The ongoing COVID-19 pandemic has placed tremendous strain on healthcare services and has called for the repurposing of available resources; resulting in forced suspension of elective surgery in most countries. Suggestions from surgeons working in the early epicentres of this pandemic in Asia and Europe led to the formulation of early recommendations for managing surgical patients during the crisis 1-3 . Additionally, countries responded by altering their surgical services according to their own circumstances and contributed to emerging guidelines 4 . At the same time, many patients being deprived of elective surgical access prompted prescient surgeons to start making contingency plans for maintaining surgical care in an ongoing or post-pandemic phase 5,6 .
An important step in this direction was taken by the Welsh Surgical Research Initiative (WSRI) Collaborative who conducted an international Delphi exercise to have a global consensus on safe operating room (OR) practices during the COVID-19 pandemic 7 . One of the contentious issues addressed in this landmark study was the risk of virus transmission via aerosol generated during general anaesthesia and surgical procedures 8 . Suggestions for dealing with this were 'operating rooms should be filtered and ventilated, ideally with negative pressure, for CV19 patients' and 'use of special automatic diathermy smoke evacuators' 7 .
Lack of equitable surgical services in low-and middle-income countries (LMICs) is well known 9 . The majority of ORs in LMICs are non-modular without laminar flow systems and work on stand-alone air conditioners. Upgrading these to the recommended level of filtration, ventilation and negative pressure may not be possible, due to economic constraints. We suggest the use of strong exhaust fans in ORs to create a temporary negative pressure room; a lesson learned from Severe Acute Respiratory Syndrome (SARS), the first pandemic of the 21 st century 10 . A simple duct system can be easily constructed, which connects to an exhaust and releases the air at least 3 meters above the roof. This idea can be adopted as a alternate solution.
Similarly, acquiring expensive devices such as specialized diathermy smoke evacuators (which cost around INR 1 000 000/£11 000) may not be possible for most small independent hospitals, which are the backbone of surgical services in smaller towns of LMICs. We suggest the use of indigenous low-cost heat and moisture exchanger (HME) smoke filters (approx INR 600-1200/£7-14) for laparoscopy 11 and incorporation (tying with rubber bands) of traditional suction cannula to a cautery hand piece (for open surgery) as simple frugal solutions.
The speed of transmission and severity of COVID-19 has prompted many frugal innovative responses; especially in LMICs 12 . Our low cost ideas may not be ideal but have the potential to provide good enough healthcare in the best way possible under given constraints. 'Social distancing' has become a current buzz word; greater inclusion of the needs of LMICs in scientific discussions will avoid the impression of 'social distancing' between the global North and global South. 