Activated carbon fiber filters could reduce the risk of surgical smoke exposure during laparoscopic surgery: application of volatile organic compounds. Surg Endosc. 2018;32:4290-4298. [PMID: 29770884 DOI: 10.1007/s00464-018-6222-0]

Surgical smoke: a matter of hygiene, toxicology, and occupational health

The use of devices for tissue dissection and hemostasis during surgery is almost unavoidable. Electrically powered devices such as electrocautery, ultrasonic and laser units produce surgical smoke containing more than a thousand different products of combustion. These include large amounts of carcinogenic, mutagenic and potentially teratogenic noxae. The smoke contains particles that range widely in size, even as small as 0.007 µm. Most of the particles (90%) in electrocautery smoke are ≤6.27 µm in size, but surgical masks cannot filter particles smaller than 5 µm. In this situation, 95% of the smoke particles which pass through the mask reach deep into the respiratory tract and frequently cause various symptoms, such as headache, dizziness, nausea, eye and respiratory tract irritation, weakness, and abdominal pain in the acute period. The smoke can transport bacteria and viruses that are mostly between 0.02 µm and 3 µm in size and there is a risk of contamination. Among these viruses, SARS-CoV-2, influenza virus, HIV, HPV, HBV must be considered. The smoke may also carry malignant cells. The long-term effects of the surgical smoke are always ignored, because causality can hardly be clarified in individual cases. The quantity of the smoke changes with the technique of the surgeon, the room ventilation system, the characteristics of the power device used, the energy level at which it is set, and the characteristics of the tissue processed. The surgical team is highly exposed to the smoke, with the surgeon experiencing the highest exposure. However, the severity of exposure differs according to certain factors, e.g., ventilation by laminar or turbulent mixed airflow or smoke evacuation system. In any case, the surgical smoke must be removed from the operation area. The most effective method is to collect the smoke from the source through an aspiration system and to evacuate it outside. Awareness and legal regulations in terms of hygiene, toxicology, as well as occupational health and safety should increase.

Efficacy of Filter Trocar for Clear Visualization during Laparoscopic Cholecystectomy: A Prospective Randomized Controlled Trial

Filter trocar designed to eliminate harmful smoke is also regarded as effective for improving surgical visualization. The aim of this study is to evaluate the efficacy of filter trocar in maintaining clear operative view. From 2019 to 2020, 100 patients underwent laparoscopic cholecystectomy and they were randomized to either the control or filter group. The primary end point was a laparoscopic operative view score (1, clear; 2, slightly blurry; 3, completely blurry) during gallbladder dissection from the liver bed when dissection was started (LV1), when dissection was half completed (LV2) and when dissection was completed (LV3). Between the control and filter groups, there were no significant differences in mean LV1 (1.44 vs. 1.40, p = 0.234) and LV3 (1.86 vs. 2.01, p = 0.880). There was no significant difference in the mean duration of suction after dissection (3.82 s vs. 3.67 s, p = 0.097) and the mean number of laparoscope removals from inside to outside the body to clean during gallbladder dissection from the liver bed (0.55 vs. 0.22, p = 0.963) or the mean amount of time required to dissect the gallbladder from the liver bed (221.58 s vs. 177.09 s, p = 0.253). The study demonstrated that filter trocar is not as effective as expected in the maintenance of clear operative view. Further study is needed to develop devices to improve clear surgical visualization.

Surgical smoke: A hidden killer in the operating room

Surgical smoke is a byproduct of aerosols containing several components produced by energy equipment. The characteristics of surgical smoke components produced by different types of tissues or using different kinds of energy devices vary. For example, the average diameter of smoke particles produced by electrocautery is smaller, and the possibility of viable cells and pathogens in surgical smoke produced by an ultrasonic knife is higher. According to the characteristics of its composition, surgical smoke may be an important risk factor affecting the health and safety of operating room staff and patients. The use of surgical masks, suction devices and portable smoke evacuation systems can reduce this risk to some extent. However, most operating room staff members do not implement corresponding measures to protect themselves. In this paper, the characteristics of surgical smoke and the research progress in protective measures are briefly reviewed.

