Commentary On: “Surgical Smoke – A Health Hazard in the Operating Theatre: A Study to Quantify Exposure and a Survey of the Use of Smoke Extractor Systems in UK Plastic Surgery Units”

Over the last 20 years, smoke plumes have been proven to be mutagenic, carcinogenic, and a vehicle of transmission for malignant cells and viruses.^1–3 Smoke plumes can be generated by electrosurgical, laser, and ultrasonic devices. Studies have shown electrosurgical devices led to the formation of smaller particles (0.07 μm), which are chemical health hazards.⁴ Lasers and ultrasonic devices lead to the formation of larger particles (0.31 μm–6.6 μm), acting as biological hazards.^3,5 Studies have been performed in laboratories showing various pulmonary changes in rats when exposed to smoke plumes.^6,7 It has been shown previously that 1 g of tissue would create a smoke plume with a mutagenic effect equivalent to smoking 6 unfiltered cigarettes.^8,9 Furthermore, vaporisation of 3 g of tissue with a surgical laser can generate an amount of acrolein or polycyclic hydrocarbons exceeding standards established by the Occupational Safety and Health Administration (OSHA).³ Based on these findings, many leading authorities have provided recommendations and guidelines to use smoke extraction devices. However, there is no study quantifying the exposure of smoke plumes and looking into the compliance with the use of smoke extraction devices in the United Kingdom.

In this study, Hill et al. attempt to answer these questions through an intriguing preclinical study.¹⁰ The investigators quantified the mass of tissue converted into a smoke plume over a period of 2 months by determining the duration of diathermy use and additionally attempted to determine the prevalence of surgical smoke evacuators in plastic surgery units in the United Kingdom. They utilised a novel method of determining the number of device activations and the total duration of activation of devices. This was achieved by accessing built-in service functions of the device. It gave very precise measurements of cutting and coagulation. However, it should be noted that the investigators did not evaluate desiccation and fulguration functions. Also, many plastic surgeons use bipolar electrocautery, which has not been evaluated in this paper.

Regarding results, the authors used this experimental data along with the number and duration of activation to estimate the mass of tissue destroyed during the 44 operating days, and extrapolated that to provide descriptive analysis of the amount of tissue destroyed per day. If we extrapolate these findings, taking into consideration that 1 g of tissue creates a surgical smoke plume with the mutagenic effect of smoking 6 unfiltered cigarettes,^8,9 a total of approximately ³⁰ unfiltered cigarettes would need to be smoked in the operating room per day to produce equivalent mutagenicity. This finding emphasises the importance of evacuation of smoke plumes. However, it should be noted that this finding is based on measurements calculated by Tomita et al. in 1981.⁸ Recently, it has been shown that electrocautery and ultrasonic dissection produce significantly lower concentrations of the most commonly detected carcinogenic and irritant hydrocarbons than cigarette smoke.¹¹ In addition, a study on a cohort of 121,700 American registered nurses showed no significant correlation between the duration of exposure and incidence of cancer.¹²

This study also raises an important question about effects of the smoke plume exposure on patients, who will have decreased immunity due to the surgical procedure. Marsh et al. demonstrated the potential harm to patients from surgical smoke especially in laparoscopic procedures.² High levels (100–2200 ppm) of carbon monoxide (CO) have been observed intra-peritoneally during laparoscopic procedures. ^13,14 This exceeds limits set by OHSA (400 ppm during a 15 minutes exposure) and the Environmental Protection Agency (EPA) (35 ppm during a one-hour exposure).^15,16 However, there is no consensus regarding harmful effects of carboxyhaemoglobin in patients.^13,17,18 Furthermore, there is a theoretical risk of dissemination of cancer cells through plumes.¹⁹ Should we inform patients about this prior to operating?

This study utilised only muscle tissue samples.² Surgical smoke plumes are also generated during other intraoperative steps such as skin incisions, and dissections of soft tissue or scar tissue. Due to the difference in the density of these tissues, there may be a difference in the amount and content of any surgical smoke plume. This should have received some attention in the study as it evaluates plastic surgery units in the UK. Tissue density also varies with patient age. Other factors which would affect the amount and content of a smoke plume are: the type of procedure, surgeons’ technique, pathology of the target tissues, type of energy transferred, power levels used, and amount of cutting, coagulation, or ablating performed.^1,20 Therefore, future studies will need to evaluate these factors. Additionally, further studies will need to take into consideration other confounding factors such as cigarette smoking among surgeons and other perioperative staff, and general environmental pollution.

There are multiple precautions suggested in order to reduce the exposure of smoke plumes. For example, use of a standard surgical mask, laser or high filtration mask, masks coated with nanoparticles, operating room ventilation guidelines, and use of wall suction. However, the standard surgical masks cannot filter smaller smoke particles, high-filtration masks hinder normal breathing, and use of suction lacks sufficient power to clear the smoke at the source of combustion. ²¹ Therefore, various leading authorities have recommended using smoke extraction devices. The authors have made a valiant attempt to determine the use of smoke evacuators in 56 plastic surgery units in the UK. Sixty-six percent of the units had specialised smoke extractors available for use, but there is no data on how many actually utilised them. The use of smoke evacuators was not universal and varied among surgeons. Similar results have been obtained from surveys in the United States and Canada.^22,23 A multispecialty survey, by the Royal College of Surgeons (England), found only 3% of surgeons used a smoke extracting device in their practice.²⁴

Based on the data of usage of smoke extraction devices, it raises a question of whether its usage should be made legally or regulatory mandatory. A few reasons for lack of use of smoke evacuation devices may include high cost, inconvenience due to loud noise, and a general lack of knowledge regarding potential hazards associated with exposure to surgical smoke plumes.^25,26 Further studies on the cost of evacuation systems may promote the use of such devices if the cost:benefit ratio is preferable. Different countries have regulatory authorities providing guidelines regarding ‘smokefree’ operating environments.^27,28 However, surveys have shown no improvement in compliance.^22–24 Other modes of education, such as advertisements regarding smoke plume hazards, should be attempted to improve the awareness of the health hazards of this smoke. Such interventions can increase the use of smoke extraction devices. Nurses’ knowledge and training are most strongly linked to better compliance.²⁹ If none of these attempts increases adherence, should it be made mandatory to use extraction devices?

Ethical approval

No ethical approval required for this review.

Conflict of interest

No conflicts of interest have been declared by the author.

Author contribution

Single author manuscript.

Funding

No funding source declared by author.

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