Health Risks Associated with Exposure to Surgical Smoke for Surgeons and Operation Room Personnel
Although electrosurgical technology was developed by Harvey Cushing and William T. Bovie in 19261, "surgical smoke" was not officially recognized as a significant hazard until the National Institute for Occupational Safety and Health (NIOSH) published and distributed a Health Hazard Evaluation Report in 1985.2
Surgeons and operating room (OR) personnel are routinely exposed to surgical smoke. Many research studies have confirmed that this smoke can contain potentially hazardous substances, including dead and living cellular material3,4, blood fragments5, bacteria6,7, viruses8,9,10,11, toxic gases and vapors (e.g., benzene2,12, toluene13,12,14,15,16, carbon monoxide17,18, acrylonitrile12, methylpropene16, acetaldehyde19 and lung - damaging particulates.20
Surgical smoke control by local exhaust ventilation (LEV) has been recommended by professional organizations and government agencies in the U.S., including the Association of periOperative Registered Nurses (AORN), the American National Standards Institute (ANSI), the Occupational Safety and Health Administration (OSHA), NIOSH and the CDC.21,22 However, according to a survey from the U.S. and Canada, many ORs still do not provide protection from exposure to surgical smoke, and the most common obstacle to providing such protection has been the surgeons' resistance or refusal to allow the use of LEV.23
The authors set out with a primary objective of this article to demonstrate to surgeons that surgical smoke may present serious hazards to themselves and other OR personnel. The secondary objective is to discuss the possible means of avoiding or minimizing exposure to surgical smoke.
Potential health risks of surgical smoke
The composition of surgical smoke varies considerably, with the nature and size of the particles generated depending greatly on the type of procedure, energy used and power level employed. The adverse effects to OR personnel vary depending on what the smoke contains. A list of potential risks to health are shown in the table below.
Particles that are 5 µm or larger are deposited on the oropharyngeal walls, whereas aerosols between 2 and 5 µm are delivered to the airways and aerosols between 0.8 and 3.0 µm reach the pulmonary parenchyma.25
Surgical smoke exposure may increase the risk of acute or chronic pulmonary conditions, such as asthma or pneumonia. With respect to acute respiratory symptoms, Navarro-Meza et al.26 reported that in Mexico, many surgical residents develop lumps in their throat (58%) and sore throat (22%) as a result of exposure to electrocautery smoke. The plastic surgeons at Bryn Mawr Hospital experiencing acute health effects, including upper respiratory and eye irritation, headache and nausea, during breast reduction procedures.2 Ball et al. reported that the incidence of some respiratory problems, such as bronchitis, asthma, sinus infections and allergies in perioperative nurses was double that of the general population.27,28
Components of surgical smoke
Surgical smoke is made up of 95% water or steam and 5% cellular debris in the form of particulate materials.22 The mean aerodynamic size of particles generated varies greatly depending on the device used. Electrocautery creates particles of the smallest aerodynamic size (0.07 µm)29, whereas laser tissue ablation creates larger particles (0.31 µm)30, and the largest particles are generated by ultrasonic scalpels (0.35-6.5 µm)5. In general, smaller particles are of greater concern from a chemical standpoint, whereas larger particles are of more concern from a biological standpoint.31
The chemical composition of surgical smoke has been well documented; a number of toxic chemical byproducts have been identified. According to a review by Pierce et al.32, researchers have reported 150 chemical constituents of plume. Electrothermal injuries and the burning of proteins and lipids produce a noxious odor that is noticeable to personnel in the OR.
Smoke generated by various surgical devices
Numerous chemicals, some of which are hazardous and present in greater than negligible quantities, have been found in surgical smoke generated by electrocautery. The most abundant chemicals in electrocautery smoke are hydrocarbons, nitriles, fatty acids and phenols.31
Exposure to surgical smoke in the OR
It is commonly believed that the scrubbed members of a surgical team are at greater risk from inhaling smoke than those further away. In fact, surgeons working 20-40 cm from the point of smoke generation are exposed to the highest concentrations of plumes.33 However, nurses and other OR personnel, along with anesthesia providers, are constantly exposed to the hazards of surgical smoke; the exposure of surgeons is often much less because they may operate only a few times a week.21
Limitations of surgical masks and respirators
Surgical masks are the most commonly used type of protective facemask in perioperative and other hospital settings. Although surgical masks provide a barrier to splashes and droplets impacting on the wearer's nose, mouth and respiratory tract, they do not provide protection against airborne (aerosol) particles:34 most surgical masks are designed to filter particles that are >5 µm.21
- Surgical masks do not provide protection against airborne (aerosol) particles in surgical smoke.
- Surgical smoke should be removed by a smoke evacuation system during both open and laparoscopic procedures.
- Surgeons should assess the potential dangers of surgical smoke, educate the OR staff about these dangers and encourage the use of evacuation devices to minimize potential health hazards to surgical personnel.
- Cushing H. Electro-surgery as an aid to the removal of intra.cranial tumors. With a preliminary note on a new surgical-current generator by W.T. Bovie, Ph.D., Chicago. Surg Gynecol Obstet. l 928;47:751-84.
- NIOSH, Health Hazard Evaluation Report. HETA 85-126-1932, 1988. p. 2.
- Fletcher JN, Mew D, Descoteaux JG. Dissemination of melanoma cells within electrocautery plume. Am J Surg. 1999;178:57-9.
- Nduka CC, Poland N, Kennedy M, Dye J, Darzi A. Does the ultrasonically activated scalpel release viable airborne cancer cells? Surg Endosc. 1998; 12: 1031--4.
- Ott DE, Moss E, Martinez K. Aerosol exposure from an ultrasonically activated (Hannonic) device. J Am Assoc Gynecol Laparosc. 1998;5:29-32.