Comparison of the Effects of Surgical Smoke on the Air Quality and on the Physical Symptoms of Operating Room Staff

BACKGROUND

Surgical smoke can be a hazard because e it contains toxic gases with carcinogenic effects that may threaten health. This study aims to determine the effect of surgical smoke containing toxic chemicals on indoor air quality and examine employees' physical symptoms in the operating room.

METHOD

The study was conducted in the operating room between June 2020 and July 2020. In the study, 45 air samples were taken before, during, and after surgery using the active sampling method. Nineteen employees working in the operating room were asked about their physical complaints and their throat cultures were taken before and after surgery. These results were compared with those of the employees working in internal units.

RESULTS

The Total Volatile Organic Compounds value at the time of surgery was significantly higher (p ≤ 0.05). Benzene concentrations remained constantly high (p ≤ 0.05) throughout the surgery, exceeding the limit values. Other VOCs (Volatile Organic Compounds) were significantly higher during surgery and remained below the limit values (p ≤ 0.05). When compared in terms of open and laparoscopic surgery, no difference between VOC concentrations was observed (p ≤ 0.05). The physical symptoms of the surgical team increased during the operation, and they experienced more complaints of tearing, burning in the eyes, hair odor, nausea, and cough than those working in the internal units (e.g., internal medicine, dermatology; (p ≤ 0.05).

CONCLUSIONS

Surgical smoke was an important contaminant for indoor air quality in the operating room.

Chemical composition of smoke produced by open versus laparoscopic surgery for cholecystectomy

BACKGROUND

Smoke produced by traditional open surgery (TOS) has long been considered hazardous to medical staff. Compared with TOS, minimally invasive surgery under carbon dioxide pneumoperitoneum is associated with a faster recovery and less wound pain. However, the impact of oxygen-deficient environment on the chemical contents of smoke has not been comprehensively assessed.

METHODS

This research evaluated the chemical composition and volatile organic compound (TVOC) level in smoke produced by open cholecystectomy (OC) versus laparoscopic cholecystectomy (LC) for gallbladder diseases. Smoke samples were collected and analyzed via gas chromatography-mass spectrometry. Chemical compounds were further grouped according to molecular weight and toxicity.

RESULTS

Compared with the OC, LC had significantly higher halocarbon and TVOC levels but lower cycloalkene and aldehyde levels. No halocarbons were isolated from OC specimens. When stratified based on molecular weight, LC had a bimodal pattern (i.e., high levels of small-sized [<60 Da] and large-sized [>120 Da] compounds). There was no difference in terms of toxicity types, incidence, and severity associated with detected compounds between two groups.

CONCLUSION

LC is associated with a higher TVOC level and proportion of low- and high-molecular-weight organic compounds. Further strategies of evacuating these health hazards and preventing smoke leakage through trocars should be considered.

Determination of activated carbon fiber adsorption capacity for several common organic vapors: applications for respiratory protection

In the context of workplace safety, activated carbon in the fiber form (i.e., activated carbon fiber, ACF) represents an alternative adsorbent to granular activated carbon (GAC) for use in organic vapor respiratory protection devices. ACFs are high surface area carbonaceous materials that are often available in a self-supporting non-woven form. The physical form of ACF suggests the potential for a filtration medium that is capable of supporting both organic vapor adsorption and particulate filtration. To study the application of these materials in respiratory protection devices, ACFs (ACFF 1200 m²/g, ACFF 1800 m²/g, and ACFF 2000 m²/g) were challenged with representative organic vapors (toluene, hexane, and methyl ethyl ketone (MEK)) at an occupationally relevant concentration (200 ppm). Breakthrough curves were generated for at least three different bed weights of adsorbent. Pressure drop (i.e., the resistance across the filtration media) was also measured to determine maximum ACF bed depths for use in respiratory protection devices. Breakthrough experiments indicate that ACFF 2000 has the highest adsorption capacity for toluene (381 mg/g), followed by ACFF 1800 and ACFF 1200 (344 mg/g and 239 mg/g, respectively). A similar trend was observed for hexane: 221 mg/g, 196 mg/g, and 146 mg/g for ACFF 2000, ACFF 1800, and ACFF 1200, respectively. ACFF 1200 showed the highest adsorption capacity for the polar adsorbate MEK (168 mg/g), followed by ACFF 1800 and ACFF 2000 (166 mg/g and 147 mg/g, respectively). Based on the constraints of pressure drop, it seems unlikely the exclusive use of ACF in a filtering facepiece respirator can provide an adsorbent mass sufficient for full shift protection against organic vapor contaminants at or above the legally enforceable permissible exposure level (PEL). Nevertheless, the incorporation of ACF into a facepiece respirator appears promising for "nuisance odor" applications; i.e., the further reduction of organic vapor concentrations when workplace exposures are already below PEL concentrations.Implications: This research brings innovation to the field of occupational health and air pollution control technology by investigating the adsorption performance of activated carbon fiber (ACF) media in the context of worker respiratory protection. ACF properties such as high specific surface area (m²/g), high permeability to airflow, and rapid adsorption kinetics make it ideal for use in thin, N95-style respirators for organic vapors. Respiratory protection is an exciting and relevant application for ACF media. A lightweight adsorbent such as ACF, if incorporated into an N95-style respirator, could potentially provide nuisance-level VOC protection in a physical form that is accessible to workers and consistent with OSHA's voluntary use provisions for facepiece respirators. The research presented in this manuscript represents one of several steps planned in the characterization of ACF media for this particular application.

