The document summarizes a review of literature on surgical smoke. It finds that surgical smoke from various energy-based instruments contains particles small enough to be inhaled, some with known carcinogenic properties. While several studies identified bacteria, viruses, and malignant cells in smoke, no research has directly linked smoke components to disease transmission. The review concludes surgical smoke poses potential health risks to operating room staff and recommends smoke evacuation devices be used.

1. SURGICAL SMOKE
Jibran Mohsin
Resident, Surgical Unit I
SIMS/Services Hospital, Lahore

6. AUTHORS
N. Mowbray Aneurin Bevan Health Board, Newport, UK
J. Ansell Royal College of Surgeons of England, Welsh Institute of
Minimal Access Therapy (WIMAT), Cardiff CF14 4UJ, UK
e-mail: ansellj@cf.ac.uk; ansellj@cardiff.ac.uk
N. Warren Welsh Institute of Minimal Access Therapy (WIMAT), Cardiff, UK
P. Wall Isca Healthcare Research, Caerleon, UK
J. Torkington Department of Colorectal Surgery, University Hospital of Wales, Cardiff, UK

7. INTRODUCTION
 Surgical smoke is the airborne byproduct generated by the use of energy-
based instruments in operating theaters.
 These instruments are an integral part of modern surgery and are routinely
used across a wide range of surgical specialties.
 The hazards of surgical smoke may have wide reaching implications.
 Energy-based instruments used in operations include mono- and bipolar
diathermy (electrocautery), ultrasonic scalpels, and lasers.

8. INTRODUCTION
 Electrocautery devices and lasers heat target cells to the point of boiling, causing the cell
membranes to rupture.
 This process disperses fine particles into the atmosphere.
 Ultrasonic devices use a vibrating plate to cause cell rupture at much lower temperatures than
electrocautery.
 This causes cutting and coagulation simultaneously without an electrical current being passed
through the tissue.

9. INTRODUCTION
 Concerns have been raised regarding the infectivity, mutagenicity, and cytotoxicity
of surgical smoke from all the aforementioned devices.
 In addition, surgical smoke is odorous and reduces the view of the operative field,
especially during laparoscopic procedures.
 Many health organizations have recommended the routine use of evacuation
devices to avoid potential problems
 Despite this general consensus that surgical smoke should be treated with caution,
the use of local exhaust ventilation has changed very little in recent years

10. INTRODUCTION
 Surgical smoke is the encompassing term for a number of gaseous
byproducts produced by energy-based surgical instruments.
 The definition of ‘‘smoke’’ refers to the products of combustion, whereas
‘‘vapor,’’ ‘‘aerosol,’’ and ‘‘mist’’ refer to the suspension of liquid particles.
 Electrocautery devices are described as creating a ‘‘plume’’ of smoke,
whereas ultrasonic devices are described as creating ‘‘vapors,’’ ‘‘aerosols,’’
and ‘‘mists.’’

11. INTRODUCTION
 The byproducts of lasers have been referred to by all of these terms
 Because the terminology is used interchangeably, this review uses the
general term of ‘‘surgical smoke’’ to encompass all the aforementioned
terms.

12. INTRODUCTION
 This review identifies the current evidence for the properties of surgical
smoke and the harmful effects to health care professionals exposed to
it.
 We aim to identify whether the harmful effects are related to the type
of energy-based instrument used.
 This information is used to formulate clinical recommendations and
highlight areas requiring further research in the future.

13. MATERIALS AND METHODS
(SEARCH STRATEGY)
 A systematic review of published work was conducted according to the
Preferred Reporting Items for Systematic Review and Meta-Analyses
(PRISMA) guidelines.
 The following sources were searched for studies concerning the evaluation
of surgical smoke and its effects:
 MEDLINE (1947 to the present),
 PubMed (1966 to the present),
 Cochrane database,
 Embase classic + Embase (1947–2012), and
 the metaRegister of controlled trials.

14. MATERIALS AND METHODS
(SEARCH STRATEGY)
 The search used three search domains of exploded medical subject
heading (MeSH) terms combined by ‘‘AND.’’
 Within each domain, the terms were combined with ‘‘OR.’’
 The first domain contained the terms for surgical smoke.
 The second domain consisted of the instruments that generate or remove
smoke, and
 the third domain comprised the hazards of surgical smoke.

