Efficiencies and noise levels of portable surgical smoke evacuation systems

Do Surgical Smoke Evacuators Increase the Risk of Hearing Loss for Operative Personnel During Routine Adenotonsillectomy Surgery?

INTRODUCTION

Aerosol mitigation equipment implemented due to COVID-19 has increased noise levels in the operating room (OR) during otolaryngological procedures. Intraoperative sound levels may potentially place personnel at risk for occupational hearing loss. This study hypothesized that cumulative intraoperative noise exposures with aerosol mitigation equipment exceed recommended occupational noise exposure levels.

METHODS

Sound levels generated by the surgical smoke evacuator (SSE) during adenotonsillectomy were measured using a sound level meter and compared to surgery without SSE.

RESULTS

Thirteen adenotonsillectomy surgeries were recorded. Mean sound levels with the SSE were greater than the control (72 ± 3 A-weighted decibels (dBA) vs. 68 ± 2 dBA; p=0.015). Maximum noise levels during surgery with SSE reached 82 ± 3 dBA.

CONCLUSION

Surgeons performing adenotonsillectomy with aerosol mitigation equipment are exposed to significant noise levels. Intraoperative sound levels exceeded international standards for work requiring concentration. Innovation is needed to reduce cumulative OR noise exposures.

The Impact of Electrocautery Smoke on Surgical Staff and the Efficacy of Normal Surgical Masks Versus N95 Masks

Electrocautery is a commonly used technique in surgical procedures, generating smoke that poses health risks to surgical staff. This study investigates the comparative efficacy of normal surgical masks versus N95 masks in mitigating the harmful effects of electrocautery smoke. Through a systematic review of literature spanning two decades, we explore the causes and effects of electrocautery smoke exposure, including potential long-term inhalation effects. Our findings highlight significant disparities in the protection offered by different masks and underscore the importance of adequate respiratory protection in surgical settings. In addition, we examine the factors influencing the generation and composition of electrocautery smoke, such as the power settings used, the type of tissue being cauterized, and the duration of the procedure. Furthermore, we discuss the potential health risks associated with long-term exposure to electrocautery smoke, including the possibility of respiratory conditions, cardiovascular effects, and carcinogenicity. Our analysis also addresses the importance of implementing appropriate smoke evacuation systems and optimizing operating room ventilation to minimize the concentration of smoke particles in the surgical environment. Overall, this comprehensive analysis provides valuable insights into the impact of electrocautery smoke in surgical settings and the varying levels of protection offered by different masks.

Surgical smoke and its components, effects, and mitigation: a contemporary review

Energy-based surgical instruments produce surgical smoke, which contains harmful byproducts, such as polycyclic aromatic hydrocarbons, volatile organic compounds, particulate matter, and viable microorganisms. The research setting has shifted from the laboratory to the operating room. However, significant heterogeneity in the methods of detection and placement of samplers, diversity in the tissue operated on, and types of surgeries tested has resulted in variability in detected levels and composition of surgical smoke. State regulation limiting surgical smoke exposure through local evacuators is expanding but has yet to reach the national regulatory level. However, most studies have not shown levels above standard established limits but relatively short bursts of high concentrations of these harmful by-products. This review highlights the limitations of the current research and unsupported conclusions while also suggesting further areas of interest that need more focus to improve Occupational Safety and Health Administration guidelines.

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.

Instrumental in Surgery: A Narrative Review on Energy-based Surgical Cutting Devices and Surgical Smoke

OBJECTIVE

To provide an informed understanding of existing energy-based surgical cutting technologies and aerosol-generating surgical procedures. We provide a perspective on the future innovation and research potential in this space for the benefit of surgeons, physicians, engineers, and researchers alike.

BACKGROUND

Surgery is a treatment for many medical conditions, the success of which depends on surgical cutting instruments that enable surgeons to conduct surgical procedures for tissue cutting and manipulation. Energy-based surgical cutting tools improve accuracy and limit unnecessary destruction of healthy tissues and cells, but can generate surgical smoke and aerosols, which can be handled using surgical smoke evacuation technology.

