A novel inspection protocol to detect volatile compounds in breast surgery electrocautery smoke

The research on the effect of temperature of electro-surgical unit to surgical smoke distribution in theatre-in vitro and simulation study

In electro-surgery, surgical smoke was hazard to surgeons and patient in theatre. In order to institute effective countermeasures, quantifying of the effect of tip temperature of electro-surgical unit to surgical smoke distribution in theatre was studied. The relation of tip temperature to power of electro-surgical unit through in vitro cutting experiment. Based on experiment data, the mathematical model was established to simulate the electro-surgery in laminar operation room. As the power of electro-surgical knife increased, the knife tip temperature increased. Total content of (CO, CO2, CH4, NH3) in waste gas and net flow rate of waste gas at outlet increased with the rising temperature of knife tip and formation rate of condensed tar droplets and non-viable particles also increased. Based on simulation, it was found that The maximum height of surgical smoke rising right above the incision of electro-surgical unit was increased with rising temperature of electro-surgical knife tip. There was a spread route of dispersed surgical smoke near the walls of theatre through natural convection. The polynomial fitting relationship was derived. As the tip temperature of knife increased from 200 to 500°C, maximum ascending height of surgical smoke right above the incision position of electro-surgical unit increased from 1.1 m to 1.45 m. When the tip temperature of electro-knife was more 400°C, the CO content in the surgeon's operating zone was more than 200 ppm, which would cause the surgeon's HbCO level increased. As the patient's tissue in the wound during operation was open, when the electro-knife of more than 400°C, the content of condensed tar droplets and in-viable particle was higher than 20 g/m3 and 12 g/m3 in the zone around patient's wound of open tissue, which should be hazard to health of patient.

Measurement of particulate matter 2.5 in surgical smoke and its health hazards

Purpose

Surgical smoke is generated during the cauterization, coagulation, and incision of biological tissues by electrocautery, ultrasonic coagulation, incising devices, and lasers. Surgical smoke comprises water, water vapor, steam, and some particulate matter, including bacteria, viruses, cell fragments, and volatile organic compounds, which can pose health risks to the operating room personnel. In this study, we measured the concentration of particulate matter 2.5 (particles with a diameter of ≤ 2.5 μm) in surgical smoke.

Methods

We used digital dust counters for real-time monitoring of particulate matter 2.5 generated intraoperatively in breast and gastrointestinal surgeries performed at our hospitals between 2019 and 2020.

Results

Concentrations of particulate matter 2.5 were measured in surgical smoke generated when performing 14 different surgeries. Immediately after electrocautery, the concentration of particulate matter 2.5 increased to 2258 μg/m³ and then, when we stopped using the devices, it decreased rapidly to the initial levels. Interestingly, the concentrations increased after each intermittent electrocautery procedure. Higher concentrations of particulate matter 2.5 were observed during breast surgeries than during laparoscopic procedures.

Conclusion

Surgical smoke poses potential health risks to operating room personnel by contaminating their breathing zone with high concentrations of particulate matter 2.5. A local exhaust ventilation system is needed to reduce exposure.

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.

Detection of human coronavirus RNA in surgical smoke generated by surgical devices

BACKGROUND

Gaseous by-products generated by surgical devices - collectively referred to as 'surgical smoke' - present the hazard of transmitting infective viruses from patients to surgical teams. However, insufficient evidence exists to evaluate and mitigate the risks of SARS-CoV-2 transmission via surgical smoke.

AIM

To demonstrate the existence and infectivity of human coronavirus RNA in surgical smoke using a model experiment and to evaluate the possibility of lowering transmission risk by filtration through a surgical mask.

METHODS

Pelleted HeLa-ACE2-TMPRSS2 cells infected with human coronavirus were incised by electric scalpel and ultrasonic scalpel, separately. A vacuum system was used to obtain surgical smoke in the form of hydrosol. Reverse transcription-quantitative polymerase chain reaction was used to analyse samples for the presence of viral RNA, and infectivity was determined through plaque assay. Furthermore, a surgical mask was placed centrally in the vacuum line to evaluate its ability to filter viral RNA present in the surgical smoke.

FINDINGS

In this model, 1/10⁶ to 1/10⁵ of the viral RNA contained in the incision target was detected in the collected surgical smoke. The virus present in the smoke was unable to induce plaque formation in cultured cells. In addition, filtration of surgical smoke through a surgical mask effectively reduced the amount of viral RNA by at least 99.80%.

CONCLUSION

This study demonstrated that surgical smoke may carry human coronavirus, though viral infectivity was considerably reduced. In clinical settings, surgical mask filtration should provide sufficient additional protection against potential coronavirus, including SARS-CoV-2, infection facilitated by surgical smoke.

