The characterization of surgical smoke from various tissues and its implications for occupational safety

Computational Polarization Imaging In Vivo through Surgical Smoke Using Refined Polarization Difference

In surgery, the surgical smoke generated during tissue dissection and hemostasis can degrade the image quality, affecting tissue visibility and interfering with the further image processing. Developing reliable and interpretable computational imaging methods for restoring smoke-affected surgical images is crucial, as typical image restoration methods relying on color-texture information are insufficient. Here a computational polarization imaging method through surgical smoke is demonstrated, including a refined polarization difference estimation based on the discrete electric field direction, and a corresponding prior-based estimation method, for better parameter estimation and image restoration performance. Results and analyses for ex vivo, the first in vivo animal experiments, and human oral cavity tests show that the proposed method achieves visibility restoration and color recovery of higher quality, and exhibits good generalization across diverse imaging scenarios with interpretability. The method is expected to enhance the precision, safety, and efficiency of advanced image-guided and robotic surgery.

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: 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.

Knowledge mapping of surgical smoke from 2003 to 2022: a bibliometric analysis

PURPOSE

The purpose of this study is to identify and characterize the literature on surgical smoke, visualize the data and sketch a certain trending outline.

METHODS

In the Web of Science Core Collection (WoSCC), all the data were acquired from January 1st 2003 to December 31st 2022. VOSviewer and CiteSpace were employed to visualize data, based on publications, bibliographic coupling, co-citation, or co-authorship relations. Microsoft Excel 2019 was used to comb and categorize all the statistics.

RESULT

A total 363 of journal papers were retrieved. The publication number was in a slow but steady growth between 2003 and 2019, followed by a sharp surge in 2020, and then the publication kept in a productive way. Surgical endoscopy and other interventional techniques was the most active journal on surgical smoke. USA played an important role among all the countries/regions. There were 1847 authors for these 363 papers, among whom 44 authors published more than three articles on surgical smoke. "Surgical smoke", "covid-19" and "surgery" were the top 3 appeared keywords, while the latest hot-spot keywords were "COVID-19", "virus", "transmission", "exposure" and "risk". There were 1105 co-cited references and 3786 links appeared in all 363 articles. Among them, 38 references are cited more than 10 times. The most co-cited article was "Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery." Based on the titles of references and calculated by CiteSpace, the top 3 cluster trend network are "laparoscopic surgery", "COVID-19 pandemic" and "surgical smoke".

CONCLUSION

According to bibliometric analysis, the research on surgical smoke has been drawing attention of more scholars in the world. Increasing number of countries or regions added in this field, and among them, USA, Italy, and China has been playing important roles, however, more wide and intense cooperation is still in expectation.

Comparing Aerosol Generation in Human and Animal Tissues During Common Otolaryngology Procedures

OBJECTIVE

To determine whether hamster and human tissues generate similar amounts of aerosolized particles using common otolaryngology surgical techniques.

STUDY DESIGN

Quantitative experimental research.

STUDY SETTING

University research laboratory.

METHODS

Drilling, electrocautery, and coblation were performed on human and hamster tissues. Particle size and concentration were measured during the surgical procedures using a scanning mobility particle sizer and an aerosol particle sizer (SMPS-APS) and GRIMM aerosol particle spectrometer.

RESULTS

SMPS-APS and GRIMM measurements detected at least 2-fold increases in aerosol concentrations compared to baseline during all procedures. Procedures performed on human and hamster tissues produced similar trends and order of magnitude of aerosol concentrations. Generally, hamster tissues produced higher aerosol concentrations compared to human tissues, and some of these differences were statistically significant. Mean particle sizes for all procedures were small (<200 nm), although statistically significant differences in particle size were identified between human and hamster tissues during coblation and drilling.

CONCLUSION

Aerosol-generating procedures performed on human and hamster tissue produce similar trends in aerosol particle concentrations and sizes, although we observed some differences between the 2 tissue types. Further studies should be performed to understand the clinical significance of these differences.

Fertility and Pregnancy: How Do These Affect Family Planning and Surgeon Health?

There are unique considerations to fertility and pregnancy for women surgeons. Women surgeons often decide to delay pregnancy and childbearing due to concerns of conflict with work and training. This is particularly true for surgical trainees who face many obstacles, including bias from peers and program directors, and work-life conflict. As such, rates of infertility are higher compared with the general population. Women surgeons require assisted reproductive technologies more often than the general population. During pregnancy, there are also additional occupational hazards that are unique to a surgical career. Overall, we must be aware of these issues to support surgeons who decide to become parents during a surgical career.

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.