METHODS

A narrative review was conducted to explore existing literature describing the history and development of energy-based surgical instruments, their mechanisms of action, aerosol-generating medical procedures, surgical smoke and aerosols from aerosol-generating medical procedures, and the recommended mitigation strategies, as well as research on rapid biological tissue analyzing devices to date.

CONCLUSIONS

Smoke evacuation technology may provide diagnostic information regarding tissue pathology, which could eliminate health concerns and revolutionize surgical accuracy. However, further research into surgical smoke is required to quantify the measurable risk to health it poses, the cutting conditions, under which it is generated and to develop advanced diagnostic approaches using this information.

The Problem with 'Suction Only' Methods to Reduce Surgical Smoke Exposure

Surgical staff and patients are frequently exposed to surgical smoke and there is mounting evidence that this may be harmful. Borsetti et al. have devised a novel approach to minimising intraoperative exposure to surgical smoke. Here, I briefly outline my concerns with the 'suction only' approach to addressing this problem. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Ultrafine particle concentrations during laser hair removal: Effectiveness of smoke evacuators

BACKGROUND AND OBJECTIVES

Laser smoke is a biohazard that contains potentially dangerous toxic and biological components. In laser hair removal (LHR), practitioners undergo prolonged exposure as this procedure is widely used without protective measures. Little is known about the effect of smoke evacuators on ultrafine particle concentrations during LHR. This study aims to assess the effect of different laser devices and different smoke evacuators on the ultrafine particle concentrations in the room during LHR.

STUDY DESIGN/MATERIALS AND METHODS

In a prospective observational study, we included patients with skin phototypes 2-4 for 755 nm Alexandrite LHR at two study sites, receiving treatment in axillae and pubic areas. Ultrafine particle concentrations were measured during LHR for two different alexandrite lasers, with and without an external smoke evacuator. Moreover, we assessed a device for LHR with a smoke evacuator integrated into the handpiece. Primary outcomes were the concentration of ultrafine particles (0.2-0.3 µm) per m³ at 1 min after initiation of treatment and maximum concentrations.

RESULTS

A total of 15 patients were recruited for routine LHR. Without a smoke evacuator, already at 1 minute after treatment onset, ultrafine particle concentrations rapidly increased. Both external and integrated smoke evacuators were highly effective with a 3.7-7-fold decrease in maximal particle count. Similarly, maximal particle concentrations remained low with both smoke evacuators. At both study sites, particle concentrations decreased slowly (8 min for 50% reduction) when treatment stopped.

CONCLUSION

LHR procedures generated an increase of ultrafine particles. Both the external and integrated smoke evacuators are highly effective in controlling ultrafine particle concentrations during LHR. Once particle concentrations are elevated and the process had been completed, clearance of ultrafine particles is rather slow.

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.

Assessment of the absorbed dose after exposure to surgical smoke in an operating room

Surgical smoke produced by electrosurgery contains various chemical substances such as volatile organic compounds (VOCs) and polycyclic aromatic hydrocarbons (PAHs). The aim of this study is to investigate airborne concentrations of VOCs and PAHs during electrosurgery in an operating room, in relation to metabolites in urine in order to assess the absorbed dose. A 5-day exposure study was set up in a general surgery operation room including surgeons, scrub assistants and circulation nurses (n = 15). Stationary and personal air sampling for VOCs and PAHs were carried out. Pre-, mid- and end-shift analysis of urinary S-phenylmercapturic acid (SPMA), o-cresol, mandelic acid and 1-hydroxypyrene was performed to assess the internal exposure to respectively benzene, toluene, styrene and PAHs. Several VOCs (styrene, ethyl benzene, benzene and toluene), ranging from 0.7 to 3.27 μg/m³ were detected in the air samples, along with one PAH (naphthalene, ranging from 0.012 to 0.39 μg/m³). There was no significant correlation between air monitoring and urinary biomonitoring. O-cresol levels were increased, especially among assistants and nurses at mid- and end-shift, exceeding current biological exposure indices several times. External and internal exposure for assistants and nurses was substantially more, compared to surgeons. This study confirms the presence of VOCs and PAHs in surgical smoke and shows the presence of their metabolites in urine, but the association is unclear. Urinary biomonitoring shows especially high concentrations of o-cresol.

