Surgical smoke
Surgical smoke is a by-product generated during surgical procedures that utilize energy-producing devices, such as electrosurgical units, lasers, and powered surgical tools. When bodily tissue is vaporized at high temperatures, it creates smoke that can contain a complex mix of toxic gases, harmful chemicals, and viable and nonviable cellular material, including potential pathogens like bacteria and viruses. This smoke is often associated with acute health issues, such as eye, nose, and throat irritation, headaches, and respiratory problems. Concerns extend to chronic exposure, which may lead to more severe health implications, though the extent of these risks remains debated within the medical community. Historical context shows that the issue of surgical smoke became prominent with the advent of electrosurgery in the 1920s, and its prevalence has increased alongside the use of energy-based surgical techniques. Some jurisdictions, like Rhode Island, have begun mandating smoke evacuation systems in surgical environments to mitigate these risks, reflecting growing awareness of surgical smoke as an occupational hazard for healthcare professionals. Overall, while there is consensus on the unpleasantness and potential toxicity of surgical smoke, the debate continues regarding the severity of its health consequences and the motivations behind certain claims.
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Surgical smoke
Surgical smoke is a potentially dangerous by-product of energy-generating devices such as electrosurgical units (ESUs), lasers, electrocautery and ultrasonic devices, and powered bone saws and drills. It is produced when bodily tissue is vaporized during a surgical procedure. In addition to being marked by a distinctly repulsive odor, surgical smoke can contain toxic gases, dangerous chemical components, viable and nonviable cellular material, viruses, and bacteria. As a result, acute exposure to surgical smoke can lead to conditions such as eye, nose, and throat irritation; headache; cough; nasal congestion; or asthma and asthma-like symptoms. There is also some evidence to suggest that chronic exposure to surgical smoke can have more serious medical consequences, although some critics believe that such claims may be exaggerated by medical equipment companies for commercial purposes. In any event, surgical smoke is an occupational hazard that many surgeons and other operating room (OR) personnel encounter on a regular basis.
Background
Surgical smoke first arose as an OR concern with the introduction of electrosurgical techniques and devices in the 1920s. Electrosurgery was pioneered by Harvard physician William T. Bovie and neurosurgeon Harvey W. Cushing. Bovie and Cushing invented the electrosurgical unit and used it for the first time during a 1926 operation involving the removal of a vascular tumor. Since that time, the ESU and other electrically powered surgical devices have become staples of ORs across the country and around the world.
Electrosurgery is a type of surgical procedure in which an ESU capable of producing high radio-frequency energy is used to cut, dry, cauterize, or otherwise destroy tissue. During such procedures, the electrical current produced by the ESU is applied using a special pencil- or needle-shaped electrode. ESUs allow surgeons to cleanly coagulate blood vessels or smoothly cut tissues at the site of surgery. ESUs considerably reduce the chance of tissue damage during surgery in comparison to traditional scalpels.
Electrosurgery can be used for a variety of purposes. Some of the most common include the removal of flat lesions, warts, or skin tags. It can also be used to destroy tissue, stop bleeding, and treat cancer. The two main types of electrosurgery are high-frequency electrosurgery and electrocautery. High-frequency electrosurgery involves the direct application of high-frequency alternating current that is converted to heat by the resistance it encounters as its passes through tissue. This type of electrosurgery is most often used in the treatment of malignant skin conditions and in debulking procedures that involve the removal of as much of the volume of a tumor as possible. In electrocautery, the current is used to heat a handheld element that is subsequently applied to the tissue. Electrocautery is typically used to stop bleeding and destroy tumors in situations in which high-frequency electrosurgery is deemed inappropriate.
As electrosurgery and other types of surgery involving the use of energy-generating devices have become increasingly commonplace over the years, the amount of surgical smoke to which surgeons and other OR personnel are exposed on a regular basis has also increased. To at least some degree, this has become a significant problem in modern surgery.
Overview
Surgical smoke is produced during any procedure that involves the use of an energy-generating device. Such devices can raise intracellular temperatures to more than 212 degrees Fahrenheit (100 degrees Celsius). At these high temperatures, tissue can be easily vaporized. The vaporization of tissue in this manner inevitably produces surgical smoke as a by-product.
