6. AUTHORS
N. Mowbray Aneurin Bevan Health Board, Newport, UK
J. Ansell Royal College of Surgeons of England, Welsh Institute of
Minimal Access Therapy (WIMAT), Cardiff CF14 4UJ, UK
e-mail: ansellj@cf.ac.uk; ansellj@cardiff.ac.uk
N. Warren Welsh Institute of Minimal Access Therapy (WIMAT), Cardiff, UK
P. Wall Isca Healthcare Research, Caerleon, UK
J. Torkington Department of Colorectal Surgery, University Hospital of Wales, Cardiff, UK
7. INTRODUCTION
Surgical smoke is the airborne byproduct generated by the use of energy-
based instruments in operating theaters.
These instruments are an integral part of modern surgery and are routinely
used across a wide range of surgical specialties.
The hazards of surgical smoke may have wide reaching implications.
Energy-based instruments used in operations include mono- and bipolar
diathermy (electrocautery), ultrasonic scalpels, and lasers.
8. INTRODUCTION
Electrocautery devices and lasers heat target cells to the point of boiling, causing the cell
membranes to rupture.
This process disperses fine particles into the atmosphere.
Ultrasonic devices use a vibrating plate to cause cell rupture at much lower temperatures than
electrocautery.
This causes cutting and coagulation simultaneously without an electrical current being passed
through the tissue.
9. INTRODUCTION
Concerns have been raised regarding the infectivity, mutagenicity, and cytotoxicity
of surgical smoke from all the aforementioned devices.
In addition, surgical smoke is odorous and reduces the view of the operative field,
especially during laparoscopic procedures.
Many health organizations have recommended the routine use of evacuation
devices to avoid potential problems
Despite this general consensus that surgical smoke should be treated with caution,
the use of local exhaust ventilation has changed very little in recent years
10. INTRODUCTION
Surgical smoke is the encompassing term for a number of gaseous
byproducts produced by energy-based surgical instruments.
The definition of ‘‘smoke’’ refers to the products of combustion, whereas
‘‘vapor,’’ ‘‘aerosol,’’ and ‘‘mist’’ refer to the suspension of liquid particles.
Electrocautery devices are described as creating a ‘‘plume’’ of smoke,
whereas ultrasonic devices are described as creating ‘‘vapors,’’ ‘‘aerosols,’’
and ‘‘mists.’’
11. INTRODUCTION
The byproducts of lasers have been referred to by all of these terms
Because the terminology is used interchangeably, this review uses the
general term of ‘‘surgical smoke’’ to encompass all the aforementioned
terms.
12. INTRODUCTION
This review identifies the current evidence for the properties of surgical
smoke and the harmful effects to health care professionals exposed to
it.
We aim to identify whether the harmful effects are related to the type
of energy-based instrument used.
This information is used to formulate clinical recommendations and
highlight areas requiring further research in the future.
13. MATERIALS AND METHODS
(SEARCH STRATEGY)
A systematic review of published work was conducted according to the
Preferred Reporting Items for Systematic Review and Meta-Analyses
(PRISMA) guidelines.
The following sources were searched for studies concerning the evaluation
of surgical smoke and its effects:
MEDLINE (1947 to the present),
PubMed (1966 to the present),
Cochrane database,
Embase classic + Embase (1947–2012), and
the metaRegister of controlled trials.
14. MATERIALS AND METHODS
(SEARCH STRATEGY)
The search used three search domains of exploded medical subject
heading (MeSH) terms combined by ‘‘AND.’’
Within each domain, the terms were combined with ‘‘OR.’’
The first domain contained the terms for surgical smoke.
The second domain consisted of the instruments that generate or remove
smoke, and
the third domain comprised the hazards of surgical smoke.
15. MATERIALS AND METHODS
(SEARCH STRATEGY)
The search was performed by two investigators independently.
Titles and abstracts were reviewed by each individual.
Duplicates and those clearly unrelated were discarded.