Current Evidence for Minimally Invasive Surgery During the COVID-19 Pandemic and Risk Mitigation Strategies: A Narrative Review

OBJECTIVE

Our objective was to review the literature surrounding the risks of viral transmission during laparoscopic surgery and propose mitigation measures to address these risks.

SUMMARY BACKGROUND DATA

The SARS-CoV-2 pandemic has caused surgeons the world over to re-evaluate their approach to surgical procedures given concerns over the risk of aerosolization of viral particles and exposure of operating room staff to infection. International society guidelines advise against the use of laparoscopy; however, the evidence on this topic is scant and recommendations are based on the perceived most cautious course of action.

METHODS

We conducted a narrative review of the existing literature surrounding the risks of viral transmission during laparoscopic surgery and balance these risks against the benefits of minimally invasive approaches. We also propose mitigation measures to address these risks that we have adopted in our institution.

RESULTS AND CONCLUSION

While it is currently assumed that open surgery minimizes operating room staff exposure to the virus, our findings reveal that this may not be the case. A well-informed, evidence-based opinion is critical when making decisions regarding which operative approach to pursue, for the safety and well-being of the patient, the operating room staff, and the healthcare system at large. Minimally invasive surgical approaches offer significant advantages with respect to both patient care, and the mitigation of the risk of viral transmission during surgery, provided the appropriate equipment and expertise are present.

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.

The utility of local smoke evacuation in reducing surgical smoke exposure in spine surgery: a prospective self-controlled study

BACKGROUND CONTEXT

Exposure to surgical smoke remains a potential occupational health concern to spine operating room personnel. Using a smoke evacuator (local exhaust ventilation) is currently regarded as a primary means of protection, yet few studies have evaluated its utility in actual surgeries.

OBJECTIVE

To examine the utility of two common types of local smoke evacuators, a para incisional evacuator and a smoke evacuation pencil, in reducing surgical smoke exposure in spine surgery.

STUDY DESIGN

A prospective self-controlled study.

PATIENT SAMPLE

After the pre-estimation of sample size, 51 consecutive spine surgeries (25 and 26 patients using the para incisional smoke evacuator and the smoke evacuation pencil, respectively) were enrolled between February 2018 and March 2019.

OUTCOME MEASURES

Two outcome measures were used to evaluate the level of surgical smoke exposure, which was defined as the concentration of ultrafine smoke particles in the air (number of particles per cm³, ppc) around the operating table: (a) the average smoke level was the arithmetic mean of all measurements recorded during the surgery; and (b) the peak smoke level was the highest measurement recorded.

METHODS

Consecutive surgeries that involved bilateral symmetrical surgical exposure of the spine via a posterior midline incision were evaluated. Cauterized smoke was evacuated by two smoke evacuators: a "para incisional evacuator," which used a flat broad suction pad positioned immediately adjacent to the incision (25 patients), and a "surgical smoke evacuation pencil" which is an incorporated part of the electrocautery (26 patients). The level of smoke exposure was measured separately when surgically exposing the two sides of the spine: starting with one side (determined randomly) with the smoke evacuator being turned on and, then, the other side with the smoke evacuator off. The results were compared between the two sides.

RESULTS

The para incisional smoke evacuator significantly reduced the average smoke level by an average of 59.7% (287 [interquartile range {IQR}: 126, 526] vs. 1,177 [IQR: 395, 2,702], p<.001). The surgical smoke evacuation pencil also reduced the average smoke level by an average of 44.1% (917 [IQR: 448, 1936] vs. 1,605 [IQR: 775, 4,280], p<.001). Both evacuators significantly reduced peak smoke levels as well.

CONCLUSIONS

This study provides evidence supporting the utility of local smoke evacuation in reducing surgical smoke exposure in spine surgery. Such technology may help to improve the occupational health protection for spine operating room workers.

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.