March 29, 2019

Hazards of Surgical Smoke

Surgical smoke, also called electrosurgery plume or cautery smoke, is not a new problem in the operating room1. However, advancements in energy-based surgical tools have created new and potentially hazardous sources of air contaminants in the perioperative environment1,2. Despite the scope of this problem, there is limited awareness about the negative impacts of surgical plume3. Further, significant gaps in research make it difficult to ascertain the risks associated with long-term exposure to cautery smoke. The most common sources of surgical plume are

  • High-speed electrical devices, often used in plastic and orthotic surgery1,3
  • Thermal, ultrasonic, and laser scalpels used in cellular ablation and various cosmetic surgeries1,
  • Electrocautery and diathermy units used in laparoscopic surgeries2


Risk of Exposure to Viable Cells, Respirable Particles, and Toxic Gases

“I’ve always wondered about the health impact of surgical smoke from electrocautery,” notes Ms. Albrecht, an anesthesiologist certified in emergency medicine, currently working in a level-3 intensive care unit in Germany. “I assumed it was respirable dust and that it would settle in my lungs.” Several studies have identified carcinogenic ultrafine particles (UFP) in smoke produced by various energy-generating surgical tools4,5,6,. Other harmful substances found in these plumes include

  • Viable bacterium such as Staphylococcus aureus, Neisseria, and Corynebacterium2
  • Infectious aerosols such as Mycobacterium tuberculosis (TB)4
  • Transmittable cells of Human Papilloma Virus (HPV) Hepatitis B (HBV)7
  • Toxic gases such as, benzene, formaldehyde, methane, carbon monoxide, and hydrogen cyanide1,8

Without epidemiological data, the exact impact of electrocautery smoke on surgical personnel and patients remains unclear9. Ms.Albrecht explains, “Real data does seem scarce, but I’d like to see more studies on particle size, because we know what particle size is problematic”. The mere presence of these substances may not be sufficient evidence to calculate any specific degree of risk associated with exposure to surgical smoke, but it does warrant further investigation as an occupational hazard for perioperative personnel.


Surgical Smoke, the Perioperative Environment, and Occupational Health

The potential risk of infection or irritation from respirable particles is not the only negative impact associated with these plumes. Surgical smoke obstructs the line of sight, especially in laparoscopic procedures that yield high concentrations of smaller particles1,2. For many in perioperative care, the pungent odor is the most distressing characteristic of surgical smoke. Ms. Albrecht elaborates, “The smell, depending on tissue, can be nauseating. We obviously always wear masks, but those aren’t made for respiratory protection, much less anti-nausea.” As shown above, these conditions are also detrimental to the safety and efficacy of patient care because they create distractions in the OR.“Having a smoke evac system would be a tremendous improvement if only in terms of OR personnel comfort, and I definitely believe it would do our lungs good,” confirms Ms. Albrecht.


Awareness, Compliance, Intervention and Prevention

Although debates about the specific impacts of surgical smoke persist, healthcare professionals can make several useful and actionable inferences from existing literature, such as

  • The lack of awareness about the dangers of surgical smoke is evidenced by the lack of educational resources and training. This results in low compliance with recommended procedures for evacuating smoke from the OR 9.
  • Further research is needed  about the potency or communicability of viable cells in particulate matter such as surgical vapor1. However, this does not prevent healthcare providers and institutional bodies from taking steps to protect patients and personnel from surgical pollutants
  • Best practice dictates that many electrosurgical and ultrasonic procedures must include a smoke evacuation system or related policies in order to provide the safest and most effective quality of care1.
  • Given these points, it is necessary to equip healthcare providers and researchers with the resources to adequately train perioperative personnel and investigate the long-term effects of surgical smoke through large-scale epidemiological studies.

What’s the Difference between Electrosurgery and Electrocautery?

Both electrocautery and electrosurgery use energy-generating devices to achieve specific surgical outcomes, especially for procedures that require greater precision. However, these distinct methods of using electro-conductivity in surgery have nearly opposite applications

A common misconception about the term “electrosurgery” is that it is the broader, umbrella term for any procedure that uses electricity in the incision process, including electrocautery. In fact, each term refers to the unique task that these devices accomplish in surgery.

An electrosurgical device uses an electrical current to heat the tissue in order to achieve clean, precise incisions. These devices maybe used in laparoscopy and a variety of reconstructive and cosmetic procedures.

Similarly, electrocautery devices use an electrical current to produce heat. However, rather than heating the tissue, the current heats the needle or blade of the scalpel in order to cauterize the incision as it is made. These may also be used in laparoscopic and cosmetic procedures and will often produce a large cautery plume.

Is Electrocautery Safe?

Today, more procedures than ever before require some sort of electrosurgical or electrocautery device. Advances in medical technology have also made many procedures safer and more effective. However, progress in these areas have brought their own hazards and concerns, namely, surgical plume.

As outlined above, the danger of the toxic gases, infectious bacteria, and active virions that are present in surgical smoke has been well established. While there may be some debate about the risk of exposure to these hazards from energy-based surgical devices, there is no doubt that the removal of surgical smoke from the OR makes for a better workplace.

Besides the health hazards associated with surgical smoke for healthcare professionals, there is the issue of visibility and odor, which may affect patient safety negatively. Distractions in the work place are never ideal, but the odor of vaporized tissue is especially distressing.

While electrocautery is considered a very safe procedure, any surgery will carry some degree of risk. Best practice dictates that healthcare providers take every step to reasonably prevent such risks, which should include evacuating copious amounts of smoke produced by certain surgeries.

Bottom Line: Smoke Evacuation Systems Make Safer ORs

While these conclusions may not point toward a “smoking gun” that tells us the full extent of damage caused by surgical smoke, they do offer several avenues of inquiry that may help us more deeply understand the relationship between surgical smoke and occupational health in the OR. Through common sense preventative care and rigorous dedication to awareness, training, and compliance10, healthcare providers can clear a new path for the next generation of perioperative professionals.


References and Further Reading

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