The articles were retrieved and the inclusion criteria applied.
Cross-referencing was carried out against the most recent relevant articles.
The last search date was 4 January 2013.
16. MATERIALS AND METHODS
(INCLUSION AND EXCLUSION CRITERIA)
Studies were included if they documented the
constituents found in surgical smoke during human surgical procedures,
methods used to analyze the smoke,
implications of exposure to smoke, and
type of energy-based surgical instrument that generated the smoke.
Only original articles were included.
Studies were excluded if they were animal based, preclinical experimental
work, conference abstracts, or opinion-based reports.
17. MATERIALS AND METHODS
(DATA EXTRACTION, OUTCOME MEASURES, AND ANALYSIS)
The included studies were rated according to guidelines from the Centre
for Evidence-Based Medicine (CEBM).
Each paper was examined to identify the energy device used, the smoke
properties and particle size, the risk of infection, and the mutagenic risk.
Some additional material was used to prepare the background information
for the review e.g. manual searches and information from specialist
textbooks, government agency publications, and healthcare professional
organizations.
All sources are cited where appropriate.
18.
19. RESULTS
Parameter Total number of studies = 20
diathermy/electrocautery laser Ultrasound devices
size of the particles
(5 studies)
4 2 0
Constituents of surgical
smoke
(7 studies)
7 0 1
Infectivity
(6 studies)
1 6 0
Mutagenic effect 1 0 0
Presence of Malignant
cells
1 0 0
20. RESULTS
(PARTICLE SIZE)
Overall size of particles found in all types of
smoke for all procedures
0.05 micron to larger than 25 micron
Ultrafine particles (UFP)
[found in laser and electrocautery]
Laparoscopic laser use 0.1 – 0.8 micron
Laparoscopic electrocautery 0.1 – 0.025 micron
THR electrocautery aerosol particles < 1 micron
Peritonectomy electrocautery 0.002 – 1 micron
1 study ( electrocautery and argon laser
coagulation)
10 nm to 1 micron
22. RESULTS
(PARTICLE CHARACTERIZATION)
The surgical smoke evaluated by these studies had several components
with known carcinogenic properties
A non-significant trend showed lower levels of benzene, toluene,
heptene, ethylbenzene, and methylpropene with the use of the
ultrasonic scalpel compared with electrocautery
24. RESULTS
(INFECTION RISK)
Only Capizzi et al and Kunachak et al assessed the
infectivity of smoke
Rest only identified the presence of material in smoke
26. RESULTS
(INFECTION RISK) 5/8 laser derived vapors
4/7 electrocoagulation derived vapors
Greater amount of HPV DNA in lasers vapors
27. RESULTS
(MUTAGENESIS AND MALIGNANT SPREAD)
Ikramuddin et al. assessed the
ability of surgical smoke to spread
malignancy.
During laparoscopic surgery, the pneumoperitoneum
was sampled for either malignant or benign
conditions via a port site. Aerosolized malignant cells were
identified.
The mutagenic potential of surgical smoke from electrocautery was evaluated by one study during
reduction Mammoplasty
28. DISCUSSION
(THIS REVIEW)
This is the first systematic review to detail the potential harmful effects of
surgical smoke to theater staff.
Surgical smoke from a range of electrosurgical methods can produce
particles small enough to be inhaled.
Viruses, bacteria, and malignant cells may be present in smoke.
No existing literature establishes a direct link between the components of
smoke and the transmission of disease.
29. DISCUSSION
(COMPARISON WITH PREVIOUS REVIEWS)
Although several published reviews have collated current information on
surgical smoke, none has used a systematic format.
Unlike previous reviews, we looked solely at studies using in vivo
techniques.
We accept that by excluding all in vitro and experimental data, we may
have underestimated the full potential effects of surgical smoke. The
research identified in this study was, however, thought to be more clinically
relevant and hence applicable to theater staff.
