Surgical smoke is the

by-product A by-product or byproduct is a secondary product derived from a production process, manufacturing process or chemical reaction; it is not the primary product or service being produced. A by-product can be useful and marketable or it can be cons ...

produced by

electrosurgery Electrosurgery is the application of a high-frequency (radio frequency) alternating polarity, electrical current to biological tissue as a means to cut, coagulate, desiccate, or fulgurate tissue.Hainer BL, "Fundamentals of electrosurgery", '' ...

laser A laser is a device that emits light through a process of optical amplification based on the stimulated emission of electromagnetic radiation. The word ''laser'' originated as an acronym for light amplification by stimulated emission of radi ...

tissue

ablation Ablation ( – removal) is the removal or destruction of something from an object by vaporization, chipping, erosion, erosive processes, or by other means. Examples of ablative materials are described below, including spacecraft material for as ...

, or other surgical techniques. Surgical smoke, as a health threat to those exposed to it, has become a growing concern. Studies have demonstrated, depending on several factors, it may contain

carcinogens A carcinogen () is any agent that promotes the development of cancer. Carcinogens can include synthetic chemicals, naturally occurring substances, physical agents such as ionizing and non-ionizing radiation, and biologic agents such as viruse ...

, mutagens, irritant chemicals, live

viruses A virus is a submicroscopic infectious agent that replicates only inside the living cells of an organism. Viruses infect all life forms, from animals and plants to microorganisms, including bacteria and archaea. Viruses are found in almo ...

and

bacteria Bacteria (; : bacterium) are ubiquitous, mostly free-living organisms often consisting of one Cell (biology), biological cell. They constitute a large domain (biology), domain of Prokaryote, prokaryotic microorganisms. Typically a few micr ...

, and viable malignant cells. These all pose a theoretical and demonstrable

risk In simple terms, risk is the possibility of something bad happening. Risk involves uncertainty about the effects/implications of an activity with respect to something that humans value (such as health, well-being, wealth, property or the environ ...

of harming

patients A patient is any recipient of health care services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, optometrist, dentist, veterinarian, or other healt ...

operating room Operation or Operations may refer to: Arts, entertainment and media * ''Operation'' (game), a battery-operated board game that challenges dexterity * Operation (music), a term used in musical set theory * ''Operations'' (magazine), Multi-Man ...

personnel upon exposure. Other names for surgical smoke are cautery smoke, plume,

diathermy Diathermy is electrically induced heat or the use of high-frequency electromagnetic currents as a form of physical therapy and in surgical procedures. The earliest observations on the reactions of the human organism to high-frequency electromagn ...

plume, or, sometimes,

aerosols An aerosol is a suspension of fine solid particles or liquid droplets in air or another gas. Aerosols can be generated from natural or human causes. The term ''aerosol'' commonly refers to the mixture of particulates in air, and not to t ...

produced during

surgery Surgery is a medical specialty that uses manual and instrumental techniques to diagnose or treat pathological conditions (e.g., trauma, disease, injury, malignancy), to alter bodily functions (e.g., malabsorption created by bariatric surgery s ...

, vapor

contaminants Contamination is the presence of a constituent, impurity, or some other undesirable element that renders something unsuitable, unfit or harmful for the physical body, natural environment, workplace, etc. Types of contamination Within the scie ...

, or air contaminants. Electrosurgery and

laser ablation Laser ablation or photoablation (also called laser blasting) is the process of removing material from a solid (or occasionally liquid) surface by irradiating it with a laser beam. At low laser flux, the material is heated by the absorbed laser ...

are the most common sources of surgical smoke. Heat generated during surgery causes

cell membranes The cell membrane (also known as the plasma membrane or cytoplasmic membrane, and historically referred to as the plasmalemma) is a biological membrane that separates and protects the interior of a cell from the outside environment (the extra ...

to heat and rupture, releasing cellular debris alongside

water vapor Water vapor, water vapour, or aqueous vapor is the gaseous phase of Properties of water, water. It is one Phase (matter), state of water within the hydrosphere. Water vapor can be produced from the evaporation or boiling of liquid water or from th ...

. Surgical smoke is composed of 95% water and the remaining 5% contains byproducts of combustion and cellular debris. The negative health effects due to exposure of surgical smoke is attributed to what is contained in the 5%. The size of particles within the plume of smoke varies depending on the device that generated it. On average electrosurgery produces particles that are .07 μm, while laser ablation generates larger particles that are .31 μm on average. Particles smaller than 2 micrometers are able to reach the alveoli within the

lower respiratory tract The respiratory tract is the subdivision of the respiratory system involved with the process of conducting air to the alveoli for the purposes of gas exchange in mammals. The respiratory tract is lined with respiratory epithelium as respirator ...

and, if 0.1 μm or smaller, can enter

systemic circulation In vertebrates, the circulatory system is a organ system, system of organs that includes the heart, blood vessels, and blood which is circulated throughout the body. It includes the cardiovascular system, or vascular system, that consists of ...

. The amount of cellular debris in a smoke plume changes with the tissue being cauterized. The

liver The liver is a major metabolic organ (anatomy), organ exclusively found in vertebrates, which performs many essential biological Function (biology), functions such as detoxification of the organism, and the Protein biosynthesis, synthesis of var ...

has been shown to generate the largest amount of particles. Other than type of tissue and surgical device, operating room

airflow Airflow, or air flow, is the movement of air. Air behaves in a fluid manner, meaning particles naturally flow from areas of higher pressure to those where the pressure is lower. Atmospheric air pressure is directly related to altitude, temperat ...

can also affect smoke exposure. read more o

Health impact

The cellular debris included in surgical smoke has been shown to include live

and

, and even viable malignant cells. The negative effects of surgical smoke exposure to Human, humans is less documented than its effects on

animals Animals are multicellular, eukaryotic organisms in the biological kingdom Animalia (). With few exceptions, animals consume organic material, breathe oxygen, have myocytes and are able to move, can reproduce sexually, and grow from a ...

