Surgical smoke

SURGICAL SMOKE

Jibran MohsinResident, Surgical Unit I

SIMS/Services Hospital, Lahore

AUTHORS

N. Mowbray Aneurin Bevan Health Board, Newport, UK

J. Ansell Royal College of Surgeons of England, Welsh Institute ofMinimal Access Therapy (WIMAT), Cardiff CF14 4UJ, UKe-mail: [email protected]; [email protected]

N. Warren Welsh Institute of Minimal Access Therapy (WIMAT), Cardiff, UK

P. Wall Isca Healthcare Research, Caerleon, UK

J. Torkington Department of Colorectal Surgery, University Hospital of Wales, Cardiff, UK

mailto:[email protected]

INTRODUCTION

Surgical smoke is the airborne byproduct generated by the use of energy-based instruments in operating theaters.

These instruments are an integral part of modern surgery and are routinely used across a wide range of surgical specialties.

The hazards of surgical smoke may have wide reaching implications.

Energy-based instruments used in operations include mono- and bipolar diathermy (electrocautery), ultrasonic scalpels, and lasers.

INTRODUCTION

Electrocautery devices and lasers heat target cells to the point of boiling, causing the cell membranes to rupture.

This process disperses fine particles into the atmosphere.

Ultrasonic devices use a vibrating plate to cause cell rupture at much lower temperatures than electrocautery.

This causes cutting and coagulation simultaneously without an electrical current being passed through the tissue.

INTRODUCTION

Concerns have been raised regarding the infectivity, mutagenicity, and cytotoxicity of surgical smoke from all the aforementioned devices.

In addition, surgical smoke is odorous and reduces the view of the operative field, especially during laparoscopic procedures.

Many health organizations have recommended the routine use of evacuation devices to avoid potential problems

Despite this general consensus that surgical smoke should be treated with caution, the use of local exhaust ventilation has changed very little in recent years

INTRODUCTION

Surgical smoke is the encompassing term for a number of gaseous byproducts produced by energy-based surgical instruments.

The definition of ‘‘smoke’’ refers to the products of combustion, whereas ‘‘vapor,’’ ‘‘aerosol,’’ and ‘‘mist’’ refer to the suspension of liquid particles.

Electrocautery devices are described as creating a ‘‘plume’’ of smoke, whereas ultrasonic devices are described as creating ‘‘vapors,’’ ‘‘aerosols,’’ and ‘‘mists.’’

INTRODUCTION

The byproducts of lasers have been referred to by all of these terms

Because the terminology is used interchangeably, this review uses the general term of ‘‘surgical smoke’’ to encompass all the aforementioned terms.

INTRODUCTION

This review identifies the current evidence for the properties of surgical smoke and the harmful effects to health care professionals exposed to it.

We aim to identify whether the harmful effects are related to the type of energy-based instrument used.

This information is used to formulate clinical recommendations and highlight areas requiring further research in the future.

MATERIALS AND METHODS(SEARCH STRATEGY)

A systematic review of published work was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines.

The following sources were searched for studies concerning the evaluation of surgical smoke and its effects:

MEDLINE (1947 to the present), PubMed (1966 to the present), Cochrane database, Embase classic + Embase (1947–2012), and the metaRegister of controlled trials.


The search used three search domains of exploded medical subject heading (MeSH) terms combined by ‘‘AND.’’

Within each domain, the terms were combined with ‘‘OR.’’ The first domain contained the terms for surgical smoke. The second domain consisted of the instruments that generate or

remove smoke, and the third domain comprised the hazards of surgical smoke.


The search was performed by two investigators independently.

Titles and abstracts were reviewed by each individual.

Duplicates and those clearly unrelated were discarded.

The articles were retrieved and the inclusion criteria applied.

Cross-referencing was carried out against the most recent relevant articles. The last search date was 4 January 2013.

MATERIALS AND METHODS(INCLUSION AND EXCLUSION CRITERIA)

Studies were included if they documented the constituents found in surgical smoke during human surgical procedures, methods used to analyze the smoke, implications of exposure to smoke, and type of energy-based surgical instrument that generated the smoke.

Only original articles were included.

Studies were excluded if they were animal based, preclinical experimental work, conference abstracts, or opinion-based reports.

MATERIALS AND METHODS(DATA EXTRACTION, OUTCOME MEASURES, AND ANALYSIS)

The included studies were rated according to guidelines from the Centre for Evidence-Based Medicine (CEBM).

Each paper was examined to identify the energy device used, the smoke properties and particle size, the risk of infection, and the mutagenic risk.

Some additional material was used to prepare the background information for the review e.g. manual searches and information from specialist textbooks, government agency publications, and healthcare professional organizations.

All sources are cited where appropriate.

RESULTS

Parameter Total number of studies = 20diathermy/electrocautery

laser Ultrasound devices

size of the particles(5 studies)

4 2 0

Constituents of surgical smoke(7 studies)

7 0 1

Infectivity(6 studies)

1 6 0

Mutagenic effect 1 0 0Presence of Malignant cells

1 0 0

RESULTS(PARTICLE SIZE)

Overall size of particles found in all types of smoke for all procedures

0.05 micron to larger than 25 micron

Ultrafine particles (UFP)

[found in laser and electrocautery]

Laparoscopic laser use 0.1 – 0.8 micron

Laparoscopic electrocautery 0.1 – 0.025 micron

THR electrocautery aerosol particles < 1 micron

Peritonectomy electrocautery 0.002 – 1 micron1 study ( electrocautery and argon laser coagulation)

10 nm to 1 micron

RESULTS(PARTICLE CHARACTERIZATION)

RESULTS(PARTICLE CHARACTERIZATION)

The surgical smoke evaluated by these studies had several components with known carcinogenic properties

A non-significant trend showed lower levels of benzene, toluene, heptene, ethylbenzene, and methylpropene with the use of the ultrasonic scalpel compared with electrocautery

RESULTS(INFECTION RISK)


Only Capizzi et al and Kunachak et al assessed the infectivity of smoke

Rest only identified the presence of material in smoke


.

