Surgical Plume Research Articles

COVID‐19 and dermatologic surgery: Hazards of surgical plume

Dermatologic TherapyVolume 33, Issue 4 e13593 Letter COVID-19 and dermatologic surgery: Hazards of surgical plume Firas Al-Niaimi, Corresponding Author Firas Al-Niaimi firas55@hotmail.com orcid.org/0000-0002-0684-4322 Department of Dermatology, Aalborg University Hospital, Aalborg, Denmark Department of Skin Cancer and Laser, Guy's and St. Thomas Hospital, London, UK Correspondence Firas Al-Niaimi, Dermatological Surgery and Laser Unit, Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London SE1 9RS, UK. Email: firas55@hotmail.comSearch for more papers by this authorFaisal R. Ali, Faisal R. Ali Department of Skin Cancer and Laser, Guy's and St. Thomas Hospital, London, UKSearch for more papers by this author Firas Al-Niaimi, Corresponding Author Firas Al-Niaimi firas55@hotmail.com orcid.org/0000-0002-0684-4322 Department of Dermatology, Aalborg University Hospital, Aalborg, Denmark Department of Skin Cancer and Laser, Guy's and St. Thomas Hospital, London, UK Correspondence Firas Al-Niaimi, Dermatological Surgery and Laser Unit, Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London SE1 9RS, UK. Email: firas55@hotmail.comSearch for more papers by this authorFaisal R. Ali, Faisal R. Ali Department of Skin Cancer and Laser, Guy's and St. Thomas Hospital, London, UKSearch for more papers by this author First published: 15 May 2020 https://doi.org/10.1111/dth.13593Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URLThe site is currently under maintenance and this functionality is not available right now. Please try later. Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume33, Issue4July/August 2020e13593 This article also appears in:Dermatologic Therapy COVID-19 Articles RelatedInformation

Smoke and particulate filters in endoscopic surgery reviewed during COVID-19 pandemic

This study aimed to evaluate the efficacy of smoke filters for use in endoscopic surgery and their significance during the present COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The literature was reviewed by analyzing articles on PubMed using the search terms “smoke”, “filter”, and “laparoscopy”. A systematic literature search revealed six smoke filter clinical studies pertinent to endoscopic surgery. The studies focused on the different aspects and efficacy of these filters: (1) UGF1 filter (Pall Biomedical, St. Germaine en Laye, France) investigated captured mesothelial cells and other debris, (2) Valve-less trocar AirSeal™ (SurgiQuest, Orange, CT) fitted with an ultra-low particulate air (ULPA) filter investigated smoke evacuation and filtration to reduce exposure of staff to hazardous fumes, (3) automatic smoke evacuator (IES2, ERBE) equipped with ULPA identified 37 filtered carcinogenic substances, (4/5) the Tropian trocar (Tropian Tech., Gunpo, Korea), a charcoal filter, investigated in two studies focused on filtration of further hazardous compounds, and (6) charcoal/ULPA combination filter by Dyeing and Finishing Technology Institute investigated filtration rates of volatile organic compounds. Surgical plume can be cleared of hazardous chemical through smoke filters. There were six different filter studies identified with regards to endoscopic surgery which can aid in protecting the surgical staff from dangerous smoke by filtering cells, recirculating, and filtering gas, and removal of carbon-based substances. No clinical study has specifically investigated the removal of viruses by smoke filters including the SARS-CoV-2.

Surgical Team Exposure to Cautery Smoke and Its Mitigation during Tonsillectomy.