Investigating surgical smoke in otolaryngology operating rooms

Surgical smoke is a common chemical hazard produced from the use of electrocautery, laser, or ultrasonic scalpels during surgery. It has been proved harmful to medical personnel. Thus, it is important to monitor surgical smoke concentrations in the operating room. In the past decade, many researches regarding surgical smoke were discussed in different professional healthcare fields, but few showed the correlation between surgical smoke and otolaryngology surgery. In this study, the concentrations of particulate matter and formaldehyde were measured during thirty cases of several types of otolaryngology surgery in a regional research hospital in Taiwan. The concentrations of 0.3 µm and 0.5 µm particulate matter raised rapidly in the main knife range at the beginning of the electrocautery knife used, and then decreased by half after 5-10 min of use. The concentrations of formaldehyde were ranged from 1 to 2 ppm during the surgery, which is higher than the permissible exposure limit. While many medical staffs are working in the operating room and are exposed to the smoke hazard, effective strategies for collecting and eliminating the smoke should be taken in all medical facilities.

In vivo and in vitro study of the potential hazards of surgical smoke during cervical cancer treatment with an ultrasonic scalpel

OBJECTIVE

To explore the composition and potential hazards of cervical cancer surgical smoke generated by ultrasonic scalpels.

METHODS

Surgical smoke was collected during the cutting and coagulation of cervical cancer xenograft tumors using an ultrasonic scalpel. Surgical smoke-filtered cells were cultured and subcutaneously injected into nude mice. Cell morphology and viability were assessed by HE, Pap and trypan blue staining. HPV DNA in surgical smoke samples was identified by PCR. HPV transmission was determined by culturing HPV-negative C33A cells in HPV-positive surgical smoke-filtered medium. The cytotoxicity of surgical smoke to small airway epithelial cells (SAECs) and THP-1 cells was determined by CCK-8, MTS and LDH release assays. Volatile organic compounds (VOCs), which are present in cervical cancer surgical smoke samples obtained by laparoscopic hysterectomy, were analyzed by gas chromatography-mass spectrometry (GC-MS).

RESULTS

Cellular debris and epithelioid cells were found in surgical smoke, but no malignant cells were observed. HPV DNA was identified in all smoke samples, and HPV genotypes were matched to those in cervical cancer cells. Coculture with HPV-positive surgical smoke-filtered medium induced an 83% (15 of 18) HPV positivity rate in C33A cells. Subculture in normal medium decreased this rate to 50% (9 of 18). The proliferation of SAECs and THP-1 cells was inhibited by smoke-filtered medium in a time-dependent manner. The concentration of total VOCs, especially benzene, toluene and xylene, in surgical smoke exceeded the standard for good indoor air quality.

CONCLUSION

Cervical cancer surgical smoke contains HPV and VOCs and exhibits cytotoxicity and infectivity in vitro. Surgical smoke is an occupational hazard to health care workers.

Impact of Surgical Smoke on the Surgical Team and Operating Room Nurses and Its Reduction Strategies: A Systematic Review

BACKGROUND

Surgical smoke is an integral part of surgical operations that the surgical team has been exposed to for so long. This study aimed to investigate the effects of smoke, on members of the surgical team.

