Evaluation of Fine Particles in Surgical Smoke from an Urologist's Operating Room by Time and by Distance

Introduction

Electrocautery, harmonic scalpel tissue dissection and other surgical techniques can generate surgical smoke with high proportion of "fine particles" (PM2.5) <2.5µ,m, which is known to have adverse effects on human health.

Surgeons are exposed to surgical smoke not only from open surgeries, but also from laparoscopic surgeries,1 transurethral resection of bladder tumors (TURBT) and trans urethral resection of the prostate (TURP).2 Surgical smoke is usually composed of chemicals, blood and tissue particles, viruses and bacteria, bringing potential harmfulness to the health of operating room personnel.3 Large amounts of carbon monoxide and carcinogenic compounds such as acrylonitrile, hydrogen cyanide, formaldehyde and benzene were found in surgical smoke.4 It is also said that HPV may be transmitted by surgical plume, making its infectiousness of great concern.5

The horrible thing of PM2.5 is that they can directly reach the small airways and alveoli, thus leading to local inflammatory response, activation of prothrombotic factors, development of artherosclerosis and cardiovascular disease.6 Meta-analysis showed that PM2.5 is associated with increased hospitalization and mortality due to cardiopulmonary disease.7

Surgery types and patients

The authors conducted a prospective study to analyze PM2.5 generated through open surgeries, laparoscopic surgeries and transurethral surgeries. The authors chose three subtypes of surgeries due to surgery depth for the open surgery: inguinal lymph node dissection for penile cancer (superficial surgeries), partial nephrectomy (abdominal surgeries) and radical prostatectomy (pelvic surgeries). Laparoscopic partial nephrectomy was chosen for the laparoscopic surgery group. Transurethral surgeries included TURBT.

Instruments and measurement strategy

For open surgeries, the inlet of Dylos was placed in three different distances (40, 60, and 120 cm) from the incision site, near the breath­ing zone of surgical personnel, to imitate the position of the operator (40cm), the assistant (60cm) and the scrub nurse (120cm). Every cut should last for 2-3 s, and the measuring of PM2.5 should be started and continued for 15 s right after the cut. The PM2.5 was measured with and without a wall suction for surgical smoke evacuation.8

Discussion

The real-time concentration of PM2.5 will reach a peak level about 3-6 s after a single cut. At this period of time, PM2.5 may become 'very unhealthy' or even 'hazardous' (Table below).

G good, M moderate, USG unhealthy for sensitive groups, U unhealthy, VU very unhealthy, H hazardous

In 2004, the first American Heart Association scientific statement concluded that exposure to particulate matter air pollution contributes to cardiovascular morbidity and mortality.9

We investigated that regular surgical masks (used in the author's institute) are not effective in reducing PM2.5.

Key take-aways

  • Surgical smoke evacuation in the first few seconds of a cut is essential; however, using smoke evacuators such as a wallsuction alone may not be enough.
  • Surgeons and other OR personnel should be aware of the potential health hazards and should take proper measures tominimize their exposure to surgical PM2.5.

References

  1. Choi SH, Kwon TG, Chung SK, Kim TH (2014) Surgical smoke may be a biohazard to surgeons performing laparoscopic surgery. Surg Endosc 28(8):2374-2380. doi: 10.1007/s00464-014-3472-3
  2. Zhao C, Kim MK, Kim HJ, Lee SK, Chung YJ, Park JK (2013) Comparative safety analysis of surgical smoke from transurethral resection of the bladder tumors and transurethral resection of the prostate. Urology 82(3):744.e9-744.el4. doi: 10.1016/j. urology.2013.05.028
  3. Hensman C, Baty D, Willis RG, Cuschieri A (1998) Chemical composition of smoke produced by high-frequency electrosurgery in a closed gaseous environment. An in vitro study. Surg Endosc 12(8): 1017-1019
  4. Barrett WL, Garber SM (2003) Surgical smoke: a review of the literature. Is this just a lot of hot air? Surg Endosc 17(6):979-987.doi: 10.1007/s00464-002-8584-5
  5. Garden JM, O'Banion MK, Bakus AD, Olson C (2002) Viral disease transmitted by laser-generated plume (aerosol). Arch Dermatol138(10): 1303-1307
  6. Walczak DA, Grobelski B, Pasieka Z (2011) "There is no smoke without a fire"-surgical smoke and the risk connected with it. Pol PrzeglChir 83(11):634-639. doi: 10.2478/ vl0035-0l l-0101-x.
  7. Atkinson RW, Kang S, Anderson HR, Mills IC, Walton HA (2014) Epidemiological time series studies of PM2.5 and daily mortality and hospital admissions: a systematic review and meta-analysis. Thorax 69(7):660-665. doi: 10.1136/ thoraxjnl-2013-204492.
  8. Edwards BE, Reiman RE (2012) Comparison of current and past surgical smoke control practices. AORN J 95(3):337-350.doi: 10.1016/j.aom.201l.07.019
  9. Brook RD, Franklin B, Cascio W, Hong Y, Howard G, Lipsett M, Luepker R, Mittleman M, Samet J, Smith SC Jr, Tager I (2004) Air pollution and cardiovascular disease: a statement for healthcare professionals from the Expert Panel on Population and Prevention Science of the American Heart Association. Circulation 109(21):2655-2671. doi: 10. l 161/01.CIR.0000128587.30041.C8