Surgical smoke is a complex substance that can contain many potentially dangerous components. These include a variety of toxic gases and numerous biological products. Among the most common chemical components of surgical smoke are perchloroethylene, hydrogen cyanide, toluene, formaldehyde, ethylbenzene, and benzene. Perchloroethylene is one of the primary chemicals used in dry cleaning. Hydrogen cyanide is a neurotoxin that is often found in chemical weapons. Toluene is a known carcinogen that is akin to paint thinner. Formaldehyde is typically used as a preservative for surgical specimens and as an embalming fluid. Ethylbenzene is most commonly used in the manufacture of Styrofoam. Benzene, another known carcinogen, is used in the manufacture of plastics, rubbers, lubricants, dyes, detergents, and pesticides. The possible biological components of surgical smoke include various particulates, cellular material, bacteria, and viruses.
Given all of its potentially dangerous components, it is clear that exposure to surgical smoke can be harmful. One study that compared surgical smoke to cigarette smoke even concluded that inhaling the surgical smoke produced by electrocautery of just one gram of tissue is equivalent to smoking six unfiltered cigarettes. Much like exposure to cigarette smoke, exposure to surgical smoke can lead to acute health problems. Some of these include irritation of the eyes, nose, or throat, as well as headache, cough, nasal congestion, or asthma or asthma-like symptoms. Because it can also contain biological components such as bacteria and viruses, surgical smoke can also contribute to the spread of infectious disease. In fact, surgical smoke has been directly tied to the spread of the human papillomavirus (HPV) among operating room personnel in a number of documented cases. Some evidence also suggests that long-term exposure to surgical smoke can lead to even more serious health consequences. Anthony Hedley, a veteran orthopedic surgeon, was forced to undergo a double lung transplant after being diagnosed with idiopathic pulmonary fibrosis in 2013. It is believed that Hedley’s condition was a direct result of years of exposure to surgical smoke.
Not everyone in the medical community agrees on just how dangerous surgical smoke really is, however. While no one disputes the fact that surgical smoke is unpleasant and certainly contains numerous toxic substances, some critics argue that there is little reliable evidence to realistically support the theory that surgical smoke is seriously harmful. Others are also quick to point out that much of the existing evidence used to support such theories is supplied by medical equipment companies that have a direct financial interest in selling devices used to evacuate surgical smoke from operating rooms. That being said, some authorities are taking steps to prevent surgical smoke–related health problems. Most notably, Rhode Island became the first state to require all licensed hospitals and ambulatory surgical facilities to use some sort of smoke evacuation system during procedures that generate surgical smoke.
Bibliography
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Hedley, Anthony. “Surgical Smoke Nearly Killed Me.” Outpatient Surgery, Feb. 2018, www.outpatientsurgery.net/issues/2018/02/surgical-smoke-nearly-killed-me. Accessed 29 Oct. 2018.
Karjalainen, Markus, et al. “The Characterization of Surgical Smoke from Various Tissues and Its Implications for Occupational Safety.” PLoS ONE, vol. 13, no. 4, 12 Apr. 2018.
Lee McFarling, Usha. “Blowing Smoke: Profit Motive — and Scant Evidence — Propel Dire Warnings about Surgical Fumes.” STAT, 11 May 2017, www.statnews.com/2017/05/11/surgical-smoke-health-risks. Accessed 29 Oct. 2018.
“Rhode Island Passes Surgical Smoke Law.” Healthcare Facilities Today, 14 June 2018, www.healthcarefacilitiestoday.com/posts/Rhode-Island-passes-surgical-smoke-law--18651. Accessed 29 Oct. 2018.
Sadler, Don. “The Real Risks: Surgical Smoke.” OR Today, 17 Jan. 2017, ortoday.com/the-real-risks-surgical-smoke. Accessed 29 Oct. 2018.
Stratton, Martha. “Surgical Smoke Transmits Infectious Diseases; Here’s How to Stop It.” Infection Control Today, 3 Apr. 2017, www.infectioncontroltoday.com/operating-room/surgical-smoke-transmits-infectious-diseases-heres-how-stop-it. Accessed 29 Oct. 2018.
“Surgical Smoke: What’s the Risk to OR Staff?” I.C. Medical, icmedical.com/surgical-smoke-whats-the-risk-to-or-staff-%E2%80%A8. Accessed 29 Oct. 2018.