METHODS

A systematic review was conducted focusing on the complexity of surgical smoke. PubMed, Scopus and web of science databases were searched until May 2020 without any time or language limitation. All documents were reviewed by title or abstract according to the search strategy. The screening process of articles was performed by two independent authors. The articles were selected according to the inclusion and exclusion criteria.

RESULTS

Overall, 37 studies in this systematic study were investigated. The effects of many surgical smokes were found in a nutshell including complications such as carcinogenic, toxicity, mutation, irritant, transmission of tumor cells, virus transmission, headaches, dizziness, sleepiness, headache, the bad odor in head hair, the tearing of the eye on the surgical team and staff.

CONCLUSION

Surgical smoke, produced during surgical operations, is one of the risks and threats to which the surgical team and operating room staff are at risk then can affect the organs of different bodies from the body of all operating room staff and surgical team.

State of the Science: A Concept Analysis of Surgical Smoke

Surgical smoke has not been clearly defined in the literature and often is identified using surrogate terms (eg, plume). In January 2020, a literature search was performed and a principle-based concept analysis involving four general principles (epistemological, pragmatic, linguistic, and logical) was used to define surgical smoke and identify implications for perioperative personnel, patients, researchers, and policymakers. Surgical smoke is a visible plume of aerosolized combustion byproducts produced by heat-generating surgical instruments. It consists of water vapor and gaseous substances; can carry toxic chemicals, bacteria, viruses, and tumors; can obscure the surgical field; and can be inhaled. Surgical smoke has a distinctive noxious odor and can cause physical symptoms such as watery eyes and throat irritation. Perioperative leaders should promote protection from occupational harm by educating their staff members on the use of smoke evacuators to mitigate the effects of surgical smoke on perioperative patients and personnel.

Minimizing the Risk of Aerosol Contamination During Elective Lung Resection Surgery

BACKGROUND

In the setting of the COVID-19 pandemic, the conduct of elective cancer surgery has become an issue because of the need to balance the requirement to treat patients with the possibility of transmission of the virus by asymptomatic carriers. A particular concern is the potential for viral transmission by way of aerosol which may be generated during perioperative care. There are currently no guidelines for the conduct of elective lung resection surgery in this context.

METHODS

A working group composed of 1 thoracic surgeon, 2 anesthesiologists and 1 critical care specialist assessed the risk for aerosol during lung resection surgery and proposed steps for mitigation. After external review, a final draft was approved by the Committee for the Governance of Perioperative and Surgical Activities of the Hôpital Maisonneuve-Rosemont, in Montreal, Canada.

RESULTS

The working group divided the risk for aerosol into 6 time-points: (1) intubation and extubation; (2) Lung isolation and patient positioning; (3) access to the chest; (4) conduct of the surgical procedure; (5) procedure termination and lung re-expansion; (6) chest drainage. Mitigating strategies were proposed for each time-point.

CONCLUSIONS

The situation with COVID-19 is an opportunity to re-evaluate operating room protocols both for the purposes of this pandemic and similar situations in the future. In the context of lung resection surgery, specific time points during the procedure seem to pose specific risks for the genesis of aerosol and thus should be the focus of attention.

Safe management of surgical smoke in the age of COVID-19

Background

The COVID-19 global pandemic has resulted in a plethora of guidance and opinion from surgical societies. A controversial area concerns the safety of surgically created smoke and the perceived potential higher risk in laparoscopic surgery.

Methods

The limited published evidence was analysed in combination with expert opinion. A review was undertaken of the novel coronavirus with regards to its hazards within surgical smoke and the procedures that could mitigate the potential risks to healthcare staff.

Results

Using existing knowledge of surgical smoke, a theoretical risk of virus transmission exists. Best practice should consider the operating room set-up, patient movement and operating theatre equipment when producing a COVID-19 operating protocol. The choice of energy device can affect the smoke produced, and surgeons should manage the pneumoperitoneum meticulously during laparoscopic surgery. Devices to remove surgical smoke, including extractors, filters and non-filter devices, are discussed in detail.

Conclusion

There is not enough evidence to quantify the risks of COVID-19 transmission in surgical smoke. However, steps can be undertaken to manage the potential hazards. The advantages of minimally invasive surgery may not need to be sacrificed in the current crisis.