30. DISCUSSION
(COMPARISON WITH PREVIOUS REVIEWS)
The literature contains a wide variety of studies with varying
methodologic designs and presentations of results.
The papers included in this review detail a range of operations using
different electrosurgical instruments.
Collection and analysis of surgical smoke was conducted in different
ways.
31. DISCUSSION
(COMPARISON WITH PREVIOUS REVIEWS)
Whereas some methods involved sampling immediately adjacent to the
instrument, others sampled from atmospheric air and from the air termed
‘‘the breathing zone.’’
This could have introduced variation into the concentration of compounds
and also into the size or type of particle captured.
Heavier particles may not travel as far.
We have, however, shown that common end points such as particle nature
and infectivity are identifiable, but clear standardization of smoke analysis
studies in the future could prove useful.
32. DISCUSSION
(PARTICULATE SIZE)
The evidence suggests that the surgical smoke particles are of respirable size.
Particles smaller than 10 lm are inhalable, and particles 2.5–10 lm in size can deposit
in the respiratory tract.
Ultrafine particles can precipitate into the alveolar region of the lung, where the only
clearance mechanism is phagocytosis via alveolar macrophages
There were no studies to indicate the effect of UFPs.
It should be noted that surgical masks, even if correctly fitted and frequently
changed, can effectively filter only particles larger than 5 micron in size.
33. DISCUSSION
(INFECTIVITY RISK)
The debate over the infectivity of surgical smoke appears to focus
largely on skin lesions. Perhaps this is due to the popular application of
lasers to treat viral lesions.
These lesions often are easily accessible, numerous, and treatable under
local or general anesthesia.
34. DISCUSSION
(INFECTIVITY RISK)
Some evidence shows HPV DNA to be present in surgical smoke, but
this does not prove its ability to transmit infection
Indeed, no evidence was found to suggest viral infectivity, and only one
study examined the bacterial component of surgical smoke.
35. DISCUSSION
(INFECTIVITY RISK)
Perhaps bacterial infectivity is a subject of less concern because electrosurgical
devices are not used specifically to treat bacterial infections.
Evidence is lacking for infectivity of other energy-based instruments, including
electrocautery and ultrasonic devices.
Given that ultrasonic devices reach a lower temperature, the possibility exists that
this cellular debris remains infectious.
Future research in this area may be useful together with a direct comparative study
of the smoke generated from similar operations in infectious and noninfectious
patients.
36. DISCUSSION
(MUTAGENIC RISK)
A small body of evidence suggests that surgical smoke carries a
mutagenic risk with no link to disease.
A longitudinal study of theater nursing staff (86,747 women adjusted
for smoking history and increased risks of lung cancer) did not show an
increased rate of lung cancer even among those with the longest
operating room history
37. EXISTING RECOMMENDATIONS
UK British Occupational Hygiene society (BOHS)
The Association for Perioperative Practice (AfPP)
Medicines and Healthcare Products Agency (MHRA)
Canada Canadian Standards Association (CSA)
Operating Room Nurses Association of Canada (ORNAC)
Australia Australian College of Operating Room Nurses (ACORN)
International The International Federation of Perioperative Nurses (IFPN)
International Society Security Association (ISSA)
38. EXISTING RECOMMENDATIONS
USA Association of periOperative Registered Nurses (AORN)
Occupational Safety & Health Administration (OSHA)
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
National Institute for Occupational Safety and Health/Centre for Disease Control
(NIOSH/CDC)
American National Standards Institute (ANSI)
American Society for Laser Medicine and Surgery (ASLMS)
39.
40. CONCLUSION
This review confirms that surgical smoke contains potentially carcinogenic compounds
physically small enough to be respirable and even reach the lower airways.
Despite this, we have found little evidence for the long-term effects of surgical smoke in
vivo. Both infective and malignant cells exist in surgical smoke, but their viability has not
been assessed.
This review can conclude that although the potential for harm is present, the risk
presented to the theater staff remains unproven.