Formaldehyde Reduction in an Operating Room Setting: Comparison of a Catalytic Surgical Vacuum Device With a Traditional Smoke Evacuator

Introduction Electrosurgery exposes healthcare workers to volatile organic compounds (VOCs) including formaldehyde. Adopting electrosurgical devices that catalytically transform formaldehyde to benign substances has the potential to improve safety in surgical settings. Materials and methods We compared the efficiency of formaldehyde removal of two medical devices. The first was a novel surgical vacuum (SV) device containing ultra-low particulate air (ULPA) filtration, activated carbon and catalytic transition metal oxide. The second was a commonly utilized handpiece evacuator (HE) that contained only mechanical filtration and activated carbon granules. Both devices were exposed to formalin vapor. Results The time weighted average (TWA), median and peak concentrations of detected formaldehyde at the outflow of the SV unit were 90% lower than the corresponding values detected at the outflow of the HE device (p = 0.0034). When catalytic material was added to the HE device, the detected formaldehyde concentration at the outflow was reduced by 55% (p = 2.9 x 10^-15). Conclusions The catalytic SV device has the potential to considerably reduce formaldehyde levels in operating room (OR) environments.

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.

Distribution of surgical smoke particles within a simulated laparoscopic cavity utilizing an AirSeal® system

An exploratory study was performed to determine the distribution of surgical smoke particulate matter (SSPM) and evacuation times within an AirSeal® System and a traditional insufflation access system in various simulated surgical scenarios. Identified trends showed statistical significance when setting the AirSeal® System to Low smoke evacuation that it reduces the percentage of particulate matter at the Access Port opening. Additionally, it was observed that when utilising a laparoscopic tool a similar trend in particle distributions were seen between either insufflation and access system at the opening of the Access Port and trocar. Evacuation times for SSPM removal within the AirSeal® System showed an overall average to ≥95% reduction of 5.64 min within the surgical cavity, 3.69 min at the Access Port opening, and 3.61 min within the smoke evacuation line. The overall average for the traditional insufflation and access system was 9.38 min within the surgical cavity and 6.06 min at the trocar opening. Results showed that when using the traditional system compared to the AirSeal® System, it resulted in a percent change increase in evacuation times of 66.31% within the surgical cavity and 64.23% at the trocar opening.

Comparison of surgical smoke between two approaches for endoscopic thyroidectomy and open thyroidectomy

BACKGROUND

Surgical smoke has been recognized as a potential health risk by an increasing number of researchers. Moreover, the counts of surgical smoke produced during different surgical approaches are different. This study aimed to measure and compare the particulate matter (PM) of surgical smoke generated during open thyroidectomy and two endoscopic approaches for thyroidectomy to provide guidance for safe clinical practices.

METHODS

Forty-eight patients with thyroid cancer admitted to our hospital from June 2020 to December 2021 and treated with different surgical approaches were enrolled in this study. The total and peak counts of PM, dynamic changes, and other characteristics of surgical smoke produced during surgery were recorded. PM was classified as PM2.5 (size ≤ 2.5 μm) and PM10 (size ≤ 10 μm).

RESULTS

In a single cut, both the peak and total counts of PM2.5 and PM10 of surgical smoke in the open thyroidectomy group (n = 15) were significantly higher than those in the breast approach endoscopic thyroidectomy with CO2 insufflation group (n = 15) and the gasless transaxillary endoscopic thyroidectomy group (n = 18) (p < 0.001). Moreover, the latter two groups showed no significant differences in the peak and total counts of PM2.5 and PM10 (p > 0.05).

CONCLUSION

In thyroid surgery, more surgical smoke is produced during open thyroidectomy than during endoscopic thyroidectomy, while different endoscopic approaches showed no significant difference in surgical smoke production. Thus, endoscopic approaches outperform the open thyroidectomy approach with regard to surgical smoke production.

Bile-volatile organic compounds in the diagnostics of pancreatic cancer and biliary obstruction: A prospective proof-of-concept study

OBJECTIVES

Detection of volatile organic compounds (VOCs) from bodily fluids with field asymmetric waveform ion mobility spectrometry (FAIMS) and related methods has been studied in various settings. Preliminary results suggest that it is possible to detect prostate, colorectal, ovarian and pancreatic cancer from urine samples. In this study, our primary aim was to differentiate pancreatic cancer from pancreatitis and benign tumours of the pancreas by using bile samples obtained during endoscopic retrograde cholangiopancreatography (ERCP). Secondarily, we aimed to differentiate all pancreatic region malignancies from all other kinds of benign causes of biliary obstruction.

METHODS

A bile sample was successfully aspirated from 94 patients during ERCP in Tampere University Hospital. Hospital and patient records were prospectively followed up for at least two years after ERCP. Bile samples were analysed using a Lonestar chemical analyser (Owlstone, UK) using an ATLAS sampling system and a split-flow box. Diagnoses and corresponding data from the analyses were matched and divided into two subcategories for comparison. Statistical analysis was performed using linear discriminant analysis, support vector machines, and 5-fold cross-validation.

