At the end of 2019, several mysterious pneumonia cases of suspected viral origin were reported for the first time in Wuhan, China. Detailed virological and genomic analyses of patient swab samples subsequently traced these cases to a novel type of corona virus termed SARS-CoV-2, which is responsible for the clinical condition and now global pandemic referred to as “COVID-19” .
Coronaviruses are single-stranded RNA viruses that are classified into 4 types . SARS-CoV-2, as well as the previously characterized SARS-CoV which caused the 2002/2003 SARS pandemic, belongs to the genus of beta coronaviruses [1, 2]. These viruses show 82% homology in their genomic sequences  and attach to host cells through their spike proteins (SARS-2-S and SARS-S, respectively) binding to angiotensin-converting enzyme 2 (ACE2) as a receptor . Viral fusion with the host cell and then infection follows as a result of cellular cysteine and serine protease-mediated cleavage of SARS-2-S and SARS . Importantly, ACE2 is found not only in cells of the cardiopulmonary system (lungs, heart, endothelium, kidney), but also in epithelial cells lining the gastrointestinal tract [5, 6]. This expression pattern of ACE2 has implications for the clinical symptoms of patients suffering from SARS-CoV-2 infection. During the SARS outbreak in 2002/2003, patients not only showed pulmonary symptoms, but also presented with gastrointestinal complaints (16–73% of cases) [2, 5]. Covid-19 patients also appear to have gastrointestinal issues in up to 10% of cases [7,8,9,10].
Due to the rapid global spread of SARS-CoV-2 , healthcare systems and their workers worldwide face tremendous challenges, and surgery as a discipline is by no means an exception. Preparations for the developing crisis have initially centred on the provision of intensive care capacities to ventilate seriously ill patients and the maintenance of an adequate supply of protective equipment for medical personnel. As a result, politicians have demanded postponement or even outright cancellation of all elective operations [11, 12]. So far, these measures have failed to take into account SARS-CoV-2 positive patients whose main symptoms of disease are not specific to COVID-19 (e.g. respiratory symptoms, fever) and are thus diagnosed as asymptomatic or oligosymptomatic but with surgical disease (e.g. acute appendicitis, acute limb ischemia, distal radius fracture). These patients must therefore be treated primarily surgically without the need for COVID-19 designation or allocation (e.g. in intensive care medicine).
Surgery is a basic pillar of medical care, which results in the following challenges for everyday clinical practice:
Prioritization of surgical interventions
Establishment of SARS-CoV-2 and non-SARS-CoV-2 emergency rooms
Establishment of a SARS-CoV-2 surgical non-intensive care ward
Establishment of a surgical SARS-CoV-2 operating area
Necessary precautions when using certain surgical techniques
This article is based on real-time experiences from a Surgical Department at the University Hospital Würzburg, Germany, in planning and preparing clinical pathways to ensure high-quality surgical care during the COVID-19 pandemic. These pathways were developed and established in consultation with colleagues from the departments of anaesthesiology, intensive care medicine, microbiology and virology and the specialist team for hospital hygiene.
Since the COVID-19 outbreak is of a very dynamic nature, the following recommendations need to be reevaluated and adapted according to the current situation. This needs to be assessed at least on a daily basis by an interdisciplinary team consisting of members of anaesthesiology, intensive care, internal medicine, surgery, infectiology and hospital hygiene. It may be necessary that due to the high dynamics of events, multi-interdisciplinary exchange needs to take place to modify or adapt existing concepts on demand .