Further research is needed to identify this and should focus on comparing the smoke
produced by different energy-based devices, the use of removal systems, and the long-
term consequences of smoke exposure.
42. REFERENCES
1. Massarweh NN, Cosgriff N, Slakey P (2006) Electrosurgery: history, principles, and current and future
uses. J Am Coll Surg 202:520–530
2. Lawrentschuk N, Fleshner NE, Bolton DM (2010) Laparoscopic lens fogging: a review of etiology and
methods to maintain a clear visual field. J Endourol 24:905–913
3. Spruce L, Braswell ML (2012) Implementing AORN-recommended practises for electrosurgery.
AORN J 96:373–388
4. British Occupational Hygiene Society (2006) COSHH guidance: surgical smoke. Retrieved 7 January
2013 at http://www.bohs. org/uploadedFiles/Groups/Pages/Surgical_smoke.pdf
5. The National Institute for Occupation Safety and Health (1996) Control of smoke from laser/electric
surgical procedures. Retrieved 7 January 2013 at
http://www.cdc.gov/niosh/docs/hazardcontrol/pdfs/hc11.pdf
43. REFERENCES
6. CSA Group (2009) Surgical, diagnostic, therapeutic, aesthetic plume scavenging. Retrieved 7 January
2013 at http://www.csa.ca/cm/ca/en/home
7. Edwards BE, Reiman RE (2008) Results of a survey on current surgical smoke control practices. AORN
J 87:739–749
8. Edwards BE, Reiman RE (2012) Comparison of current and past surgical smoke control practices.
AORN J 95:337–350
9. Barrett WL, Garber SM (2003) Surgical smoke: a review of the literature. Surg Endosc 17:979–987
10. PRISMA (2012) PRISMA transparent reporting of systematic reviews and meta-analyses. Retrieved
19 December 2012 at http://www.prisma-statement.org/statement.htm
44. REFERENCES
11. Centre for EBM Levels of Evidence (2012) Oxford centre for evidence-based medicine: levels of
evidence. Retrieved 19 December 2012 at http://www.cebm.net/index.aspx?o=1025
12. Andreasson SN, Anundi H, Sahlberg B, Ericsson CG, Walinder R, Enlund G, Pahlman L, Mahteme H
(2009) Peritonectomy with high-voltage electrocautery generates higher levels of ultrafine smoke
particles. Eur J Surg Oncol 35:780–784
13. Bruske-Hohfeld I, Preissier G, Jauch KW, Pitz M, Nowak D, Peters A, Wichmann HE (2008) Surgical
smoke and ultrafine particles. J Occup Med Toxicol 3:31
14. DesCoteaux JG, Picard P, Poulin E, Baril M (1996) Study ofelectrocautery smoke particles produced
in vitro and during laparoscopic procedures. Surg Endosc 10:152–158
15. Nezhat C, Winer WK, Nezhat F, Nezhat C, Forrest D, Reeves WG (1987) Smoke from laser surgery: is
there a health hazard?Lasers Surg Med 7:376–382
45. REFERENCES
16. Smith J, Yeh HC, Muggenburg B, Guilmette R, Martin LS, Strine PW (1992) Study design for the
characterization of aerosols during surgical procedures. J Scand J Work Environ Health 18(Suppl 2):106–109
17. Fitzgerald JE, Malik M, Ahmed I (2012) A single-blind controlled study of electrocautery and ultrasonic
scalpel smoke plumes in laparoscopic surgery. Surg Endosc 26:337–342
18. Hollmann R, Hort CE, Kammer E, Naegele M, Sigrist MW, Meuli-Simmen C (2004) Smoke in the operating
theatre: an unregarded source of danger. Plast Reconstr Surg 114:458–463
19. Lin YW, Fan SH, Chang KH, Huang CS, Tang CS (2010) A novel inspection protocol to detect volatile
compounds in breast surgery electrocautery smoke. J Formos Med Assoc 109:511–516
20. Moot AR, Ledingham KM, Wilson PF, Senthilmohan ST, Lewis DR, Roake J, Allardyce R (2007) Composition
of volatile organic compounds in diathermy plume as detected by selected ion flow tube mass spectrometry.
