Surgical Smoke in Dermatologic Surgery

Hazards of surgical smoke from electrocautery: A critical review of the data

INTRODUCTION

Concerns have been voiced regarding the possibility of health risks to the operating room personnel from exposure to surgical smoke generated from electrocautery.

METHODS

Ovid Medline was queried using search terms "surgical smoke", "electrosurgery," "smoke evacuator". The NIOSH Health Hazard Evaluations Database was searched using terms, "hospital", "operating room", "Ames", "mutagen", and "salmonella".

RESULTS

Levels of pollutants in the breathable airspace within the operating room have been repeatedly shown to be very low. Absolute counts of particulate matter in the operating room are low when compared to other environments. The possibility for virus transmission with electrocautery in the operating room is unknown.

CONCLUSIONS

The risks related to the exposure to electrocautery surgical smoke have been overstated. Rigid mandates requiring smoke evacuators in all situations are not justified at this time.

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.

Plume Generated by Different Electrosurgical Techniques: An In Vitro Experiment on Human Skin

BACKGROUND

Plume generated by electrosurgical techniques is a health hazard to patients and dermatologists.

OBJECTIVE

To compare the particle concentration generated by various energy devices used in dermatologic surgery.

MATERIALS AND METHODS

Five surgical techniques were tested on human tissue samples in a closed chamber. A particle counter, positioned at a fixed point 20 cm away from the sample, recorded the concentrations of aerosolized particles generated over 7 particle sizes (0.3, 0.5, 0.7, 1, 2.5, 5, and 10 μm).

RESULTS

Monopolar electrocoagulation created the greatest concentration of particles followed by electrocautery, electrodesiccation, electrofulguration, and bipolar electrocoagulation. Bipolar electrocoagulation created 80 times fewer 0.3 μm particles and 98 times fewer 0.5 μm particles than monopolar electrocoagulation. Across all electrosurgical techniques, the greatest concentrations of particles generated were of the 0.3 and 0.5 μm particle size.

CONCLUSION

Bipolar electrocoagulation created the lowest concentration of particulate matter. Given the noxious and hazardous nature of surgical plume, the bipolar forceps offer surgeons a safer method of performing electrical surgery for both the surgical staff and the patient.

1,3-Butadiene: a ubiquitous environmental mutagen and its associations with diseases

1,3-Butadiene (BD) is a petrochemical manufactured in high volumes. It is a human carcinogen and can induce lymphohematopoietic cancers, particularly leukemia, in occupationally-exposed workers. BD is an air pollutant with the major environmental sources being automobile exhaust and tobacco smoke. It is one of the major constituents and is considered the most carcinogenic compound in cigarette smoke. The BD concentrations in urban areas usually vary between 0.01 and 3.3 μg/m³ but can be significantly higher in some microenvironments. For BD exposure of the general population, microenvironments, particularly indoor microenvironments, are the primary determinant and environmental tobacco smoke is the main contributor. BD has high cancer risk and has been ranked the second or the third in the environmental pollutants monitored in most urban areas, with the cancer risks exceeding 10^-5. Mutagenicity/carcinogenicity of BD is mediated by its genotoxic metabolites but the specific metabolite(s) responsible for the effects in humans have not been determined. BD can be bioactivated to yield three mutagenic epoxide metabolites by cytochrome P450 enzymes, or potentially be biotransformed into a mutagenic chlorohydrin by myeloperoxidase, a peroxidase almost specifically present in neutrophils and monocytes. Several urinary BD biomarkers have been developed, among which N-acetyl-S-(4-hydroxy-2-buten-1-yl)-L-cysteine is the most sensitive and is suitable for biomonitoring BD exposure in the general population. Exposure to BD has been associated with leukemia, cardiovascular disease, and possibly reproductive effects, and may be associated with several cancers, autism, and asthma in children. Collectively, BD is a ubiquitous pollutant that has been associated with a range of adverse health effects and diseases with children being a subpopulation with potentially greater susceptibility. Its adverse effects on human health may have been underestimated and more studies are needed.

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.