To assess the exposure of surgical personnel to known carcinogens during pediatric tonsillectomy and adenoidectomy (T&A) and compare the efficacy of surgical smoke evacuation systems during T&A. Prospective, case series. Tertiary children's hospital. The present study assessed operating room workers' exposure to chemical compounds and aerosolized particulates generated during T&A. We also investigated the effect of 3 different smoke-controlling methods: smoke-evacuator pencil cautery (SE), cautery with suction held by an assistant (SA), and cautery without suction (NS). Thirty cases were included: 12 in the SE group, 9 in SA, and 9 in NS. The chemical exposure levels were lower than or similar to baseline background concentrations, with the exception of methylene chloride and acetaldehyde. Within the surgical plume, none of the chemical compounds exceeded the corresponding occupational exposure limit (OEL). The mean particulate number concentration in the breathing zone during tonsillectomy was 508 particles/cm3 for SE compared to 1661 particles/cm3 for SA and 8208 particles/cm3 for NS cases. NS was significantly different compared to the other two methods (P = .0009). Although the exposure levels to chemicals were considerably lower than the OELs, continuous exposures to these chemicals could cause adverse health effects to surgical personnel. These findings suggest that the use of a smoke-evacuator pencil cautery or an attentive assistant with handheld suction would reduce exposure levels to the aerosolized particles during routine T&A, compared to the use of cautery without suction.

Surgical smoke and the anesthesia provider.

Surgical smoke generated by use of electrosurgical units (ESUs), lasers, and ultrasonic scalpels constitutes a physical, chemical, and biological hazard for anesthesia personnel. Inhalation of particulate matter with inflammatory consequences, pulmonary injury from products of tissue pyrolysis, exposure to mutagens and carcinogens, and the transmission of human papillomavirus (HPV) and possibly other pathogens represent a spectrum of adverse effects associated with the occupational exposure to surgical plume. While adequate operating room ventilation and use of high filtration-efficiency masks offer some protection from these conditions, the most effective method of safeguarding against surgical smoke involves its removal with a dedicated smoke evacuation device (SED). Despite the fact that many professional and governmental agencies have endorsed widespread usage of SEDs, anesthesia providers have been largely silent on this subject, with few reports within the field of anesthesiology and perioperative medicine regarding these hazards. SED use is relatively infrequent in most surgeries, and this condition reflects surgeons' reluctance to employ these devices, likely resulting from lack of education and less than optimal technology. Anesthesia societies and academic centers can serve critical roles in advocating employment of SEDs in much the same way that they have supported perioperative smoking cessation.

Effect of Electrocautery Settings on Particulate Concentrations in Surgical Plume during Tonsillectomy.

To describe the effect of monopolar electrocautery (EC) settings on surgical plume particulate concentration during pediatric tonsillectomy. Cross-sectional study. Tertiary medical center. During total tonsillectomy exclusively performed with EC, air was sampled with a surgeon-worn portable particle counter. The airborne mean and maximum particle concentrations were compared for tonsillectomy performed with EC at 12 W vs 20 W, with smoke evacuation system (SES) and no smoke evacuation (NS). A total of 36 children were included in this analysis: 9 cases with EC at 12 W and SES (12SES), 9 cases with EC at 20 W and SES (20SES), 9 cases with EC at 12 W without SES (12NS), and 9 cases with EC at 20 W without SES (20NS). Mean particle number concentration in the breathing zone during tonsillectomy was 1661 particles/cm3 for 12SES, 5515 particles/cm3 for 20SES, 8208 particles/cm3 for 12NS, and 78,506 particles/cm3 for 20NS. There was a statistically significant difference in the particle number concentrations among the 4 groups. The correlation between the particle number concentration and EC time was either moderate (for 12SES) or negative (for remaining groups). Airborne particle concentrations during tonsillectomy are over 9.5 times higher when EC is set at 20 W vs 12 W with NS, which is mitigated to 3.3 times with SES. Applying lower EC settings with SES during pediatric tonsillectomy significantly reduces surgical plume exposure for patients, surgeons, and operating room personnel, which is a well-known occupational health hazard.

COVID Operation Theatre- Advisory and Position Statement of Indian Society of Anaesthesiologists (ISA National).

COVID Operation Theatre- Advisory and Position Statement of Indian Society of Anaesthesiologists (ISA National).

Electrostatic Precipitation in Low Pressure Laparoscopic Hysterectomy and Myomectomy.