Use of urinary hippuric acid and o-/p-/m-methyl hippuric acid to evaluate surgical smoke exposure in operating room healthcare personnel

Toluene and xylene are common components of surgical smoke, whereas hippuric acid (HA) and methylhippuric acid (MHA) are the products of toluene and xylene metabolism in humans, respectively. HA and MHA can be used as indicators to evaluate the exposure hazards of toluene and xylene. In this study, we used liquid chromatography tandem mass spectrometry (LC-MS/MS) to simultaneously analyze the HA, o-/m-/p-MHA, and creatinine contents in the urine of healthcare personnel. Concentrations of HA and o-/m-/p-MHAs were normalized to those of creatinine and used to analyze urine samples of 160 operating room (OR) healthcare personnel, including administrative staff, surgical nurses, nurse anesthetists, and surgeons. The results showed that the five analytes could be accurately separated and exhibited good linearity (r > 0.9992). The rate of recovery was between 86% and 106%, and the relative standard deviation was less than 5%. Urine from administrative staff presented the highest median concentration of hippuric acid (0.25 g/g creatinine); this was significantly higher than that found in the urine of surgeons (0.15 g/g). The concentrations of urinary o-/m-/p-MHAs in surgical nurses were higher than those in administrative staff, nurse anesthetists, and surgeons. Furthermore, the type, sex, and age of healthcare personnel were associated with changes in urine HA and o-/m-/p-MHA concentrations. Healthcare personnel should be aware of the risk of exposure to surgical smoke.

Chemical composition of surgical smoke produced during the loop electrosurgical excision procedure when treating cervical intraepithelial neoplasia

BACKGROUND

As LEEP (loop electrosurgical excision procedure) is being increasingly used for the diagnosis and treatment of uterine cervical intraepithelial neoplasia, surgical smoke during LEEP has become an inevitable health issue. Therefore, in this study, exposure to the chemical substances in surgical smoke produced during LEEP was assessed.

METHODS

Smoke samples from patients with high-grade cervical intraepithelial neoplasia undergoing LEEP were collected by smoke-absorbing devices situated 1 m away from the operating table and near the nose of the operator during LEEP. Each plume sample was collected after 5 patients underwent LEEP, requiring 5 min for smoke collection for each patient. The chemicals of exposure to surgical smoke were assessed, and the hazard classes of these chemical components were evaluated by the International Agency for Research on Cancer.

RESULTS

Qualitative analysis of the smoke produced during LEEP revealed a variety of potentially toxic chemicals under standard detection, such as benzene, toluene, xylene, ethylbenzene, styrene, butyl acetate, acrylonitrile, 1,2-dichloroethane, phenol, chlorine, cyanide, hydrogen cyanide and carbon monoxide. Additionally, the average concentration of carbon dioxide was 0.098 ± 0.015% during surgery and was higher than that before surgery (0.072 ± 0.007%, P < 0.001), and the concentration of formaldehyde was significantly higher during surgery (0.023 ± 0.009 mg/m³, P < 0.05) than before surgery (0.012 ± 0.001 mg/m³, P < 0.05).

CONCLUSIONS

Most of the detected chemical concentrations in smoke generated during LEEP were below the exposure limits when local exhaust ventilation procedures were efficiently used. However, the concentrations of carbon dioxide and formaldehyde found in smoke were significantly higher after surgery. Wearing a high-filtration mask and using evacuation devices routinely and consistently when performing LEEP are recommended to protect perioperative personnel.

Are Smoke and Aerosols Generated During Laparoscopic Surgery a Biohazard? A Systematic Evidence-Based Review

Background. Laparoscopic surgery generates end products that can have potentially harmful effects for the surgical team from short- or long-time exposure. In view of the current SARS-CoV-2 circumstances, controversy has risen concerning the safety of surgical smoke (SS) and aerosols and the perception of an increased risk of exposure during laparoscopic surgery. Methods. The present qualitative systematic review was conducted according to Meta-Analyses and Systematic Reviews of Observational Studies (MOOSE). A literature search was performed from March 2020 up to May 10, 2020, using the PubMed database, Cochrane, and Google Scholar to assess the risk of airborne transmission of viruses and the potential health risk of surgical smoke- and aerosol-generating procedures produced during laparoscopic surgery. The keywords were introduced in combination to obtain better search results. Application of the inclusion and exclusion criteria identified 44 relevant articles. Results. Genetic material from certain viruses, or the virus itself, has been detected in SS and aerosols. However, in the current SARS-CoV-2, as in other coronavirus situations, studies analyzing the presence of airborne transmission of viruses in surgical smoke are lacking. Conclusion. Despite the lack of clear evidence regarding the risk of diseases as the result of smoke- and aerosol-generating procedures during laparoscopic surgery, further investigation is needed. Meanwhile, all available precautions must be taken.