RESULTS

Pancreatic cancers (n=8) were differentiated from benign pancreatic lesions (n=9) with a sensitivity of 100%, specificity of 77.8%, and correct rate of 88%. All pancreatic region cancers (n=19) were differentiated from all other kinds of benign causes of biliary obstruction (n=75) with corresponding values of 21.1%, 94.7%, and 80.7%. The sample size was too small to try to differentiate pancreatic cancers from adjacent cancers.

CONCLUSION

Analysing bile VOCs using FAIMS shows promising capability in detecting pancreatic cancer and other cancers in the pancreatic area.

Smoke analysis of a new surgical system that applies low-temperature plasma

Background

The high-frequency electrotome (ES), which is widely used in surgical procedures, generates surgical smoke that is potentially hazardous to operating personnel. Previous research shows that the PlasmaBlade (PB) may be able to overcome this problem. The present study set out to analyze potentially hazardous surgical smoke generated during electrosurgery by the ES, the PB, and. a new surgical system that applies low-temperature plasma, the NTS-100.

Methods

In vitro and in vivo healthy porcine models were used to compare volatile organic compounds (VOCs) and particulate matter (PM) in smoke generated by the NTS-100, the PB, and the conventional ES when cutting liver, muscle, and skin and subcutaneous tissues. The detected indexes included the VOCs in surgical smoke, the concentration and percentage of each part, the PM2.5 concentration, the mass of particles, and the diameter distribution of particles.

Results

The smoke generated by the NTS-100 contained fewer hazardous components than that generated by the ES (P<0.05) and a comparable amount to that generated by the PB (P>0.05). The PM2.5 concentration and mass of particles in the smoke generated by the NTS-100 were lower than those with the ES (P<0.05 and P<0.01, respectively) and similar to those with the PB (P>0.05). The NTS-100 generated larger particles than did the ES and the PB (P<0.05).

Conclusions

Surgical smoke contains harmful VOCs and PM, but the NTS-100 generated less hazardous surgical smoke than did the conventional ES and performed comparably to the PB. Therefore, using the NTS-100 may reduce the potential hazard of surgical smoke to operating room personnel.

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.

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.

The Nursing Effect of PRECEDE Management on Occupational Exposure to Surgical Smoke: Based on a Randomized Controlled Study

Background

Occupational exposure seriously threatens the physical and mental health of professionals and has become an important public health problem. In clinical medical and nursing work, medical staff, especially nursing staff, are faced with the status quo of occupational exposure with high risk, serious harm, and severe situation. Therefore, a sound management system must be established to control the occupational exposure of nurses.

Aims

According to the PRECEDE management model, evaluate the operating room nurses' knowledge, belief, and behavior scores on the protection of surgical smoke, understand their awareness of surgical smoke and the current status of protection, improve the mastery rate and protection compliance of surgical smoke-related knowledge in the operating room, reduce the harm of surgical smoke to the human body, and provide a basis for smoke protection.Materials and methods. 125 doctors working in the operating room of our hospital were selected as the control group of this study, and 112 nonsmoke-exposed nurses working in the operating room of our hospital were selected as the observation group. The nurses' knowledge-belief behavior scores and self-evaluation scores of smoke influence were counted before and after the intervention in the operating room. SPSS25.0 was used to process the data. Tests and repeated measures analysis of variance were used to compare the effects before and after intervention.

Results

After one month of intervention, the knowledge scores of nurses in the operating room on the protection of surgical smoke increased significantly, and the difference was significant (P < 0.05); the scores of related concepts, physical properties, chemical properties, and authoritative protection standards increased significantly (P < 0.05). There was no significant increase in the scores of smoke hazards (P > 0.05); the attitude of smoke protection increased significantly, which was statistically significant (P < 0.05); and the behavior compliance of smoke protection was significantly increased, which was statistically significant (P < 0.05). After one month of intervention, the self-evaluation score of smoke effect of operating room nurses decreased significantly, and the difference was statistically significant (P < 0.05). The data was analyzed by repeated measure analysis of variance. The knowledge of surgical smoke (F = 65.570, P < 0.001), attitude (F = 78.307, P < 0.001), and behavior (F = 403.015, P < 0.001) scores gradually increased. The observation group's total cholesterol, low-density lipoprotein cholesterol, and the proportion of low-density lipoprotein cholesterol were higher than that of the control group, and the proportion of high-density lipoprotein cholesterol was lower than that of the control group. The difference was statistically significant P < 0.05.