- McKinley IB Jr, Ludlow MO. Hazards of laser smoke during endodontic therapy. J Endod. 1994;20:558---9.
- Capizzi PJ, Clay RP, Battey MJ. Microbiologic activity in laser resurfacing plume and debris. Lasers Surg Med. 1998;23: 172--4.
- Ferenczy A, Bergeron C, Richart RM. Human papillomavirus DNA in CO2 laser-generated plume of smoke and its consequences to the surgeon. Obstet Gynecol. 1990;75: 114-8.
- Taravella MJ, Weinberg A, May M, Stepp P. Live virus survives excimer laser ablation. Ophthalmology. 1999;106:1498---9.
- Garden JM, O'Banion MK. Shelnitz LS, Pinski KS, Bakus AD, Reichmann ME, et al. Papillomavirus in the vapor of carbon dioxide laser-treated verrucae. JAMA. 1988;259: 1199-202.
- Baggish MS, Poiesz BJ, Joret D, Williamson P, Refai A. Presence of human immunodeficiency virus DNA in laser smoke. Lasers Surg Med. 1991;11:197-203.
- Zhao C, Kim MK, Kim HJ, Lee SK, Chung Y J, Park JK. Comparative safety analysis of surgical smoke from transurethral resection of the bladder tumors and transurethral resection of the prostate. Urology. 20l3;82(744):e9-l 4.
- Hensman C, Baty D, Willis RG, Cuschieri A. Chemical composition of smoke produced by high-frequency electrosurgery in a closed gaseous environment: an in vitro study. Surg Endosc. 1998;12:1017-9.
- Al Sahaf OS, Vega-Catrnscal I, Cunningham FO, McGrath JP, Bloomfield FJ. Chemical composition of smoke produced by high-frequency electrosurgery. Ir J Med Sci. 2007;176:229-32.
- Lin YW, Fan SZ, Chang KH, Huang CS, Tang CS. A novel inspection protocol to detect volatile compounds in breast surgery electrocautery smoke. J Formos Med Assoc. 2010;109:511-6.
- Fitzgerald JE, Malik M, Ahmed I. A single-blind controlled study of electrocautery and ultrasonic scalpel smoke plumes in laparoscopic surgery. Surg Endosc. 2012;26:337--42.
- Beebe DS, Swica H, Carlson N, Palahniuk RJ, Goodale RL. High levels of carbon monoxide are produced by electrocautery of tissue during laparoscopic cholecystectomy. Anesth Analg. 1993;77:338---41.
- Gianella M, Hahnloser D, Rey JM, Sigrist MW. Quantitative Chemical analysis of surgical smoke generated during laparoscopic surgery with a vessel-sealing device. Surg Innov. 2013. doi:10.l 177/1553350613492025.
- Takahashi H, Yamasaki M, Hirota M, Miyazaki Y, Moon JH, Souma Y, et al. Automatic smoke evacuation in laparoscopic surgery: a simplified method for objective evaluation. Surg Enclose. 2013;27:2980-7.
- Baggish MS, Elbakry M. The effects of laser smoke on the lungs of rats. Am J Obstet Gynecol. 1987;156:1260-5.
- Ball K. Update for nurse anesthetists. Part 1. The hazards of surgical smoke. AANAJ. 2001;69:125---32.
- Ulmer BC. The hazards of surgical smoke. AORN J. 2008;87:721-34.
- Edwards BE, Reiman RE. Comparison of current and past surgical smoke control practices. AORN J. 2012;95:337-50.
- Alp E, Bijl D, Bleichrodt RP, Hansson B, Voss A. Surgical smoke and infection control. J Hosp Infect. 2006;62: 1-5.
- American College of Chest Physicians. Aerosol consensus statement. Consensus conference on aerosol delivery. Chest. 1991; 100: 1106--9.
- NavatTO-Meza MC, Gonzalez-Baltazar R, Aldrete-Rodriguez MG, Carmona-NavatTO DE, Lopez-Cardona MG. Respiratory symptoms caused by the use of electrocautery in physicians being trained in surgeiy in a Mexican hospital. Rev Peru Med Exp Salud Publica. 2013;30:41--4.
- Ball K. Compliance with surgical smoke evacuation guidelines: implications for practice. AORN J. 2010;92: 142-9.
- Ball K. Surgical smoke evacuation guidelines: Compliance among perioperative nurses. AORN J. 2010;92:el-23.
- Heinsohn PA, Jewett DL, Balzer L, Bennett CH, Seipel P, Rosen A. Aerosols created by some surgical power tools: paiticle size distribution and qualitative hemoglobin content. Appl Occup Environ Hyg. 1991 ;6:773-6.
- Nezhat C, Winer WK, Nezhat F, Nezhat C, Forrest D, Reeves WG. Smoke from laser surgery: is there a health hazard? Lasers Surg Med. 1987;7:376-82.
- Barrett WL, Garber SM. Surgical smoke-a review of the literature. Is this just a lot of hot air? Surg Endosc. 2003;17:979-87.
- Pierce JS, Lacey SE, Lippert JF, Lopez R, Franke JE. Laser-generated air contaminants from medical laser applications: a stateof-the-science review of exposure characterization, health effects, and control. J Occup Envi.tun Hyg. 2011;8:447-66.
- Hill DS, O'Neill JK. Powell RJ, Oliver DW. 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 surgeiy units. J Plast Reconstr Aesthet Surg. 2012;65:911-6.
- Coia JE, Ritchie L, Adisesh A, Makison Booth C, Bradley C, Bunyan D, et al. Guidance on the use of respiratory and facial protection equipment. J Hosp Infect. 2013;85: 170-82.