Diathermy smoke shown to be hazardous, so why are we not protecting ourselves?

Diathermy smoke has been studied for over three decades and data has been collected to establish its composition. Although its full structure has not been established, the compounds confirmed pose a health hazard to all exposed. Recommendations suggest that theatre staff need to protect themselves using smoke evacuating systems and masks. This review looks at the compliance of theatre staff within these guidelines and the reasons behind noncompliance.

Surgical smoke: still an underestimated health hazard in the operating theatre

OBJECTIVES

Smoke generated from electrocautery dissection contains irritating and/or carcinogenic components. The aim of this study was to investigate the effectiveness of a mobile smoke evacuation system (SES) in protecting surgical personnel from these hazardous fumes.

METHODS

Standardized cuts with an electrocautery device were performed on fresh porcine tissue, and the generated surgical fume was analysed with and without the additional use of a mobile SES using a real-time proton-transfer-reaction time-of-flight mass spectrometer. Furthermore, 2 different surgical masks were tested to investigate their filter capacity.

RESULTS

Several toxic and/or carcinogenic volatile organic compounds including 1,3-butadiene, benzene and furfural were found in concentrations clearly above the limits that were set by the National Institute of Occupational Safety and Health: 1,3-butadiene at 19.06 ± 1.54 ppm (limit: 5 ppm), benzene at 6.21 ± 1.33 ppm (limit: 0.5 ppm) and furfural at 14.34 ± 2.97 ppm (limit: 2 ppm). Although the mobile SES was able to reduce these substances to a certain degree, butadiene and benzene still remained above the permissible exposure limits with concentrations of 14.21 ± 0.07 and 1.16 ± 0.05, respectively. Both surgical masks were unable to reduce the 'inhaled' concentrations of volatile organic compounds.

CONCLUSIONS

Although the SES reduced the concentrations of most of the detected volatile organic compounds to a certain amount, especially the carcinogenic substances, butadiene and benzene remained high above exposure limits. According to the abovementioned significant data, further investigation on this topic is imperative, especially when considering that surgical masks were absolutely ineffective in protecting individuals from the toxic smoke and that the cautery was only used for 10 s in this experiment.

Pilot Studies of VOC Exposure Profiles during Surgical Operations

Volatile organic chemical exposure resulting from surgical operations is common in operating room personnel. The potential risk of long-term exposure to these low-level chemicals is always a concern. This study was conducted in an area hospital located in northern Taiwan to investigate the internal exposure scenario for operating room personnel. Breath samples were collected before and after surgery, whereas area samples were collected during the surgeries in process. There were 18 volatile organic compounds identified in the samples with gas chromatography-mass spectrometry. The average concentrations of sevoflurane (P = 0.0082), dimethyl sulfide (P = 0.0550), and methyl methacrylate (P = 0.0606) in breath samples collected after surgical operations were significantly higher compared to those obtained before surgical operations, whereas only slight elevations were present for benzene and hexamethyldisiloxane (P < 0.100). In addition, electrosurgical smoke-related chemicals, such as benzene, toluene, ethylbenzene, and m/p-xylene, also presented higher levels in operating room samples compared to the control area. Specifically, the findings in this preliminary study suggested the associations of elevated exposure to sevoflurane across various surgeries to methyl methacrylate with orthopedic surgery and to hexamethyldisiloxane with conventional electrosurgical units. Future study is warranted to explore the short-term high-level chemical exposure in operating rooms and to propose effective preventive measures accordingly to keep any exposure to chemicals at the lowest practical level.

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.

Removal of Hazardous Surgical Smoke Using a Built-in-Filter Trocar: A Study in Laparoscopic Rectal Resection

BACKGROUND

Surgical smoke containing potentially carcinogenic and harmful materials is an inevitable consequence of surgical energy devices, and constitutes a substantial occupational hazard in the operating room. This study aimed to evaluate the efficacy of a built-in-filter trocar in eliminating hazardous surgical smoke during laparoscopic and robotic rectal surgery.

METHODS

Ten patients who underwent rectal cancer resection were enrolled. Five patients underwent surgery utilizing a nonfiltered trocar, and the remaining 5 utilized a built-in-filter trocar. Gas samples were aspirated from the peritoneal cavity over 30 minutes of electrocauterization and collected in a Tedlar bag. Concentrations of surgical smoke were measured using ultraperformance liquid chromatography and gas chromatography.