Surgical smoke and the anesthesia provider

Surgical smoke generated by use of electrosurgical units (ESUs), lasers, and ultrasonic scalpels constitutes a physical, chemical, and biological hazard for anesthesia personnel. Inhalation of particulate matter with inflammatory consequences, pulmonary injury from products of tissue pyrolysis, exposure to mutagens and carcinogens, and the transmission of human papillomavirus (HPV) and possibly other pathogens represent a spectrum of adverse effects associated with the occupational exposure to surgical plume. While adequate operating room ventilation and use of high filtration-efficiency masks offer some protection from these conditions, the most effective method of safeguarding against surgical smoke involves its removal with a dedicated smoke evacuation device (SED). Despite the fact that many professional and governmental agencies have endorsed widespread usage of SEDs, anesthesia providers have been largely silent on this subject, with few reports within the field of anesthesiology and perioperative medicine regarding these hazards. SED use is relatively infrequent in most surgeries, and this condition reflects surgeons' reluctance to employ these devices, likely resulting from lack of education and less than optimal technology. Anesthesia societies and academic centers can serve critical roles in advocating employment of SEDs in much the same way that they have supported perioperative smoking cessation.

Analysis of electrocautery smoke released from the tissues frequently cut in orthopedic surgeries

BACKGROUND

Electrosurgical smoke could be different by the device of cutting or the type of tissue that is being cut.

AIM

To analyze the electrocautery smoke released from the tissues that are frequently cut in orthopedic surgeries.

METHODS

The released smoke from electrocautery of five different tissue types (meniscus, ligament, adipose, muscle, and synovium) of five patients who underwent total knee arthroplasty were collected and analyzed for volatile organic compounds (VOCs) and 27 candidate polycyclic aromatic hydrocarbons (n = 25). Surgical smoke was produced with an electrocautery device for 4 min.

RESULTS

None of the 27 evaluated polycyclic aromatic hydrocarbons compounds were detectable ‎in electrocautery smoke collected from the surgical cutting of the different tissues.‎ The number and identity of detected VOCs were similar between the patients but not between tissue types. The number of detected VOCs was the highest in synovial tissue (n = 21) and the lowest in the meniscus and adipose tissue (n = 12). ‏‎The number of toxic and/or carcinogenic VOCs were the most in the muscle and meniscus tissues (‎Toluene, Ethylbenzene, and Styrene). No ‎ toxic and/or carcinogenic VOCs were identified in the ligament and adipose tissue.

CONCLUSION

Meniscus and muscle tissue are associated with the highest number of toxic and/or carcinogenic VOCs. Therefore, we recommend that surgeons avoiding the electrocautery of these tissues.

Chemicals in Surgical Smoke and the Efficiency of Built-in-Filter Ports

Background and Objectives:

Surgical smoke contains various malodorous and hazardous combustion byproducts. We aimed to analyze hydrocarbons accumulated in the abdominal cavity during laparoscopic gynecologic surgery and determine the efficiency of a built-in-filter port.

Methods:

We prospectively followed seven patients with benign uterine pathology. Surgical smoke was generated using laparoscopic or robotic electrocautery. The smoke was collected twice for each patient using a built-in-filter port and a conventional port. The concentrations of volatile organic compounds and aldehydes were determined using gas chromatography with mass spectrometry and high-performance liquid chromatography with ultraviolet visible light detection and compared using the paired-sample Wilcoxon signed-rank test.

Results:

Five volatile organic compounds and five aldehydes had toxic effects or unpleasant odors. The median concentration of formaldehyde before filtration (0.870 ppm) exceeded the time-weighted average concentration (0.75 ppm) of the Occupational Safety and Health Administration. Built-in-filter ports significantly reduced the concentration of five volatile organic compounds and two aldehydes but not that of formaldehyde, acetaldehyde, and propionaldehyde. Formaldehyde concentration decreased by 50% after filtration but remained above the recommended exposure limit (0.016 ppm) of the National Institute of Occupational Safety and Health.

Conclusions:

Surgical smoke in minimally invasive gynecologic procedures contains several hazardous hydrocarbons including formaldehyde. Built-in-filter ports have the potential to reduce the exposure of surgical smoke to surgeons and operating room personnel; nevertheless, development of built-in-filter ports is necessary to improve the filtering efficiency for highly concentrated formaldehydes.

