question: BACKGROUND: Throughout the COVID-19 pandemic, there has been worldwide debate regarding whether open surgery should be performed in preference to laparoscopic surgery due to the theoretical higher risk of viral aerosolization by the release of pneumoperitoneum. We aimed to assess the consistency of national and international surgical society recommendations regarding the choice of surgical approach; assess the quality of evidence of viral emission in surgical aerosol; and assess the quality of evidence comparing aerosol generation by different surgical energy devices. METHODS: A systematic review of PubMed, Medline, Embase and Cochrane databases was performed. Three search strategies were employed. Twenty-eight studies were included in the final analysis and quality appraised. Confidence in review findings was assessed using the GRADE-CERQual (Confidence in Evidence from Reviews of Qualitative research) tool. RESULTS: Worldwide recommendations regarding open versus laparoscopic surgery are consistent, with a majority recommending that surgical approach is decided on a case-by-case, risk minimization approach. There is limited, low-quality evidence that viral particles can be emitted in surgical aerosol. There is a paucity of literature on the quantity of aerosol produced by different surgical energy devices, and no evidence to support the use of certain surgical instruments to minimize aerosol production. CONCLUSIONS: There is considerable consistency among worldwide recommendations regarding the choice of surgical approach, although the evidence base is lacking. To inform clinical recommendations, further research examining viral emission, transmission, infectivity and amount of surgical aerosol produced is required.