Conclusion

After the intervention of operating room nurses under the guidance of PRECEDE management mode, the theoretical knowledge of operating room nurses is effectively improved, the operations are standardized, the self-evaluation scores of smoke influence are reduced, and the safety level of operating room is improved. More importantly, the health of nursing staff is fully guaranteed.

Polarization-based smoke removal method for surgical images

Smoke generated during surgery affects tissue visibility and degrades image quality, affecting surgical decisions and limiting further image processing and analysis. Polarization is a fundamental property of light and polarization-resolved imaging has been studied and applied to general visibility restoration scenarios such as for smog or mist removal or in underwater environments. However, there is no related research or application for surgical smoke removal. Due to differences between surgical smoke and general haze scenarios, we propose an alternative imaging degradation model by redefining the form of the transmission parameters. The analysis of the propagation of polarized light interacting with the mixed medium of smoke and tissue is proposed to realize polarization-based smoke removal (visibility restoration). Theoretical analysis and observation of experimental data shows that the cross-polarized channel data generated by multiple scattering is less affected by smoke compared to the co-polarized channel. The polarization difference calculation for different color channels can estimate the model transmission parameters and reconstruct the image with restored visibility. Qualitative and quantitative comparison with alternative methods show that the polarization-based image smoke-removal method can effectively reduce the degradation of biomedical images caused by surgical smoke and partially restore the original degree of polarization of the samples.

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.

Clinical Issues-November 2021

Occupational human papillomavirus vaccination for health care workers Key words: human papillomavirus (HPV), vaccination, occupational exposure, surgical smoke. Respiratory protection during smoke-generating treatment of human papillomavirus lesions Key words: human papillomavirus (HPV), respiratory protection, surgical smoke evacuation, surgical N95 respirator, loop electrosurgical excision procedure (LEEP). Most penetrating particle size in air filtration media testing Key words: most penetrating particle size (MPPS), ultra-low particulate air (ULPA), filtration efficiency, filtration media, surgical smoke evacuation. Smoke evacuation in surgical simulation laboratories Key words: surgical smoke evacuation, simulation laboratories, surgical energy devices, surgical smoke safety.

A Multidisciplinary Approach and Review of Safety Recommendations for Plastic Surgeons during the COVID-19 Pandemic: Are N95 Masks Enough?

SUMMARY

The novel coronavirus disease of 2019 pandemic presents a unique challenge to the field of plastic and reconstructive surgery. Although plastic surgeons may be postponing elective operations, there are still a number of emergent or urgent procedures that may need to be performed, and surgeons may be facing the reality of returning to a new normalcy of operating with coronavirus disease of 2019. These procedures, consisting of those such as head and neck reconstruction or maxillofacial trauma, largely require a multidisciplinary approach and may be considered of higher risk to health care workers because of the involvement of areas of the body identified as sources for viral transmission. Moreover, viral transmission may potentially extend beyond respiratory secretions, which has been the main focus of most safety precautions. The authors aim to present the scope of these procedures and the means of viral transmission, and to provide safety precaution recommendations for plastic surgery and its related disciplines.

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.

Fine particles in surgical smoke affect embryonic cardiomyocyte differentiation through oxidative stress and mitophagy

Surgical smoke is widespread in operating rooms, and fine particles are the main toxic components. However, the effect of fine particles in surgical smoke on embryonic development has not yet been studied. This study evaluated the effect of fine particles in surgical smoke on embryonic development and compared it with that of atmospheric fine particles. Afterwards, differentiated cardiomyocytes were purified, and the effect of exposure to fine particles in surgical smoke on cardiomyocyte differentiation was evaluated. Fine particles in surgical smoke exhibited weak embryotoxicity toward an embryonic stem cell test model, and their inhibitory effect on cardiomyocyte differentiation was slightly stronger than that of atmospheric fine particles. Fine particles in surgical smoke specifically inhibited the differentiation of the mesoderm lineage and promoted the differentiation of the ectoderm lineage. Furthermore, fine particles in surgical smoke reduced the beating rate of purified cardiomyocytes, promoted mitophagy, reduced ATP production and increased the reactive oxygen species (ROS) content. Antioxidants attenuated the inhibition of cardiomyocyte differentiation and the reduction in the cardiomyocyte beating rate caused by fine particles in surgical smoke and simultaneously restored mitophagy and other processes to the control levels. However, mitophagy inhibitors treatment blocked only the inhibition of cardiomyocyte differentiation caused by fine particles in surgical smoke; it had little effect on other changes caused by fine particles. Based on the results described above, we propose that fine particles in surgical smoke and atmospheric fine particles exhibit similar levels of toxicity toward embryonic development. Fine particles in surgical smoke potentially affect the beating of cardiomyocytes by damaging mitochondria and increasing oxidative stress.