. Acute negative effects due to the exposure of surgical smoke may include

headaches A headache, also known as cephalalgia, is the symptom of pain in the face, head, or neck. It can occur as a migraine, tension-type headache, or cluster headache. There is an increased risk of depression in those with severe headaches. Head ...

eye An eye is a sensory organ that allows an organism to perceive visual information. It detects light and converts it into electro-chemical impulses in neurons (neurones). It is part of an organism's visual system. In higher organisms, the ey ...

and

throat irritation Throat irritation can refer to a dry cough, a scratchy feeling at the back of the throat, a sensation of a lumpy feeling, something stuck at the back of the throat, or possibly a feeling of dust in the throat. The symptoms are unpleasant and usual ...

nausea Nausea is a diffuse sensation of unease and discomfort, sometimes perceived as an urge to vomit. It can be a debilitating symptom if prolonged and has been described as placing discomfort on the chest, abdomen, or back of the throat. Over 30 d ...

drowsiness Somnolence (alternatively sleepiness or drowsiness) is a state of strong desire for sleep, or sleeping for unusually long periods (compare hypersomnia). It has distinct meanings and causes. It can refer to the usual state preceding falling asleep ...

and

dizziness Dizziness is an imprecise term that can refer to a sense of disorientation in space, vertigo, or lightheadedness. It can also refer to Balance disorder, disequilibrium or a non-specific feeling, such as giddiness or foolishness. Dizziness is a ...

. Operating personnel have been found to have an increased risk of chronic

pulmonary The lungs are the primary organs of the respiratory system in many animals, including humans. In mammals and most other tetrapods, two lungs are located near the backbone on either side of the heart. Their function in the respiratory syste ...

and upper respiratory health problems compared to other populations. Human papilloma virus has been the only virus to demonstrate spreading via surgical smoke, despite concern for other viruses. Besides potential health effects, surgical smoke can visually obscure the surgical field. The amount of

benzene Benzene is an Organic compound, organic chemical compound with the Chemical formula#Molecular formula, molecular formula C6H6. The benzene molecule is composed of six carbon atoms joined in a planar hexagonal Ring (chemistry), ring with one hyd ...

detected in operating room air has been shown to be greater than the recommended exposure limits established by the

National Institute for Occupational Safety and Health The National Institute for Occupational Safety and Health (NIOSH, ) is the List of United States federal agencies, United States federal agency responsible for conducting research and making recommendations for the prevention of work-related occ ...

(NIOSH) and the

Occupational Safety and Health Administration The Occupational Safety and Health Administration (OSHA; ) is a regulatory agency of the United States Department of Labor that originally had federal visitorial powers to inspect and examine workplaces. The United States Congress established ...

(OSHA) which are 0.1 mg/m³ and 0.2 mg/m³ respectively.

Minimizing exposure

The pores on a standard

surgical mask A surgical mask, also known by other names such as a medical face mask or procedure mask, is a personal protective equipment used by healthcare professionals that serves as a mechanical barrier that interferes with direct airflow in and out of r ...

are 5-15 μm in diameter, which is inadequate in completely protecting operating room personnel from the harms of surgical smoke. Due to studies evaluating particles passing through standard surgical masks, some suggested that more effective masks such as HEPA-filters and N95 should be used to provide better protection from cellular debris. Others suggest that even N95s are ineffective at reducing health risks associated with ultra-fine particulate matter.

Particulate matter Particulate matter (PM) or particulates are microscopic particles of solid or liquid matter suspended in the air. An ''aerosol'' is a mixture of particulates and air, as opposed to the particulate matter alone, though it is sometimes defin ...

is not the only

pollutant A pollutant or novel entity is a substance or energy introduced into the environment that has undesired effect, or adversely affects the usefulness of a resource. These can be both naturally forming (i.e. minerals or extracted compounds like oi ...

produced by surgical smoke. Various

volatile organic compounds Volatile organic compounds (VOCs) are organic compounds that have a high vapor pressure at room temperature. They are common and exist in a variety of settings and products, not limited to house mold, upholstered furniture, arts and crafts sup ...

are also created. Masks will be ineffective against gaseous compounds unless specialized filtration is used such as

activated carbon Activated carbon, also called activated charcoal, is a form of carbon commonly used to filter contaminants from water and air, among many other uses. It is processed (activated) to have small, low-volume pores that greatly increase the surface ar ...

or catalytic mesh. Smoke evacuation devices (SED) are the most effective at reducing exposure of surgical smoke. However, the use of these devices is not widespread. Lack of SED usage has been attributed to low amounts of education surrounding the risks of surgical smoke and the

surgeons In medicine, a surgeon is a medical doctor who performs surgery. Even though there are different traditions in different times and places, a modern surgeon is a licensed physician and received the same medical training as physicians before spec ...

' unwillingness to adopt such devices. It has been suggested that the bulkiness of these devices and noise are factors contributing to lack of surgeons' enthusiasm for SED usage.

Health impact

Minimizing exposure

References

Further reading