team and the ongoing training of assistants and nurses. The management of patients diagnosed with COVID-19 prior to, during, and following the surgical procedures requires thorough examination. The surgical team must focus on patient management during both the preoperative and postoperative phases. Health managers should prioritize and plan for both emergency and elective surgeries, oversee the management of materials and devices, optimize time management, implement infection control measures, and maintain effective communication and high staff motivation within operating room processes during the pandemic.