RESULTS

Eleven hazardous chemical compounds (benzene, toluene, ethylbenzene, xylene, styrene, formaldehyde, acetaldehyde, propionaldehyde, butyraldehyde, isovaleraldehyde, and valeraldehyde) were identified in the surgical smoke. With the built-in-filter trocar, removal rates of 69% for benzene (P=0.028), 72% for toluene (P=0.009), 67% for butyraldehyde (P=0.047), 46% for ethylbenzene (P=0.092), 44% for xylene (P=0.086), 35% for styrene (P=0.106), 39% for formaldehyde (P=0.346), and 33% for propionaldehyde (P=0.316) were achieved.

CONCLUSIONS

This study confirmed the presence of harmful materials in surgical smoke. Evacuation of surgical smoke through a disposable built-in-filter trocar is a simple and effective way in reducing volatile organic compounds concentrations.

Diathermy smoke shown to be hazardous, so why are we not protecting ourselves?

Diathermy smoke has been studied for over three decades and data has been collected to establish its composition. Although its full structure has not been established, the compounds confirmed pose a health hazard to all exposed. Recommendations suggest that theatre staff need to protect themselves using smoke evacuating systems and masks. This review looks at the compliance of theatre staff within these guidelines and the reasons behind noncompliance.

Surgical smoke control with local exhaust ventilation: Experimental study

This experimental study aimed to evaluate airborne particulates and volatile organic compounds (VOCs) from surgical smoke when a local exhaust ventilation (LEV) system is in place. Surgical smoke was generated from human tissue in an unoccupied operating room using an electrocautery surgical device for 15 min with 3 different test settings: (1) without LEV control; (2) control with a wall irrigation suction unit with an in-line ultra-low penetration air filter; and (3) control with a smoke evacuation system. Flow rate of LEVs was approximately 35 L/min and suction was maintained within 5 cm of electrocautery interaction site. A total of 6 experiments were conducted. Particle number and mass concentrations were measured using direct reading instruments including a condensation particle counter (CPC), a light-scattering laser photometer (DustTrak DRX), a scanning mobility particle sizer (SMPS), an aerodynamic particle sizer (APS), and a viable particle counter. Selected VOCs were collected using evacuated canisters using grab, personal and area sampling techniques. The largest average particle and VOCs concentrations were found in the absence of LEV control followed by LEV controls. Average ratios of LEV controls to without LEV control ranged 0.24-0.33 (CPC), 0.28-0.39 (SMPS), 0.14-0.31 (DustTrak DRX), and 0.26-0.55 (APS). Ethanol and isopropyl alcohol were dominant in the canister samples. Acetaldehyde, acetone, acetonitrile, benzene, hexane, styrene, and toluene were detected but at lower concentrations (<500 μg/m3) and concentrations of the VOCs were much less than the National Institute for Occupational Safety and Health recommended exposure limit values. Utilization of the LEVs for surgical smoke control can significantly reduce but not completely eliminate airborne particles and VOCs.

Electrosurgical Smoke: Ultrafine Particle Measurements and Work Environment Quality in Different Operating Theatres

Air cleanliness in operating theatres (OTs) is an important factor for preserving the health of both the patient and the medical staff. Particle contamination in OTs depends mainly on the surgery process, ventilation principle, personnel clothing systems and working routines. In many open surgical operations, electrosurgical tools (ESTs) are used for tissue cauterization. ESTs generate a significant airborne contamination, as surgical smoke. Surgical smoke is a work environment quality problem. Ordinary surgical masks and OT ventilation systems are inadequate to control this problem. This research work is based on numerous monitoring campaigns of ultrafine particle concentrations in OTs, equipped with upward displacement ventilation or with a downward unidirectional airflow system. Measurements performed during ten real surgeries highlight that the use of ESTs generates a quite sharp and relevant increase of particle concentration in the surgical area as well within the entire OT area. The measured contamination level in the OTs are linked to surgical operation, ventilation principle, and ESTs used. A better knowledge of airborne contamination is crucial for limiting the personnel’s exposure to surgical smoke. Research results highlight that downward unidirectional OTs can give better conditions for adequate ventilation and contaminant removal performances than OTs equipped with upward displacement ventilation systems.

