Surgical Plume Research Articles

CE: Our Journey to Pass a Surgical Plume Evacuation Law.

Surgical plume is produced when heat-generating instruments are used to cut, cauterize, or vaporize tissue during surgery. Surgical plume can rapidly diffuse, and without the use of plume evacuators to ensure it is captured, filtered, and removed, health care workers and patients are at risk for inhalation exposure to airborne contaminants, including smoke and biological hazards. The use of surgical plume evacuators in health care facilities is inconsistent across the United States. This article describes the experience of two nurses who led a grassroots coalition to pass a surgical plume evacuation law in Illinois. It also outlines strategies they used in the legislative process that nurses can apply to their own efforts to advocate for health policy change at the state level.

Promoting surgical smoke management in a pediatric operating room: a best practice implementation project.

The routine use of heat-producing tools in the perioperative setting generates surgical smoke. Surgical smoke poses a known health hazard for perioperative staff working in the operating room. The objective of this best practice project was to promote evidence-based practices regarding surgical plume management in a pediatric operating room. This project was guided by the JBI Model of Evidence-Based Healthcare and used the JBI Practical Application of Clinical Evidence System and the Getting Research into Practice audit and feedback strategy to promote evidence-based practices regarding surgical smoke management in a pediatric operating room. Seven audit criteria representing best-practice recommendations were used. A baseline audit was conducted, followed by the implementation of multiple strategies developed by the key stakeholders. The project was finalized with a follow-up audit to determine any changes in compliance with best-practice recommendations. Baseline audit data indicated an average of 41% compliance with best practices across all audit criteria, revealing the need for significant improvement in five of the seven criteria. Three barriers were identified and strategies were implemented, including the development and implementation of an educational module and a surgical smoke exposure risk assessment tool. Follow-up audits showed an overall improvement of 30% among five of the seven audit criteria. This project yielded improvements with best practices for surgical smoke management in the perioperative setting. However, additional work is required to ensure the sustainability of best practices in this setting.

Nanoparticle Concentration in Surgical Plume During Tonsillectomy: A Comparison of Four Techniques.

Surgical plume has known potential occupational health hazards. This study compares nanoparticle concentrations in surgical plumes generated between different pediatric tonsillectomy surgical techniques and assesses the efficacy of mitigation measures. This is a cross-sectional study performed at a tertiary care academic center. Extracapsular or intracapsular tonsillectomy was performed in 60 patients using four techniques and in 10 additional patients using mitigation measures. Two nanoparticle counters were used to measure particulate concentrations: CPC™ and DiSCmini™. Tonsillectomy techniques included: (1) microdebrider (MD), (2) Bovie with manual suctioning by an assistant (B), (3) Bovie with built-in smoke evacuation system (BS), and (4) Coblator™ (CB). An additional Yankauer suction was used in the mitigation groups (BSY) and (CBY). Comparative analysis was performed using one-way ANOVA on ranks and pairwise comparisons between the groups. The mean concentrations (particles/cm3) and coefficient of variants for the DiSCmini particulate counter were MD: 5140 (1.6), B: 30700 (1.5), BS: 25001 (0.8), CB: 54814 (1.7), CBY: 2395 (1.3) and BSY: 11552 (1.0). Mean concentrations for the CPC particulate counter were MD: 1223 (1.4), B: 3405 (0.7), BS: 5002 (0.9), CB: 13273 (1.0), CBY: 1048 (1.2) and BSY: 3046 (0.6). The lowest mean concentrations were noted in cases using MD and the highest in cases using CB. However, after mitigation, CBY had the lowest overall levels. Tonsillectomy technique does impact the levels of nanoparticles emitted within the surgical plume, which may present an occupational hazard for operating room personnel. 3 Laryngoscope, 134:2444-2448, 2024.