Anz J Surg 77:20–23
46. REFERENCES
21. Sagar PM, Meagher A, Sobczak S, Wolff BG (1996) Chemical composition and potential hazards of
electrocautery smoke. Br J Surg 83:1792
22. Weston R, Stephenson RN, Kutarski PW, Parr NJ (2009) Chemical composition of gases surgeons
are exposed to during endoscopic urological resections. Urology 74:1152–1155
23. Wu YC, Tang CS, Huang HY, Liu CH, Chen CH, Chen CR, Lin YW (2011) Chemical production in
electrocautery smoke by a novel predictive model. Eur Surg Res 46:102–107
24. Abramson AL, Dilorenzo TP, Steinberg BM (1990) Is papillomavirus detectable in the plume of
laser-treated laryngeal papilloma? Arch Otolaryngol Head Neck Surg 116:604–607
25. Capizzi PJ, Clay RP, Battey MJ (1998) Microbiologic activity in laser resurfacing plume debris. Lasers
Surg Med 23:172–174
47. REFERENCES
26. Hughes PSH, Hughes AP (1998) Absence of human papillomavirus DNA in the plume of erbium: YAG laser-
treated warts. J Am Acad Dermatol 38:426–428
27. Kunachak S, Sithisarn P, Kulapaditharom (1996) Are laryngeal papillomavirus-infected cells viable in the
plume derived from a continuous mode carbon dioxide laser, and are they infectious? A preliminary report on
one laser mode. J Laryngol Otol 110: 1031–1033
28. Sawchuk WS, Weber PJ, Lowy DR, Dzubow LM (1989) Infectious papillomavirus in the vapor of warts treated
with carbon dioxide laser or electrocoagulation: detection and protection. J Am Acad Dermatol 21:41–49
29. Wisniewski PM, Warhol MJ, Rando RF, Sedlacek TV, Kemp JE, Fisher JC (1990) Studies on transmission of
viral disease via the CO2 laser plume and ejecta. J Reprod Med 35:1117–1123
30. Gatti JE, Bryant CJ, Noone RB, Murphy JB (1992) The mutagenicity of electrocautery smoke. Reconstr Surg
89:781–784
48. REFERENCES
31. Ikramuddin S, Lucas J, Ellison EC, Schirmer WJ, Melvin WS (1998) Detection of
aerosolised cells during carbon dioxide laparoscopy. J Gastro Surg 2:580–583
32. Ulmer BC (2008) The hazards of surgical smoke. AORN J 87:721–734
33. Sanderson C (2012) Surgical smoke. J Perioper Pract 22:122–128
34. Lewin JM, Brauer JA, Ostad A (2011) Surgical smoke and the dermatologist. J Am Acad
Dermatol 65:636–641
35. Donaldson K, Brown D, Clouter A, Duffin R, Macnee W, Renwick L, Tran L, Stone V
(2002) The pulmonary toxicology of ultrafine particles. J Aerosol Med 15:213–220
49. REFERENCES
36. Gates MA, Feskanich D, Speizer FE, Hankinson SE (2007) Operating room nursing
and lung cancer risk in a cohort of female registered nurses. Scand J Work Environ
Health 33: 140–147
37. Medicines and Healthcare Product Regulatory Agency (2008) Guidance on the
safe use of lasers, intense light source systems and LEDs in medical, surgical, dental,
and aesthetic practices. Retrieved 4 December 2012 at
http://www.mhra.gov.uk/home/groups/dtsiac/documents/publication/con014843.pd
f
38. American National Standard (2007) American National Standard for Safe Use of
Lasers Institute. Retrieved 7 January 2013 at http://www.lia.org/PDF/Z136_1_s.pdf