Surgical Smoke-Hazard Perceptions and Protective Measures in German Operating Rooms

(1) Background: Hazardous substances in surgical smoke that is generated during laser or electrosurgery pose a potential health hazard. In Germany, the Technical Rules for Hazardous Substances (TRGS 525) have included recommendations for appropriate protective measures since 2014. Up to now, no empirical data has been available on the extent to which recommendations have been implemented in practice. (2) Methods: In 2018, 7089 surgeons in hospitals and outpatient practices were invited by email to participate in an online survey. In addition, 219 technical assistants were interviewed. The questionnaire dealt with knowledge of, and attitudes toward, the hazard potential of surgical smoke, as well as the availability and actual use of protective measures. Furthermore, manufacturers and distributors of smoke extraction devices were asked to give their assessment of the development of prevention in recent years. (3) Results: The survey response rate was 5% (surgeons) and 65% (technical assistant staff). Half of all surgeons assumed that there were high health hazards of surgical smoke without taking protective measures. Operating room nurses were more often concerned (88%). Only a few felt properly informed about the topic. The TRGS recommendations had been read by a minority of the respondents. In total, 52% of hospital respondents and 65% of the respondents in outpatient facilities reported any type of special suction system to capture surgical smoke. One-fifth of respondents from hospitals reported that technical measures had improved since the introduction of the TRGS 525. Fifty-one percent of the surgeons in hospitals and 70% of the surgeons in outpatient facilities "mostly" or "always" paid attention to avoiding surgical smoke. The most important reason for non-compliance with recommendations was a lack of problem awareness or thoughtlessness. Twelve industrial interviewees who assessed the situation and the development of prevention in practice largely confirmed the prevention gaps observed; only slight developments were observed in recent years. (4) Conclusions: The low response rate among surgeons and the survey results both indicate a major lack of interest and knowledge. Among other measures, team interventions with advanced training are needed in the future.

Evaluation of Personal Exposure to Surgical Smoke Generated from Electrocautery Instruments: A Pilot Study

Hospital technician surgical smoke exposures during several types of electrocautery-based procedures were evaluated. Personal and area air sampling was performed for 106 individual analytes including ultrafine particulate matter (UFP), volatile organic compounds, polycyclic aromatic hydrocarbons, phenol, aldehydes, carbon monoxide, hydrogen sulfide, and hydrogen cyanide. Acetone, d-limonene, ethanol, ethyl acetate, and fluorene were measured in surgical suites at concentrations 1.1- to 3.7-fold higher than those observed in background. Benzene, α-pinene, methylene chloride, and n-hexane were measured in the absence of a detectable background concentration. All analytes were measured at concentrations that were <1% of the corresponding US federal and state 8-h permissible exposure limits (PELs), if PELs existed. Full-shift average UFP concentrations ranged from 773 to 2257 particles/cm3, approximately one order of magnitude higher than surgical suite background concentrations. A comparison of two breast reduction procedures suggested that the use of smoke evacuators reduced UFP exposure by 6-fold. We concluded that selection and evaluation of key hazards, particularly UFP, under a variety of experimental conditions would be beneficial to elucidate potential health effects and causes osf employee complaints. Recommendations for successful sampling campaigns in future surgical smoke occupational exposure studies are provided. We also recommend the continued use of engineering controls, local exhaust ventilation, and surgical N95 respirators to reduce personal exposures to UFP in surgical smoke.

Awareness of surgical smoke hazards and enhancement of surgical smoke prevention among the gynecologists

Surgical smoke is the gaseous by-product produced by heat generating devices in various surgical operations including laser conization and loop electrosurgical procedures that often are performed by gynecologists. Surgical smoke contains chemicals, blood and tissue particles, bacteria, and viruses, which has been shown to exhibit potential risks for surgeons, nurses, anesthesiologists, and technicians in the operation room due to long term exposure of smoke. In this review, we describe the detailed information of the components of surgical smoke. Moreover, we highlight the effects of surgical smoke on carcinogenesis, mutagenesis, and infection in gynecologists. Furthermore, we discussed how to prevent the surgical smoke via using high-filtration masks and smoke evacuation systems as well as legal guidelines for protection measures among the gynecologists.