Surgically generated aerosol and mitigation strategies: combined use of irrigation, respirators and suction massively reduces particulate matter aerosol

Background

Aerosol is a health risk to theatre staff. This laboratory study quantifies the reduction in particulate matter aerosol concentrations produced by electrocautery and drilling when using mitigation strategies such as irrigation, respirator filtration and suction in a lab environment to prepare for future work under live OR conditions.

Methods

We combined one aerosol-generating procedure (monopolar cutting or coagulating diathermy or high-speed diamond- or steel-tipped drilling of cadaveric porcine tissue) with one or multiple mitigation strategies (instrument irrigation, plume suction and filtration using an FFP3 respirator filter) and using an optical particle counter to measure particulate matter aerosol size and concentrations.

Results

Significant aerosol concentrations were observed during all aerosol-generating procedures with concentrations exceeding 3 × 10⁶ particles per 100 ml. Considerable reductions in concentrations were observed with mitigation. In drilling, suction, FFP3 filtration and wash alone respectively reduced aerosol by 19.3–31.6%, 65.1–70.8% and 97.2 to > 99.9%. The greatest reduction (97.38 to > 99.9%) was observed when combining irrigation and filtration. Coagulating diathermy reduced concentrations by 88.0–96.6% relative to cutting, but produced larger particles. Suction alone, and suction with filtration reduced aerosol concentration by 41.0–49.6% and 88.9–97.4% respectively. No tested mitigation strategies returned aerosol concentrations to baseline.

Conclusion

Aerosol concentrations are significantly reduced through the combined use of filtration, suction and irrigation. Further research is required to characterise aerosol concentrations in the live OR and to find acceptable exposure limits, and in their absence, to find methods to further reduce exposure to theatre staff.

Quantitative Evaluation of Aerosol Generation from Non-contact Tonometry and its Correlation with Tear Film Characteristics

INTRODUCTION

Ophthalmologists are inevitably exposed to tears and ocular discharge during ophthalmologic examinations and are at high risk for SARS-CoV-2 infection. To understand the role of aerosols in disease transmission, we adopted a prospective cross-sectional study design and investigated the count and size distribution of aerosols generated by a non-contact tonometer and its correlation with individual tear film characteristics.

METHODS

This study constituted two parts. The study population included outpatients who underwent an intraocular pressure examination in an intraocular pressure examination room (Part I) and 20 participants who underwent an intraocular pressure examination in a laboratory (Part II). The following main outcomes were measured: aerosol counts at 0, 50, 100, 150, and 200 cm from the non-contact tonometer (Part I); aerosol counts after each participant underwent non-contact tonometry, and lipid layer thickness score and tear film break-up time (Part II).

RESULTS

The aerosol count decreased with increasing distance from the tonometer. The aerosol count at 0 cm had the highest value compared to that at other distances. For aerosols of diameters 0.25-0.5 μm and 0.5-1.0 μm, the count decreased at 50 cm and remained stable at further distances. For aerosols of diameters 1.0-2.5 μm and ≥ 2.5 μm, the count dropped progressively at all five distances. The aerosol count from each tonometer correlated positively with the lipid layer thickness score (r = 0.490, P = 0.028), whereas the aerosol count correlated negatively with the tear film break-up time (r =  - 0.675, P = 0.001).

CONCLUSIONS

Aerosols tended to coagulate during diffusion. A 50-cm distance from the tonometer could confer safety from aerosols with < 1.0-μm diameter. Aerosols generated during non-contact tonometry could contain a lipid layer component. Moreover, tear film stability could affect aerosol generation. Protective eyewear is recommended for reducing infection risk from aerosols. Individual tear film characteristics should be considered during non-contact tonometry.

A knowledge gap unmasked: viral transmission in surgical smoke: a systematic review

BACKGROUND

Concerns regarding the aerosolized transmission of SARS-CoV-2 via SS have caused significant apprehension among surgeons related to the use of minimally invasive surgery (MIS) during the COVID19 pandemic. While a limited number of studies have previously demonstrated the presence of viral material in SS, no comprehensive systematic review exists on the subject of viral transmission in SS. Methods A systematic review of the literature was conducted as per PRISMA guidelines. MEDLINE, EMBASE, and CENTRAL databases were searched for publications reporting the primary outcome of the presence of viral particles in SS and secondary outcomes of indices suggesting transmission of viable virus particles in SS producing clinically important infection. All human, animal, and in vitro studies which used accepted analytic techniques for viral detection were included. A meta-analysis was not complete due to methodologic heterogeneity and inconsistent reporting of outcomes of interest.