Background and Objective:The purpose of this study was to evaluate the impact of using electrostatic precipitation to manage the surgical plume during low pressure laparoscopic gynecologic procedures.Methods:This was a prospective, blinded, randomized controlled study of women with a clinical indication for laparoscopic hysterectomy (n = 30) or myomectomy (n = 5). Patients were randomized to either use electrostatic precipitation (EP) during the procedure, or not (No EP, hysterectomy group only).Results:Low pressure surgery could be undertaken in 87% of hysterectomy cases (13/15) when using EP to manage the surgical plume, compared to only 53% (8/15) in the No EP group. Overall average rating of the visual field was excellent with EP vs fair for No EP. Average CO2 consumption was reduced by 29% when using EP (16.7L vs 23.5L, p = 0.152). The average number of procedural pauses to vent smoke was lower with EP than the No EP group (1.5 per case vs. 3.7 per case, p = 0.005). Average procedure duration for the EP vs No EP group was 40.5 min vs. 46.9 min (p = 0.987). There were no measurable differences between groups for body temperature, end-tidal CO2, and discharge pain scores. In myomectomy, all five cases could be performed at low pressure, with an excellent visual field rating.Conclusion:Electrostatic precipitation enhances low pressure laparoscopic hysterectomy and myomectomy. This was achieved by minimizing interruptions to surgery and exchange of CO2; providing a clear visual field throughout the procedure; and eliminating surgical smoke at the site of origin.

Surgical Smoke in Dermatology: Its Hazards and Management.

Surgical plume with vaporized tissue particles, pathogens, and toxic gases emanating during dermatosurgical procedures is an occupational hazard to the dermatosurgeon, and protective measures must be taken to prevent their inhalation. Smoke evacuators are devices that capture and filter the plume generated during electrosurgical procedures or laser procedures, thereby maintaining a safe environment for the surgical team and the patient. A smoke evacuation system should be appropriately selected depending on the need of the facility. The objective of this article is to outline the health hazards of the smoke by-product of electrosurgery and lasers and provide details about safety measures and smoke evacuation systems.

Surgical plume and its implications: A review of the risk and barriers to a safe work place

Every year thousands of health care professionals worldwide are exposed to surgical smoke. There is evidence that this smoke consists of toxic gases, pathogens and particulate matter that is a hazard for patients and the perioperative team. Past research indicates that perioperative staff inconsistently comply with smoke evacuation recommendations. The aim of this study was to identify, review and discuss the issues related to surgical plume and its implications for patients and perioperative staff. The findings of this review relate to: surgical smoke content, its risks to the health of the perioperative staff, preventative measures, infection control measures, compliance with smoke evacuation systems, staff knowledge and barriers to implementing smoke evacuation practices. Of particular importance, the literature indicated that strong support from management and the implementation of regular staff education could improve practice for the management of surgical plume in the operating theatre.

Factors affecting surgical plume evacuation compliance

Despite the acknowledgement of the hazards of surgical plume, compliance with smoke evacuation is not routine. This review examines the current literature on factors influencing compliance with smoke evacuation. Factors identified included the design of the smoke evacuation device, surgeon refusal, education and managerial support. Strong leadership, education and policy enforcement from a local facility level are required to improve surgical plume evacuation compliance. More research in this field would help to further strengthen these findings.

Can Efficient Smoke Evacuation Limit Aerosolization of Bacteria?

Preventing surgical site infections requires knowledge of the sources of wound contamination. One possible source of wound contamination is bacteria aerosolized in diathermy plume (ie, surgical smoke). This study used an experimental model of porcine tissue embedded with Serratia marcescens to determine the extent of viable bacteria present in surgical plume. The results showed that only blended current electrosurgery, not laser plume or coagulation electrosurgery, contains viable bacteria. Further, the study revealed that placing a suction device near the electrosurgical site reduced the number of aerosolized viable bacteria. Therefore, evacuating the electrosurgical plume may help reduce contamination of the surgical wound. Nurses may wish to advocate for the use of air suction devices as one way to protect patients from surgical site infections.

