In Vitro Toxicological Evaluation of Surgical Smoke From Human Tissue

Background

Approximately 20 million Americans undergo surgery with general anesthesia each year.1 Nowadays, electrocautery, laser ablation, and ultrasonic scalpel dissection are widely recognized as major advances in surgical technique and are increasingly being used for tissue cutting and hemostatis.2

The released surgical smoke contaminates the air with many chemical compounds as by-products of tissue damage, as well as biological materials, including potentially infectious agents.3 Several studies have found that the complex mixture of surgical smoke contains both chemical pollutants and biological hazards.2,4-7 Animal studies have shown that rats exposed to smoke from pigskin showed congestive pneumonia, bronchiolitis and emphysema8, and sheep exposed to smoke from sheep bronchial tissue showed a decrease in arterial PO2 (hypoxia), depressed tracheal mucus velocity and severe inflammation with dramatic increases of inflammatory cells.9 A survey showed that operating room nurses reported respiratory problems including nasal congestion, increased coughing, allergies and sinus infections or problems and the prevalence among the nurses was greater than the prevalence in the US.

Recently, it was found that surgical smoke has ultrafine particles that are in the range of 9-81 nm, depending on the type and duration of the surgery.3,11 Ultrafine particles in the surgical smoke have the ability to reach the alveolar region of the lung and cause pulmonary inflam­mation or disease.12,13

It is important to identify the risk of surgical smoke to guide the installation of proper protection procedures and devices in surgical rooms. Recently, a survey was performed to determine if the correct engineering controls were being used to protect healthcare workers from exposure to surgical smoke.14 The survey concluded that a majority of surgical rooms did not have proper local exhaust ventilation (LEV) because the installation of LEV in these sur gical rooms was not considered in their design. Therefore, the healthcare workers who work in these surgical rooms have no proper protection procedures and devices to prevent the potential exposure to surgical smoke.

In this study, the cellular toxicity of surgical smoke in human tissue was assessed. The chemical properties and the in vitro toxicity of surgical smoke generated with real human tissues were analyzed.

Results

Airborne particles and volatile organic compound (VOC) concentrations of surgical smoke

The average background particle concentration ranged from 1 to 1600 particles/cm3. The average particle number concentrations ranged from 900 to 54,000 particles/cm3. Ratios of average of 15 min surgical smoke generation to average of background particle number concentration ranged from 2 to 5,200. All targeted 17 different VOCs were detected in most of the sampling sessions. Higher concentrations of the VOCs were found in sampling with surgical smoke compared to the background concentration.

Cytotoxicity of surgical smoke

It has been suggested that surgical smoke is toxic both in vitro and in vivo.8,15 Because the surgical smoke has ultrafine particles, the pulmonary alveolar region could potentially be affected: therefore, cytotoxicity was measured in human smal l airway epithelial cells (SAEC). Surgical smoke caused approximately 25% cell death in the SAEC and 40% in the RAW 264.7 mouse macrophages (RAW) cells compared to background and fiel d blank (figure below).

This would suggest that the cell death seen is due to the surgical smoke generated from human breast tissue.

Discussion

The levels of smoke generated in this study most likely represent the worst possible case of exposure, when OR personnel lean in over the patient during surgery, which is likely only for brief periods of time during the workday. The results of the MTS assays in this study suggest that the surgical smoke is cytotoxic in both the SAEC and RAW cell lines, but to varying degrees. This data would suggest that the surgical smoke is a potential hazard to individuals during surgery, which correlates with previously published data.15

Conclusion

The results indicate that the surgical smoke is toxic in both the SAEC and RAW cells although to varying degrees.

References

  1. Roan S. Even when surgery is over, sedation's risks could linger. Death rates are higher for months afterward, studies find. Los Angeles Times: Doctors search for a reason; 2005.
  2. Bigony L. Risks associated with exposure to surgical smoke plume: a review of the literature. AORN J. 2007;86(6): 1013-20. quiz 1021-4
  3. Ragde SF, Jorgensen RB, Foreland S. Characterisation of exposure to ultrafine particles from surgical smoke by use of a fast mobility particle sizer. Ann Occup Hyg. 2016;60(7):860-74.
  4. Barrett WL, Garber SM. Surgical smoke: a review of the literature. Is this just a lot of hot air. Surg Endosc. 2003; 17(6):979-87.
  5. Gonzalez-Bayon L, Gonzalez-Moreno S, Ortega-Perez G. Safety considerations for operating room personnel during hyperthermic intraoperative intraperitoneal chemotherapy perfusion. Eur J Surg Oneal. 2006;32(6):619-24.
  6. Al Sahaf OS, Vega-Carrascal I, Cunningham FO, McGrath JP, Bloomfield FJ. Chemical composition of smoke produced by high-frequency electrosurgery. Ir J Med Sci. 2007; 176(3):229-32.
  7. 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 surgery units. J Plast Reconstr Aesthet Surg. 2012;65(7):911-6.
  8. Baggish MS, Elbakry M. The effects of laser smoke on the lungs of rats. Am J Obstet Gynecol. 1987;156(5):1260-5.
  9. Freitag L, Chapman GA, Sielczak M, Ahmed A, Russin D. Laser smoke effect on the bronchial system. Lasers Surg Med. l 987;7(3):283-8.
  10. Ball K. Compliance with surgical smoke evacuation guidelines: implications for practice. AORN J. 2010;92(2): 142-9.
  11. Eshleman EJ, LeBlanc M, Rokoff LB, Xu Y, Hu R, Lee K, et al. Occupational exposures and determinants of ultrafine particle concentrations during laser hair removal procedures. Environ Health. 201 7; 16(1): 30.
  12. Daigle CC, Chalupa DC, Gibb FR, Morrow PE, Oberdorster G, Utell MJ, et al. Ultrafine particle deposition in humans during rest and exercise. Inhal Toxicol. 2003;15(6):539-52.
  13. Chalupa DC, Morrow PE, Oberdorster G, Utell MJ, Frampton MW. Ultrafine particle deposition in subjects with asthma. Environ Health Perspect. 2004; 112(8):879-82.
  14. Steege AL, Boiano JM, Sweeney MH. Secondhand smoke in the operating room? Precautionary practices lacking for surgical smoke. Am J Ind Med. 2016;59(11): 1020-31.
  15. Hensman C, Newman EL, Shimi SM, Cuschieri A. Cytotoxicity of electrosurgical smoke produced in an anoxic environment. Am J Surg. 1998; 175(3):240-1.