Surgical Smoke: Risks and Preventative Measures

Introduction

The application of the advanced technologies in medicine has led to the appearance of new risk factors for health personnel. One of these could be the surgical smoke produced by electrosurgical instruments, ultrasounds, or lasers.

Impact on health

Lasers, ultrasounds, and electrosurgical instruments can nebulise the operating room air with virus and viable cells, small particles, mutagens, carcinogens, and other toxic substances.

Although patients can suffer adverse effects due to exposure to surgical smoke, particularly during laparoscopic procedures, the greatest risk of chronic illness and damage to health is for the operation room staff members, who repeatedly inhale it.1

It has been published that brief patient exposure to surgical smoke generated by lasers during minimally invasive surgery produces changes in the biochemical structure of their hemoglobin and, therefore, we should also be concerned about the chronic exposure of operating room staff to it.2

It has been proven that there are particles measuring 0.07 to 25 μm in the train of the CO2 laser and in the electrocautery smoke.3-5 Odor is an indication of the content of the chemical products in the smoke, secondary to the combustion of the proteins and lipids.6,7 Basically, they cause migraines, irritation and pain in the eyes, nose and throat.6,8 In vitro studies9 have identified 80 chemical components, some of which are included in the table below.

Table - some of the chemical products identified in surgical smoke
AcroleinPalmitic acid
AcetonitrileHydrogen cyanide
Acrylonitrile
Indole
AcetyleneIsobutene
AlkylbenzenesMethanol
Benzaldehydes
6-Methylindole
Benzene2-Methylpropanol
Benzonitrile3-Methylbutanal
Butadiene2-Methylfuran
Butane4-Methylpyrazine
3-ButenenitrileMethylpyrazine
Carbon disulfide
Phenol
Carbon monoxide
Aromatic hydrocarbons
CresolsPropene
1-DecenePropylene
2,3-Dihydroindole2-Propylene nitrile
EthanePyridine
EthenePyrrole
EthylbenzeneStyrene
EthyleneToluene
Ethylbenzene1-Undecene
FormaldehydeXylene

Preventative measures

However, correct air renewal is not enough for the treatment of smoke resulting from both laparoscopic and laparotomy operations, making it necessary to combine other preventative measures to minimize exposure, such as the use of personal protective equipment, aspirators and surgical smoke filtrations systems.1,10

In the United States, the US National Institute for Occupational Safety and Health (NIOSH) recommends the use of smoke evacuators during surgical procedures in which surgical smoke or smoke plume is produced to minimize exposure, with a high suction capture speed (at least 31-46 m/s), non-standard, mounted on a wall, together with high efficiency particle filters.11,12

The NIOSH points out that local surgical smoke capturing devices should be within 5 cm of the surgical field and the aspirator should be connected at all times while surgical smoke is produced.

Conclusions

In spite of doubts about the harmful effects of long term exposure to surgical smoke, caution should be applied and existing preventative measures within our reach should be applied; use of individual protection equipment, aspirators and surgical smoke filtration systems.

Key take-aways

  • Current concern is based on the nature of the components of the surgical smoke identified to date, some are harmful and which a null degree of exposure for workers has been requested, as in the case of benzene.
  • The voluntary nature of regular physical examinations for operating room staff takes on a special meaning: performing them is not only needed to identify the state of health at any given time, but also for a correct follow-up and identification of new risk factors to workers' health, including surgical smoke

References

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  2. Ott DB. Laparoscopic surgical smoke absorbed into bloodstream. OR Manager. 1994;10:19
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  4. Jewett DL, Heinsohn P, Bennett C, Rosen A, Neuilly C. Blood-containing aerosols generated by surgical techniques: a possible infectious hazard. Am Ind Hyg Assoc J. 1992;53:228-31.
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  11. Gloster H, Roenigk R. Risk of acquiring human papillomavirus from the plume produced by the carbon dioxide laser in the treatment of warts. J Am Acad Dermatol. 1995;32:436-41.
  12. Hallmo P, Naess 0. Laryngeal papilomatosis with human papillomavirus DNA contracted by a laser surgeon. Eur Arch Otohinolaryngol.1991;248:425-7.