RESULTS

23 publications addressed the presence of viral components in SS, and 19 (83%) found the presence of viral particles in SS. 21 publications additionally studied the ability of SS to induce clinically relevant infection in host cells, with 9 (43%) demonstrating potential for viral transmission.

CONCLUSION

Evidence exists for viral transmission via SS. However, HPV remains the only virus with documented transmission to humans via SS. While meaningful translation into practical guidelines during the COVID pandemic remains challenging, no evidence exists to suggest increased risk in MIS.

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.

Electrocautery, Diathermy, and Surgical Energy Devices: Are Surgical Teams at Risk During the COVID-19 Pandemic?

Supplemental Digital Content is available in the text

Objective:

The aim of the study was to provide a rapid synthesis of available data to identify the risk posed by utilizing surgical energy devices intraoperatively due to the generation of surgical smoke, an aerosol. Secondarily it aims to summarize methods to minimize potential risk to operating room staff.

Summary Background Data:

Continuing operative practice during the coronavirus disease-19 (COVID-19) pandemic places the health of operating theatre staff at potential risk. SARS-CoV2 is transmitted through inhaled droplets and aerosol particles, thus posing an inhalation threat even at considerable distance. Surgical energy devices generate an aerosol of biological particular matter during use. The risk to healthcare staff through use of surgical energy devices is unknown.

Methods:

This review was conducted utilizing a rapid review methodology to enable efficient generation and dissemination of information useful for concurrent clinical practice.

Results:

There are conflicting stances on the use of energy devices and laparoscopy by different surgical governing bodies and societies. There is no definitive evidence that aerosol generated by energy devices may carry active SARS-CoV2 virus. However, investigations of other viruses have demonstrated aerosolization through energy devise use. Measures to reduce potential transmission include appropriate personal protective equipment, evacuation and filtration of surgical plume, limiting energy device use if appropriate, and adjusting endoscopic and laparoscopic practice (low CO₂ pressures, evacuation through ultrafiltration systems).

Conclusions:

The risk of transmission of SARS-CoV2 through aerosolized surgical smoke associated with energy device use is not fully understood, however transmission is biologically plausible. Caution and appropriate measures to reduce risk to healthcare staff should be implemented when considering intraoperative use of energy devices.

Novel Insights into the Transmission of SARS-CoV-2 Through the Ocular Surface and its Detection in Tears and Conjunctival Secretions: A Review

SARS-CoV-2 is a highly transmissible virus that spreads mainly via person-to-person contact through respiratory droplets, or through contact with contaminated objects or surfaces from an infected person. At present we are passing through a phase of slow and painful understanding of the origin, epidemiological profile, clinical spectrum, and risk profile of the virus. To the best of our knowledge there is only limited and contradictory evidence concerning SARS-CoV-2 transmission through other routes. Importantly, the eye may constitute not only a potential site of virus replication but also an alternative transmission route of the virus from the ocular surface to the respiratory and gastrointestinal tract. It is therefore imperative to gain a better insight into the potential ophthalmological transmission route of the virus and establish directions on best practice and future models of care for ophthalmological patients. This review article critically evaluates available evidence on the ophthalmological mode of viral transmission and the value of earlier identification of the virus on the eye. More evidence is urgently needed to better evaluate the need for protective measures and reliable ocular diagnostic tests to diminish further pandemic spread.

Minimally Invasive Surgery and Surgical Smoke, Decoding Fear and Ensuring Safety: Adaptations and Safety Modifications During COVID Pandemic

The most fearful word starting from C, Cancer has now been replaced with COVID-19 owing to its associated physical, emotional and financial hardships as well as its social stigma. Never before we as medical fraternity been challenged to take care of patients and at the same time consider the safety of ourselves, family members and our fellow healthcare workers. Emotions and fear-driven treatments that are otherwise inefficacious may contribute to a false sense of security, unwarranted side-effects, divert resources and delay research into treatments that may actually work. Decoding fear with available evidence i.e. practicing evidence-based medicine will guide us in better handling of situations in this pandemic. The objective of this review is to discuss the modifications required in the operating theatre during COVID-19 times for minimal access, laparoscopy and robotic surgery, especially with regard to the handling of surgical smoke, minimally invasive surgical instruments, trocars with smoke evacuator and special personal protection equipment. Although there is no evidence of viral transmission through laparoscopic or open approaches, we recommend modifications to surgical practice such as the use of safe smoke evacuation and minimizing energy device use. We have come up with Rule of 20 for 2020 pandemic in operation theatres and modification of trocar for safe handling of surgical smoke in MIS which can be used in resource-limited settings. Hospitals must follow specific protocols and arrange suitable training of the healthcare workers. We believe that “Fears are educated into us, and can, if we wish, be educated out”.