The Nature and Hazards of Diathermy Plumes: A Review

Perioperative nurses in the OR may experience more extensive and sustained exposure to surgical plumes than other surgical personnel. Compared with laser plumes, less policy attention has been given to mitigating the risks associated with exposure to diathermy plumes. Diathermy can produce ultrafine particles and volatile chemical and biological substances, of which a number are teratogenic or carcinogenic. Evidence suggests diathermy plumes contain more biohazards than laser plumes, although protective smoke evacuation equipment is less likely to be used with diathermy. Although there is no direct evidence of harm to OR personnel, further research is required to conclusively establish actual risks and appropriate standards for safe exposure. Interventional strategies should address staff attitudes toward diathermy plume exposure and protective measures. This structured review of the literature describes the nature and risks associated with exposure to diathermy plumes and clarifies the implications for protective techniques and nursing practices.

Laminar and turbulent surgical plume characteristics generated from curved- and straight-blade laparoscopic ultrasonic dissectors

To characterize laparoscopic ultrasonic dissector surgical plume emission (laminar or turbulent) and investigate plume settlement time between curved and straight blades. A straight and a curved blade laparoscopic ultrasonic dissector were activated on tissue and in a liquid environment to evaluate plume emission. Plume emission was characterized as either laminar or turbulent and the plume settlement times were compared. Devices were then placed in liquid to observed consistency in the fluid disruption. Two types of plume emission were identified generating different directions of plume: laminar flow causes minimal visual obstruction by directing the aerosol downwards, while turbulent flow directs plume erratically across the cavity. Laminar plume dissipates immediately while turbulent plume reaches a second maximum obstruction approximately 0.3 s after activation and clears after 2 s. Turbulent plume was observed with the straight blade in 10 % of activations, and from the curved blade in 47 % of activations. The straight blade emitted less obstructive plume. Turbulent flow is disruptive to laparoscopic visibility with greater field obstruction and requires longer settling than laminar plume. Ultrasonic dissectors with straight blades have more consistent oscillations and generate more laminar flow compared with curved blades. Surgeons may avoid laparoscope smearing from maximum plume generation depending on blade geometry.

Significance of surgical plume obstruction during laparoscopy.

With the advent of laparoscopic surgery, the need of optimal visualization and efficient instrumentation has created a need for better understanding of the characteristics of the surgical plume. Despite the technological advances of digital imaging and dissector technology (ultrasonic, radiofrequency electrical, and bipolar), the inconvenient and sometimes harmful generation of a surgical plume decreases visualization, often requiring the surgeon to remove the scope from the surgical field and remove the obstructing particles. If visualization is suboptimal or lost during bleeding, the outcome can be deadly. Therefore, we reviewed the available reports in the literature focused on the quantification of surgical plumes.

O39 Clearing the air in surgery: what you need to know about surgical plume

O39 Clearing the air in surgery: what you need to know about surgical plume

Chemical composition of surgical smoke produced by electrocautery, harmonic scalpel and argon beaming – a short study

BACKGROUND: The inhalation of aerosols during electrosurgery is part of daily surgical life. This study analyses the toxic and cancerogenic components of the aerosols. METHODS: Electrocautery, harmonic scalpel and argon beaming were utilised in a pig model. The collected aerosols were analysed by gas chromatography coupled with mass spectrometry for acrylamide, aldehydes and ketones, volatile and semivolatile organic compounds, and polycyclic aromatic hydrocarbons. RESULTS: Surgical plume of all instruments comprehends toxic components including e.g. acrylamide, acetaldehyde, formaldehyde, and benzene. Composition and toxicity varies from applied technique, energy, and processed tissue. High temperature induces more toxic aerosols. Offtake devices reduce toxic inhalations. CONCLUSIONS: Surgical smoke contains toxic, partly cancerogenic compounds. Concentrations estimated for daily routine are probably below relevant health risk. Nevertheless, the exposition to surgical 'smog' should be minimised at any time using offtake devices. Further examinations during clinical practice are necessary.