15. MATERIALS AND METHODS
(SEARCH STRATEGY)
 The search was performed by two investigators independently.
 Titles and abstracts were reviewed by each individual.
 Duplicates and those clearly unrelated were discarded.
 The articles were retrieved and the inclusion criteria applied.
 Cross-referencing was carried out against the most recent relevant articles.
The last search date was 4 January 2013.

16. MATERIALS AND METHODS
(INCLUSION AND EXCLUSION CRITERIA)
 Studies were included if they documented the
 constituents found in surgical smoke during human surgical procedures,
 methods used to analyze the smoke,
 implications of exposure to smoke, and
 type of energy-based surgical instrument that generated the smoke.
 Only original articles were included.
 Studies were excluded if they were animal based, preclinical experimental
work, conference abstracts, or opinion-based reports.

17. MATERIALS AND METHODS
(DATA EXTRACTION, OUTCOME MEASURES, AND ANALYSIS)
 The included studies were rated according to guidelines from the Centre
for Evidence-Based Medicine (CEBM).
 Each paper was examined to identify the energy device used, the smoke
properties and particle size, the risk of infection, and the mutagenic risk.
 Some additional material was used to prepare the background information
for the review e.g. manual searches and information from specialist
textbooks, government agency publications, and healthcare professional
organizations.
 All sources are cited where appropriate.

19. RESULTS
Parameter Total number of studies = 20
diathermy/electrocautery laser Ultrasound devices
size of the particles
(5 studies)
4 2 0
Constituents of surgical
smoke
(7 studies)
7 0 1
Infectivity
(6 studies)
1 6 0
Mutagenic effect 1 0 0
Presence of Malignant
cells
1 0 0

20. RESULTS
(PARTICLE SIZE)
Overall size of particles found in all types of
smoke for all procedures
0.05 micron to larger than 25 micron
Ultrafine particles (UFP)
[found in laser and electrocautery]
Laparoscopic laser use  0.1 – 0.8 micron
Laparoscopic electrocautery  0.1 – 0.025 micron
THR electrocautery  aerosol particles < 1 micron
Peritonectomy electrocautery  0.002 – 1 micron
1 study ( electrocautery and argon laser
coagulation)
10 nm to 1 micron

21. RESULTS
(PARTICLE CHARACTERIZATION)

22. RESULTS
(PARTICLE CHARACTERIZATION)
 The surgical smoke evaluated by these studies had several components
with known carcinogenic properties
 A non-significant trend showed lower levels of benzene, toluene,
heptene, ethylbenzene, and methylpropene with the use of the
ultrasonic scalpel compared with electrocautery

23. RESULTS
(INFECTION RISK)

24. RESULTS
(INFECTION RISK)
Only Capizzi et al and Kunachak et al  assessed the
infectivity of smoke
Rest only identified the presence of material in smoke

25. RESULTS
(INFECTION RISK)
 .
5/13 cases  coagulase negative Staphylococcus
1/13  Corynebacterium
1/13  Neisseria

26. RESULTS
(INFECTION RISK) 5/8 laser derived vapors
4/7 electrocoagulation derived vapors
Greater amount of HPV DNA in lasers vapors

27. RESULTS
(MUTAGENESIS AND MALIGNANT SPREAD)
Ikramuddin et al. assessed the
ability of surgical smoke to spread
malignancy.
During laparoscopic surgery, the pneumoperitoneum
was sampled for either malignant or benign
conditions via a port site. Aerosolized malignant cells were
identified.
The mutagenic potential of surgical smoke from electrocautery was evaluated by one study during
reduction Mammoplasty

28. DISCUSSION
(THIS REVIEW)
 This is the first systematic review to detail the potential harmful effects of
surgical smoke to theater staff.
 Surgical smoke from a range of electrosurgical methods can produce
particles small enough to be inhaled.
 Viruses, bacteria, and malignant cells may be present in smoke.
 No existing literature establishes a direct link between the components of
smoke and the transmission of disease.

29. DISCUSSION
(COMPARISON WITH PREVIOUS REVIEWS)
 Although several published reviews have collated current information on
surgical smoke, none has used a systematic format.
 Unlike previous reviews, we looked solely at studies using in vivo
techniques.
 We accept that by excluding all in vitro and experimental data, we may
have underestimated the full potential effects of surgical smoke. The
research identified in this study was, however, thought to be more clinically
relevant and hence applicable to theater staff.