Comparison of Surgical Smoke Generated During Electrosurgery with Aerosolized Particulates from Ultrasonic and High-Speed Cutting

“Surgical smoke” is an airborne by-product of electrosurgery comprised of vapour and suspended particles. Although concerns exist that exposure may be harmful, there is a poor understanding of the smoke in terms of particle size, morphology, composition and biological viability. Notably, it is not known how the biological tissue source and cutting method influence the smoke. The objective of this study was to develop a collection method for airborne by-product from surgical cutting. This would enable comprehensive analyses of the particulate burden, composition and biological viability. The method was applied to compare the electrosurgical smoke generated (in the absence of any evacuation mechanism) with the aerosolized/airborne by-products generated by ultrasonic and high-speed cutting, from bone and liver tissue cutting. We report a wide range of particle sizes (0.93–806.31 μm for bone, 0.05–1040.43 μm for liver) with 50% of the particles being <2.72 μm (~PM_2.5) and 90% being <10 μm (PM₁₀). EDX and biochemical analysis reveal components of biological cells and cellular metabolic activity in particulate from liver tissue cut by electrosurgery and ultrasonic cutting. We show for the first time however that bone saws and ultrasonic cutting do not liberate viable cells from bone.

Low-cost, safe, and effective smoke evacuation device for surgical procedures in the COVID-19 age

BACKGROUND

Smoke is generated by energy-based surgical instruments. The airborne by-products may have potential health implications.

METHODS

We developed a simple way to use de conventional surgical evacuator coupled with de electrosurgical pen attached to a 14G bladder catheter for open surgery. It was used in ten prospective patients with breast cancer.

RESULTS

We notice a high reduction in surgical smoke during all breast surgery. A questionnaire was used for all participants of the surgery to answer the impression that they had about the device. The subjective impression was that the surgical smoke in contact whit the surgical team was reduced by more than 95%.

CONCLUSIONS

Surgical smoke is the gaseous by-product produced by heat-generating devices in various surgical procedures. Surgical smoke may contain chemicals particles, bacteria, and viruses that are harmful and increase the risk of infection for surgeons and all the team in the operation room due to long term exposure of smoke mainly in coronavirus disease 2019 age. The adapted device described is a very simple and cheaper way to use smoke evacuators attached with the monopolar electrosurgical pen to reduce smoke exposure to the surgical team worldwide.

Identifying brain tumors by differential mobility spectrometry analysis of diathermy smoke

OBJECTIVE

There is a need for real-time, intraoperative tissue identification technology in neurosurgery. Several solutions are under development for that purpose, but their adaptability for standard clinical use has been hindered by high cost and impracticality issues. The authors tested and preliminarily validated a method for brain tumor identification that is based on the analysis of diathermy smoke using differential mobility spectrometry (DMS).

METHODS

A DMS connected to a special smoke sampling system was used to discriminate brain tumors and control samples ex vivo in samples from 28 patients who had undergone neurosurgical operations. They included meningiomas (WHO grade I), pilocytic astrocytomas (grade I), other low-grade gliomas (grade II), glioblastomas (grade IV), CNS metastases, and hemorrhagic or traumatically damaged brain tissue as control samples. Original samples were cut into 694 smaller specimens in total.

RESULTS

An overall classification accuracy (CA) of 50% (vs 14% by chance) was achieved in 7-class classification. The CA improved significantly (up to 83%) when the samples originally preserved in Tissue-Tek conservation medium were excluded from the analysis. The CA further improved when fewer classes were used. The highest binary classification accuracy, 94%, was obtained in low-grade glioma (grade II) versus control.

CONCLUSIONS

The authors' results show that surgical smoke from various brain tumors has distinct DMS profiles and the DMS analyzer connected to a special sampling system can differentiate between tumorous and nontumorous tissue and also between different tumor types ex vivo.

The risk of COVID-19 transmission by laparoscopic smoke may be lower than for laparotomy: a narrative review

Background

Surgical smoke is a well-recognized hazard in the operating room. At the beginning of the COVID-19 pandemic, surgical societies quickly published guidelines recommending avoiding laparoscopy or to consider open surgery because of the fear of transmission of SARS-CoV-2 through surgical smoke or aerosol. This narrative review of the literature aimed to determine whether there are any differences in the creation of surgical smoke/aerosol between laparoscopy and laparotomy and if laparoscopy may be safer than laparotomy.

Methods

A literature search was performed using the Pubmed, Embase and Google scholar search engines, as well as manual search of the major journals with specific COVID-19 sections for ahead-of-print publications.

Results

Of 1098 identified articles, we critically appraised 50. Surgical smoke created by electrosurgical and ultrasonic devices has the same composition both in laparoscopy and laparotomy. SARS-CoV-2 has never been found in surgical smoke and there is currently no data to support its virulence if ever it could be transmitted through surgical smoke/aerosol.