5/13 cases coagulase negative Staphylococcus1/13 Corynebacterium1/13 Neisseria

RESULTS(INFECTION RISK) 5/8 laser derived vapors

4/7 electrocoagulation derived vapors

Greater amount of HPV DNA in lasers vapors

RESULTS(MUTAGENESIS AND MALIGNANT SPREAD)

Ikramuddin et al. assessed the ability of surgical smoke to spread malignancy.

During laparoscopic surgery, the pneumoperitoneumwas sampled for either malignant or benignconditions via a port site. Aerosolized malignant cells wereidentified.

The mutagenic potential of surgical smoke from electrocautery was evaluated by one study during reduction Mammoplasty

DISCUSSION(THIS REVIEW)

This is the first systematic review to detail the potential harmful effects of surgical smoke to theater staff.

Surgical smoke from a range of electrosurgical methods can produce particles small enough to be inhaled.

Viruses, bacteria, and malignant cells may be present in smoke.

No existing literature establishes a direct link between the components of smoke and the transmission of disease.

DISCUSSION(COMPARISON WITH PREVIOUS REVIEWS)

Although several published reviews have collated current information on surgical smoke, none has used a systematic format.

Unlike previous reviews, we looked solely at studies using in vivo techniques.

We accept that by excluding all in vitro and experimental data, we may have underestimated the full potential effects of surgical smoke. The research identified in this study was, however, thought to be more clinically relevant and hence applicable to theater staff.


The literature contains a wide variety of studies with varying methodologic designs and presentations of results.

The papers included in this review detail a range of operations using different electrosurgical instruments.

Collection and analysis of surgical smoke was conducted in different ways.


Whereas some methods involved sampling immediately adjacent to the instrument, others sampled from atmospheric air and from the air termed ‘‘the breathing zone.’’

This could have introduced variation into the concentration of compounds and also into the size or type of particle captured.

Heavier particles may not travel as far.

We have, however, shown that common end points such as particle nature and infectivity are identifiable, but clear standardization of smoke analysis studies in the future could prove useful.

DISCUSSION(PARTICULATE SIZE)

The evidence suggests that the surgical smoke particles are of respirable size.

Particles smaller than 10 lm are inhalable, and particles 2.5–10 lm in size can deposit in the respiratory tract.

Ultrafine particles can precipitate into the alveolar region of the lung, where the only clearance mechanism is phagocytosis via alveolar macrophages

There were no studies to indicate the effect of UFPs.

It should be noted that surgical masks, even if correctly fitted and frequently changed, can effectively filter only particles larger than 5 micron in size.

DISCUSSION(INFECTIVITY RISK)

The debate over the infectivity of surgical smoke appears to focus largely on skin lesions. Perhaps this is due to the popular application of lasers to treat viral lesions.

These lesions often are easily accessible, numerous, and treatable under local or general anesthesia.


Some evidence shows HPV DNA to be present in surgical smoke, but this does not prove its ability to transmit infection

Indeed, no evidence was found to suggest viral infectivity, and only one study examined the bacterial component of surgical smoke.


Perhaps bacterial infectivity is a subject of less concern because electrosurgical devices are not used specifically to treat bacterial infections.

Evidence is lacking for infectivity of other energy-based instruments, including electrocautery and ultrasonic devices.

Given that ultrasonic devices reach a lower temperature, the possibility exists that this cellular debris remains infectious.

Future research in this area may be useful together with a direct comparative study of the smoke generated from similar operations in infectious and noninfectious patients.

DISCUSSION(MUTAGENIC RISK)

A small body of evidence suggests that surgical smoke carries a mutagenic risk with no link to disease.

A longitudinal study of theater nursing staff (86,747 women adjusted for smoking history and increased risks of lung cancer) did not show an increased rate of lung cancer even among those with the longest operating room history

EXISTING RECOMMENDATIONS

UK British Occupational Hygiene society (BOHS)

The Association for Perioperative Practice (AfPP)

Medicines and Healthcare Products Agency (MHRA)Canada Canadian Standards Association (CSA)

Operating Room Nurses Association of Canada (ORNAC)

Australia Australian College of Operating Room Nurses (ACORN)

International The International Federation of Perioperative Nurses (IFPN)

International Society Security Association (ISSA)

EXISTING RECOMMENDATIONS

USA Association of periOperative Registered Nurses (AORN)Occupational Safety & Health Administration (OSHA)

Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

National Institute for Occupational Safety and Health/Centre for Disease Control (NIOSH/CDC)

American National Standards Institute (ANSI)

American Society for Laser Medicine and Surgery (ASLMS)

CONCLUSION

This review confirms that surgical smoke contains potentially carcinogenic compounds physically small enough to be respirable and even reach the lower airways.

Despite this, we have found little evidence for the long-term effects of surgical smoke in vivo. Both infective and malignant cells exist in surgical smoke, but their viability has not been assessed.

This review can conclude that although the potential for harm is present, the risk presented to the theater staff remains unproven.

Further research is needed to identify this and should focus on comparing the smoke produced by different energy-based devices, the use of removal systems, and the long-term consequences of smoke exposure.

ACKNOWLEDGMENTS

James Ansell was sponsored by The Royal College of Surgeons of England Research Fellowship Grant.

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Surgical smoke

Health & Medicine