Composition of the electrocautery smoke: integrative literature review

Abstract OBJECTIVE To identify the composition of the smoke produced by electrocautery use during surgery. METHOD Integrative review with search for primary studies conducted in the databases of the US National Library of Medicine National Institutes of Health, Cumulative Index to Nursing and Allied Health Literature, and Latin American and Caribbean Health Sciences, covering the studies published between 2004 and 2014. RESULTS The final sample consisted of 14 studies grouped into three categories, namely; polycyclic aromatic hydrocarbons, volatile compounds and volatile organic compounds. CONCLUSION There is scientific evidence that electrocautery smoke has volatile toxic, carcinogenic and mutagenic compounds, and its inhalation constitutes a potential chemical risk to the health of workers involved in surgeries.

Electrostatic precipitation is a novel way of maintaining visual field clarity during laparoscopic surgery: a prospective double-blind randomized controlled pilot study

BACKGROUND

Ultravision™ is a new device that utilizes electrostatic precipitation to clear surgical smoke. The aim was to evaluate its performance during laparoscopic cholecystectomy.

METHODS

Patients undergoing laparoscopic cholecystectomy were randomized into "active (device on)" or "control (device off)." Three operating surgeons scored the percentage effective visibility and three reviewers scored the percentage of the procedure where smoke was present. All assessors also used a 5-point scale (1 = imperceptible/excellent and 5 = very annoying/bad) to rate visual impairment. Secondary outcomes were the number of smoke-related pauses, camera cleaning, and pneumoperitoneum reductions. Mean results are presented with 95% confidence intervals (CI).

RESULTS

In 30 patients (active 13, control 17), the effective visibility was 89.2% (83.3-95.0) for active cases and 71.2% (65.7-76.7) for controls. The proportion of the procedure where smoke was present was 41.1% (33.8-48.3) for active cases and 61.5% (49.0-74.1) for controls. Operating surgeons rated the visual impairment as 2.2 (1.7-2.6) for active cases and 3.2 (2.8-3.5) for controls. Reviewers rated the visual impairment as 2.3 (2.0-2.5) for active cases and 3.2 (2.8-3.7) for controls. In the active group, 23% of procedures were paused to allow smoke clearance compared to 94% of control cases. Camera cleaning was not needed in 85% of active procedures and 35% of controls. The pneumoperitoneum was reduced in 0% of active cases and 88% of controls.

CONCLUSIONS

Ultravision™ improves visibility during laparoscopic surgery and reduces delays in surgery for smoke clearance and camera cleaning.

Is surgical smoke harmful to theater staff? a systematic review

BACKGROUND

Smoke is generated by energy-based surgical instruments. The airborne byproducts may have potential health implications. This study aimed to evaluate the properties of surgical smoke and the evidence for the harmful effects to the theater staff.

METHODS

Cochrane Database, MEDLINE, PubMed, Embase classic and Embase, and the metaRegister of Controlled Trials were searched for studies reporting the constituents found in the smoke plume created during surgical procedures, the methods used to analyze the smoke, the implications of exposure, and the type of surgical instrument that generated the smoke. Studies were excluded if they were animal based, preclinical experimental work, or opinion-based reports. The common end points were particle size and characteristics, infection risk, malignant spread, and mutagenesis.

RESULTS

The inclusion criteria were fulfilled by 20 studies. In terms of particle size, 5 (25%) of the 20 studies showed that diathermy and laser can produce ultrafine particles (UFP) that are respirable in size. With regard to particle characterization, 7 (35%) of the 20 studies demonstrated that a variety of volatile hydrocarbons are present in diathermy-, ultrasonic-, and laser-derived surgical smoke. These are potentially carcinogenic, but no evidence exists to support a cause-effect relationship for those exposed. In terms of infection risk, 6 (30%) of the 20 studies assessed surgical smoke for the presence of viruses, with only 1 study (5%) positively identifying viral DNA in laser-derived smoke. One study (5%) demonstrated bacterial cell culture (Staphylococcus aureus) from a laser plume after surgery. Regarding mutagenesis and malignant spread, one study (5%) reported the mutagenic effect of smoke, and one study (5%) showed the presence of malignant cells in the smoke of a patient undergoing procedures for carcinomatosis.

CONCLUSIONS

The potentially carcinogenic components of surgical smoke are sufficiently small to be respirable. Infective and malignant cells are found in the smoke plume, but the full risk of this to the theater staff is unproven. Future work could focus on the long-term consequences of smoke exposure.

Surgical smoke

Surgical smoke is produced when tissues are dissected or cauterised by heat generating devices. Perioperative personnel and patients are routinely exposed to this smoke, and the use of smoke evacuation devices in operating theatres is not mandatory. This review will examine the most recent literature relating to surgical smoke in an attempt to discover guidelines for best practice and thereby provide recommendations for future practice.