Conclusion

If laparoscopy is performed in a closed cavity enabling containment of surgical smoke/aerosol, and proper evacuation of smoke with simple measures is respected, and as long as laparoscopy is not contraindicated, we believe that this surgical approach may be safer for the operating team while the patient has the benefits of minimally invasive surgery. Evidence-based research in this field is needed for definitive determination of safety.

Qualitative analysis of surgical smoke produced during burn operations

Burned tissue is necrotic and it is surrounded by a zone of stasis and hyperaemia with changed cell metabolism. The removal of burned tissue using an electric knife releases large amounts of surgical smoke. The aim of the research was to analyse volatile, nonpolar, organic compounds that are released during the excision of burned tissue using an electric knife (mono- and bipolar). The study includes analysis from 40 solid-phase microextraction (SPME) fibres, exposed during 10 interventions (6 escharotomy and 4 necrectomy). The analysis of volatile compounds was performed using mass spectrometry gas chromatography (GCxGC-ToFMS).The total analysis covered 432 compounds, whereas after the removal of the "background" compounds - 153 volatile organic substances remained. The analysis of surgical smoke showed that, including derivatives, benzene constituted as much as 17.65% of all of the studied compounds. Cyclic compounds constituted on average 22.5% of the analysed substances, out of which cycloheptatrien constituted 20.26%. Alkanes, alcohols and their derivatives constituted nearly 25% of volatile organic compounds, with chloromethane constituting as much as 13.7%. Permutational multivariate analysis of variance (PERMANOVA) revealed statistically significant differences between escharotomy and necrectomy patients (F(1.9) = 5.91, p = 0.007).Our study revealed the presence of complex toxic hydrocarbon derivatives in surgical smoke. We also observed that the content of surgical smoke is different depending on the type of the conducted intervention. So far, no studies focusing on hazards posed by surgical smoke that is released during the resection of burned tissue are in the literature.

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.

Characterization of smoke generated during the use of surgical knife in laparotomy surgeries

The staff in hospitals is the high-risk group affected by indoor air pollution for operational reasons. However, there is a lack of relevant information and research on surgical smoke in Taiwan. This study analyses the substance of the smoke and develops relative strategies to prevent harm from the working place. This study aims to evaluate the surgical smoke generated during laparotomy and laparoscopic operation. The relationship between smoke and the risk of health-care workers was also discussed in order to set suitable solutions for smoke collection and emission. The study measured surgical smoke of 30 cases in operating rooms in three different hospitals, smoke was collected at different timings and different areas during the operation using a low-flow sampler. The concentration and accumulation number of size 0.3 μm suspended particles were the highest among all size of particles in different detection areas and timing. The concentration number of 0.3 μm and 0.5 μm particles reached the maximum after 10 min of electrosurgical treatment; however, the concentration number of 5 μm particles began to decrease after 5-15 min of the treatment. Besides, the cumulative particle numbers of 0.3 μm and 0.5 μm in laparoscopic operation were higher than those of laparotomy after 10 min of the treatment. This study suggests that surgical smoke prevention should use smoke evacuator; health-care workers should also wear a highly efficient tight seal-fit mask in the operating room to avoid damage to their health and cause chronic diseases.Implications: Indoor air pollution in medical institutions is a topic of less concern, and the health of healthcare workers is threatened by surgical smoke that generated during operations. This study measured and analyzed the harmful substances in the surgical smoke in the operating rooms of hospitals, and put forward the corresponding suggestions. In April 2018, legislators in Taiwan also convened a seminar on "Respiratory protection for operating room personnel in medical institutions". The seminar applied the findings of this study and adopted the recommendations to improve related equipment and strategies in future plans.

Characterization of the PM2.5 concentration in surgical smoke in different tissues during hemihepatectomy and protective measures

The characteristics of the PM2.5 concentration in surgical smoke produced by operating on different human tissues during hemihepatectomy were explored to provide a reference for protective measures. Our results showed that the highest concentration of PM2.5 produced by the electrosurgical knife was the liver tissue, followed by muscle, adipose, and vascular tissue. When the single-layer disposable medical mask, double-layer disposable medical mask, and surgical particulate respirator were used to cover the sampling port of the detector, the PM2.5 concentration for all tissue types could be reduced by approximately 40%, 55% and 75%, respectively. In the liver, the average concentration of PM2.5 produced by the ultrasonic scalpel was approximately twice that produced by the electrosurgical knife, suggesting that the air pollution around the chief surgeon caused by the ultrasonic scalpel is more serious than that caused by the electrosurgical knife. Much more protective work should be given for the liver-related surgery.

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.