Analysis of Surgical Smoke Produced by Various Energy-Based Instruments and Effect on Laparoscopic Visibility

We analyzed the smoke plume produced by various energy-based laparoscopic instruments and determined its effect on laparoscopic visibility. The Bipolar Macroforceps, Harmonic Scalpel, Floating Ball, and Monopolar Shears were applied in vitro to porcine psoas muscle. An Aerodynamic Particle Sizer and Electrostatic Classifier provided a size distribution of the plume for particles >500 nm and <500 nm, and a geometric mean particle size was calculated. A Condensation Particle Counter provided the total particle-number concentration. Electron microscopy was used to characterize particle size and shape further. Visibility was calculated using the measured-size distribution data and the Rayleigh and Mie light-scattering theories. The real-time instruments were successful in measuring aerosolized particle size distributions in two size ranges. Electron microscopy revealed smaller, homogeneous, spherical particles and larger, irregular particles consistent with cellular components. The aerosol produced by the Bipolar Macroforceps obscured visibility the least (relative visibility 0.887) among the instruments tested. Particles from the Harmonic Scalpel resulted in a relative visibility of 0.801. Monopolar-based instruments produced plumes responsible for the poorest relative visibility (Floating Ball 0.252; Monopolar Shears 0.026). Surgical smoke is composed of two distinct particle populations caused by the nucleation of vapors as they cool (the small particles) and the entrainment of tissue secondary to mechanical aspects (the large particles). High concentrations of small particles are most responsible for the deterioration in laparoscopic vision. Bipolar and ultrasonic instruments generate a surgical plume that causes the least deterioration of visibility among the instruments tested.

COMPOSITION OF VOLATILE ORGANIC COMPOUNDS IN DIATHERMY PLUME AS DETECTED BY SELECTED ION FLOW TUBE MASS SPECTROMETRY

There is some evidence that surgical plume may pose a risk to health professionals, but the risks posed by volatile organic compounds have not been thoroughly investigated. The composition of volatile organic compounds in diathermy plume produced during surgery was analysed by selected ion flow tube mass spectrometry. Hydrogen cyanide (3-51 parts per million), acetylene (2-8 parts per million), and 1,3-butadiene (0.15-0.69 parts per million) were identified in the plume. Although there is no evidence of adverse health effects from the volatile organic compound in diathermy plume, the evidence that it is safe to breathe this plume is lacking. Therefore, we would recommend the use of smoke evacuators where practical.

Regulation of surgical smoke plume

Regulation of surgical smoke plume

Bacteriophage ΦX-174 as an aerobiological marker for surgical plume generated by the electromagnetic field focusing system

The aerosol of surgical plume could be measured effectively with the use of bacteriophage ΦX-174 as a biological marker, in contrast to previous methodologies reported by others. Recovery of virus plaqueforming units was highest from hydrophobic polytetrafluoro-ethylene membranes compared to hydrophobic polycarbonate screen filters or polyvinylidene difluoride depth filters, indicating that the method of virus recovery strongly affects the utility of a virus as an aerobiological marker. With this new method, surgical plume was indeed found in significant amounts when cutting tissue phantoms made with agar containing virus. The Electromagnetic Field Focusing System was used, which is a new thermal surgical device. The nominal power setting did not appear to be a factor in the amount of virus recovered. However, when pulse modulating the power by adjusting the crest factor from 1·4 to 4·3, a measure of the duty cycle for power delivery which adjusted the device from its cutting to haemostatic mode, a nearly five-fold increase in surgical plume, as evidenced by the recovery of ΦX-174 plaque forming units, was seen. The data indicate that bacteriophage ΦX-174 can be used effectively as an aerobiological marker for aerosols generated during clinical procedures, and reinforce the need to use a safety vacuum during aerosol generating procedures. The availability of a safe and economical biological marker for aerosols from clinical procedures, which may lead to acquired infections in hospital personnel, makes evaluation of procedures and containment systems markedly easier. The data also indicates that surgical plume biohazard may be present in other techniques that employ pulse modulation including surgical lasers and electrocauteries.