30. DISCUSSION
(COMPARISON WITH PREVIOUS REVIEWS)
 The literature contains a wide variety of studies with varying
methodologic designs and presentations of results.
 The papers included in this review detail a range of operations using
different electrosurgical instruments.
 Collection and analysis of surgical smoke was conducted in different
ways.

31. DISCUSSION
(COMPARISON WITH PREVIOUS REVIEWS)
 Whereas some methods involved sampling immediately adjacent to the
instrument, others sampled from atmospheric air and from the air termed
‘‘the breathing zone.’’
 This could have introduced variation into the concentration of compounds
and also into the size or type of particle captured.
 Heavier particles may not travel as far.
 We have, however, shown that common end points such as particle nature
and infectivity are identifiable, but clear standardization of smoke analysis
studies in the future could prove useful.

32. DISCUSSION
(PARTICULATE SIZE)
 The evidence suggests that the surgical smoke particles are of respirable size.
 Particles smaller than 10 lm are inhalable, and particles 2.5–10 lm in size can deposit
in the respiratory tract.
 Ultrafine particles can precipitate into the alveolar region of the lung, where the only
clearance mechanism is phagocytosis via alveolar macrophages
 There were no studies to indicate the effect of UFPs.
 It should be noted that surgical masks, even if correctly fitted and frequently
changed, can effectively filter only particles larger than 5 micron in size.

33. DISCUSSION
(INFECTIVITY RISK)
 The debate over the infectivity of surgical smoke appears to focus
largely on skin lesions. Perhaps this is due to the popular application of
lasers to treat viral lesions.
 These lesions often are easily accessible, numerous, and treatable under
local or general anesthesia.

34. DISCUSSION
(INFECTIVITY RISK)
 Some evidence shows HPV DNA to be present in surgical smoke, but
this does not prove its ability to transmit infection
 Indeed, no evidence was found to suggest viral infectivity, and only one
study examined the bacterial component of surgical smoke.

35. DISCUSSION
(INFECTIVITY RISK)
 Perhaps bacterial infectivity is a subject of less concern because electrosurgical
devices are not used specifically to treat bacterial infections.
 Evidence is lacking for infectivity of other energy-based instruments, including
electrocautery and ultrasonic devices.
 Given that ultrasonic devices reach a lower temperature, the possibility exists that
this cellular debris remains infectious.
 Future research in this area may be useful together with a direct comparative study
of the smoke generated from similar operations in infectious and noninfectious
patients.

36. DISCUSSION
(MUTAGENIC RISK)
 A small body of evidence suggests that surgical smoke carries a
mutagenic risk with no link to disease.
 A longitudinal study of theater nursing staff (86,747 women adjusted
for smoking history and increased risks of lung cancer) did not show an
increased rate of lung cancer even among those with the longest
operating room history

37. EXISTING RECOMMENDATIONS
UK British Occupational Hygiene society (BOHS)
The Association for Perioperative Practice (AfPP)
Medicines and Healthcare Products Agency (MHRA)
Canada Canadian Standards Association (CSA)
Operating Room Nurses Association of Canada (ORNAC)
Australia Australian College of Operating Room Nurses (ACORN)
International The International Federation of Perioperative Nurses (IFPN)
International Society Security Association (ISSA)

38. EXISTING RECOMMENDATIONS
USA Association of periOperative Registered Nurses (AORN)
Occupational Safety & Health Administration (OSHA)
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
National Institute for Occupational Safety and Health/Centre for Disease Control
(NIOSH/CDC)
American National Standards Institute (ANSI)
American Society for Laser Medicine and Surgery (ASLMS)

40. CONCLUSION
 This review confirms that surgical smoke contains potentially carcinogenic compounds
physically small enough to be respirable and even reach the lower airways.
 Despite this, we have found little evidence for the long-term effects of surgical smoke in
vivo. Both infective and malignant cells exist in surgical smoke, but their viability has not
been assessed.
 This review can conclude that although the potential for harm is present, the risk
presented to the theater staff remains unproven.
 Further research is needed to identify this and should focus on comparing the smoke
produced by different energy-based devices, the use of removal systems, and the long-
term consequences of smoke exposure.

41. ACKNOWLEDGMENTS
 James Ansell was sponsored by The Royal College of Surgeons of
England Research Fellowship Grant.

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