Optimizing Parameters for Smoke Evacuation

BACKGROUND

Current literature lacks recommendations regarding the ideal organization of the smoke evacuation system to minimize inhalation of surgical smoke.

OBJECTIVE

This study determines optimal parameters of the smoke evacuation system with respect to the surgical field.

MATERIALS AND METHODS

This study was conducted in an outpatient surgical facility at a tertiary care center. After 30 seconds of continuous electrocautery of tissue, particulate measurements were recorded using the TSI DustTrak Aerosol Monitor 8520 (>2.5 μm particles) and the TSI P-Trak Ultrafine Particle Counter 8525 (<1 μm particles) while changing the angle and distance of the smoke evacuation system.

RESULTS

Particulate matter measurements were lower when suction angle was at 45° than at 90°. For both small-sized and large-sized particles, the lowest particulate matter was recorded when the evacuator was maintained at a 45° angle, 2 to 4 inches away from the cauterizing procedure. Particulate matters dramatically increased after increasing the distance of the smoke evacuator beyond 8 inches from the procedural site.

CONCLUSION

In an effort to reduce smoke inhalation, the authors recommend that smoke evacuation should be placed at a 45° suction angle, no further than 8 inches away from the surgical site, while preserving the surgeon's field of vision.

Electrosurgery Use During Post-Mohs Micrographic Surgery Repair and Complication Rates-How Important is a Dry Field?

BACKGROUND

Electrosurgery is used to achieve hemostasis during surgery. There are no studies exploring the effects of the use or avoidance of electrodessication during Mohs micrographic surgery (MMS) repair. Given the growing concerns for tissue aerosolization, occupational smoke exposure, and spread of infectious diseases, it is important to determine the importance of electrical hemostasis.

MATERIALS AND METHODS

In this retrospective study, electronic medical records of a single, tertiary, academic dermatology practice were reviewed. All MMS cases that underwent surgical repair from January 1 to December 31, 2019, by 2 dermatologic surgeons (one who used electrodessication during repair and one who did not) were included. Patient demographic data, information regarding the procedures, and complications occurring 90 days after MMS were recorded.

RESULTS

One hundred ninety-eight cases of MMS repair used electrodessication, whereas 193 cases did not. There was no significant difference in the demographic makeup, MMS procedure, or 90-day complication rates between the 2 groups. No major adverse events were MMS-related.

CONCLUSION

The use or avoidance of electrodessication during MMS repair was not associated with increased 90-day postoperative complications, suggesting that a greater tolerance of moderate oozing at a surgical site during MMS repair is reasonable to minimize electrosurgical tissue damage and occupational smoke exposure.

Preventing and managing complications in dermatologic surgery: Procedural and postsurgical concerns

The second article in this continuing medical education series reviews the evidence regarding the intraoperative and postoperative risks for patients and health care workers. We share the most up-to-date recommendations for risk management and postoperative complication management to ensure optimal surgical efficacy and patient safety.

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.

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.

Surgical smoke: Risk assessment and mitigation strategies

BACKGROUND

Although many dermatologic surgeons are aware of the risks of surgical smoke, many do not use hazard reduction strategies.

OBJECTIVE

To identify the infectious, inhalational, chemical, and mutagenic risks of surgical smoke in dermatologic procedures and suggest evidence-based hazard reduction strategies.

METHODS

A review of articles indexed for MEDLINE on PubMed using the keywords surgical smoke, dermatology, surgical mask, respirator, smoke evacuator, and guidelines in 13 combinations was performed by using Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocols. The review included data from 45 articles from the dermatology, surgery, infectious disease, obstetrics, and cancer biology literature.

RESULTS

There are risks associated with surgical smoke, and although some dermatologists are aware of these risks, many are not using hazard reduction strategies such as smoke evacuators and surgical masks.

LIMITATIONS

Most of the data regarding the hazards of surgical smoke and methods for smoke safety are derived from in vitro and in vivo studies in nonhumans, as well as from resources outside of the dermatology literature.

CONCLUSION

Standardized guidelines for surgical smoke safety should be implemented in the dermatology community and residency curriculum.