Clinical Impact of Surgical Smoke Evacuators: A Review of the Relevant Literature

Top Level Summary

The use of electrosurgery tools, laser ablation and ultrasonic scalpels during Operating Room (OR) procedures generate surgical smoke through thermal tissue destruction. Surgical smoke causes several health hazards to OR personnel depending on chemical composition of smoke, duration and type of procedure, type of tissue ablation and worker’s proximity to surgical field. In recent studies, surgical smoke has been reported to be carcinogenic, mutagenic and capable of carrying viable viruses, viable bacteria and cells.1, 4, 6

Although surgical smoke exposure is unavoidable for OR personnel, studies have discussed the positive clinical impact of a smoke evacuator during procedures including better visualization of surgical field, reduced risk of exposure to harmful compounds and possible prevention of aerosolization of bacteria to surgical site. 1, 2

Key Take-aways

  • It is estimated that each year 500,000 healthcare workers are exposed to surgical smoke, with potentially serious repercussions.3
  • Ablation of 1 g of tissue produces a smoke plume with an equivalent mutagenicity to six unfiltered cigarettes.4
  • Surgical smoke contains intact virions (HIV, Hepatitis, HPV), viable bacteria and viable cells.6,12 In an animal
  • study, surgical smoke was reported as a vehicle for transplanting malignant cell to benign tissue.6,7
  • Standard surgical masks are inadequate in filtering smaller size particles(less than 1.1 microns) and 77% of the particulate matter of surgical smoke is less than 1.1 microns in size.5

Discussion and Conclusions

Surgical smoke evacuation devices have been shown to be effective in limiting exposure to the noxious odor and potential health hazards of smoke and plume.1,2 Although no legal or regulatory mandate specific to surgical smoke evacuation currently exists, a number of standard organizations (OSHA, NIOSH and AORN) recommend removal of surgical smoke with acceptable engineering controls and local ventilation including smoke evacuation systems.3,11 Yet, these devices have not been used on a routine and consistent basis in many ORs.5 A multispecialty survey, by the Royal College of Surgeons (England), found only 3% of surgeons used a smoke extracting device in their practice.8 A few reasons for lack of use of smoke evacuation devices may include high cost, inconvenience due to loud noise, and a general lack of knowledge regarding potential hazards associated with exposure to surgical smoke plumes.9,10 Despite the mutagenic effects and presence of carcinogens in the surgical smoke being known for over 20 years, scientific consensus on the dangers of long-term human exposure is lacking.13

Authors acknowledge that expense, convenience, and apathy are unacceptable impediments when the health and safety of OR personnel may be compromised without evacuation devices.10 Authors concluded that although studies in larger cohorts are needed on long-term health effects of surgical smoke exposure4, available study evidence indicate that it is time to mandate the use of smoke evacuation systems in every OR.10

  1. Schultz et al. “Can Efficient Smoke Evacuation Limit Aerosolization of Bacteria?” JAORN. Jul;102(1):7-14. 2015.

  2. Takahashi et al. “Automatic smoke evacuation in laparoscopic surgery: a simplified method for objective Evolution”. Surg Endosc. Aug;27(8):2980-7. 2013.

  3. Laser/Electrosurgery Plume, Occupational Safety and Health Administration, accessed at on Oct. 31, 2014.

  4. Hill et al. “Surgical smoke - a health hazard in the operating theatre: a study to quantify exposure and a survey of the use of smoke extractor systems in UK plastic surgery units,” J Plast Reconstr Aesthet Surg. Jul;65(7):911-6. 2012.

  5. Weber et al. “Aerosol penetration and leakage characteristics of masks used in the health care industry”. Am J Infect Contr. Aug;21(4):167- 73. 1993.

  6. Alp et al. “Surgical Smoke and Infection Control”. J Hosp Infect. Feb;62:1-5. 2006.

  7. Fletcher et al. “Dissemination of Melanoma Cells within Electrocautery Plume,” Am J Surg. Jul;178(1):57-9. 1999.

  8. Spearman et al. “Current attitudes and practices towards diathermy smoke”. Ann R Coll Surg Engl. 89(2):162–165. 2007.

  9. Cunnington J. “Facilitating benefit, minimizing risk: Responsibilities of the surgical practitioner during electrosurger”. J Perioper Pract. 16(4):195. 7-202. 2006.

  10. Bigony L. “Risks associated with exposure to surgical smoke plume: a review of the literature”. AORN J. 86(6):1013–1020. quiz 1021-4. 2007.

  11. Control Bulletin 96-128, Control of smoke from laser/electric surgical procedures, National Institute for Occupational Safety and Health, Washington, DC

  12. Fan et al. “Surgical smoke”. Asian J Surg. Oct; 32(4):253-7. 2009.

  13. Tomita et al. “Mutagenicity of smoke condensates induced by CO2-laser irradiation and electrocauterization”. Mutat Res. Jun; 89(2):145-9. 1981.

  14. Kwak et al. “Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery”. Occup Environ Med. Dec;73(12):857- 863.2016.

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