Surgical plume and its associated hazards to perioperative staff: A review of current standards for practice and risk management

Surgical plume poses a risk to perioperative nurses and the perioperative team as a whole, as well as the operative patient. Surgical plume contains various hazardous components which pose multiple health risks to the perioperative staff who are exposed to it. Further research is required in order to definitively understand the risks to perioperative staff from long-term exposure to surgical plume and to advance current policies and procedures. The current practice standard on surgical plume management from the Australian College of Perioperative Nurses (ACORN) sets out methods of reducing these risks. However, this standard’s utility in practice and barriers to its implementation lead to ongoing unnecessary plume exposure. Through adhering to current practice standards and educating perioperative nurses, the risks posed by surgical plume can be mitigated. Thorough education on this topic will empower nurses to advocate for their safety and the safety of their patients, leading to the reduction of surgical plume exposure.

Plume Generated by Different Electrosurgical Techniques: An In Vitro Experiment on Human Skin.

Plume generated by electrosurgical techniques is a health hazard to patients and dermatologists. To compare the particle concentration generated by various energy devices used in dermatologic surgery. Five surgical techniques were tested on human tissue samples in a closed chamber. A particle counter, positioned at a fixed point 20 cm away from the sample, recorded the concentrations of aerosolized particles generated over 7 particle sizes (0.3, 0.5, 0.7, 1, 2.5, 5, and 10 μm). Monopolar electrocoagulation created the greatest concentration of particles followed by electrocautery, electrodesiccation, electrofulguration, and bipolar electrocoagulation. Bipolar electrocoagulation created 80 times fewer 0.3 μm particles and 98 times fewer 0.5 μm particles than monopolar electrocoagulation. Across all electrosurgical techniques, the greatest concentrations of particles generated were of the 0.3 and 0.5 μm particle size. Bipolar electrocoagulation created the lowest concentration of particulate matter. Given the noxious and hazardous nature of surgical plume, the bipolar forceps offer surgeons a safer method of performing electrical surgery for both the surgical staff and the patient.

Characterization of signal kinetics in real time surgical tissue classification system

Effective surgical margin assessment is paramount for good oncological outcomes and new methods are in active development. One emerging approach is the analysis of the chemical composition of surgical smoke from tissues. Surgical smoke is typically removed with a smoke evacuator to protect the operating room staff from its harmful effects to the respiratory system. Thus, analysis of the evacuated smoke without disturbing the operation is a feasible approach. Smoke transportation is subject to lags that affect system usability. We analyzed the smoke transportation delay and evaluated its effects to tissue classification with differential mobility spectrometry in a simulated setting using porcine tissues. With a typical smoke evacuator setting, the front of the surgical plume reaches the analysis system in 380 ms and the sensor within one second. For a typical surgical incision (duration 1.5 s), the measured signal reaches its maximum in 2.3 s and declines to under 10% of the maximum in 8.6 s from the start of the incision. Two-class tissue classification was tested with 2, 3, 5, and 11 s repetition rates resulting in no significant differences in classification accuracy, implicating that signal retention from previous samples is mitigated by the classification algorithm.

SAGES 2022 guidelines regarding the use of laparoscopy in the era of COVID-19.

BackgroundSARS-CoV-2 has changed global healthcare since the pandemic began in 2020. The safety of minimally invasive surgery (MIS) utilizing insufflation from the standpoint of safety to the operating room personnel is currently being explored. The aims of this guideline are to examine the existing evidence to provide guidance regarding MIS for the patient with, or suspecting of having, the SARS-CoV-2 as well as the healthcare team involved.MethodsSystematic literature reviews were conducted for 2 key questions (KQ) regarding the safety of MIS in the setting of COVID-19 pandemic. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis criteria. Evidence-based recommendations were formulated using a narrative synthesis of the literature by subject experts. Recommendations for future research were also proposed.ResultsIn KQ1, a total of 1361 articles were reviewed, with 2 articles meeting inclusion. In KQ2, a total of 977 articles were reviewed, with 4 articles met inclusions criteria, of which 2 studies reported on the SARS-CoV2 virus specifically. Despite many publications in the field, very little well-controlled and unbiased data exist to inform the recommendations. Of that which is available, it shows that both laparoscopic and open operations in Covid-positive patients had similar rates of OR staff positivity rates; however, patients who underwent laparoscopic procedures had a lower perioperative mortality than open procedures. Also, SARS-CoV-2 particles have been detected in the surgical plume at laparoscopy.ConclusionWith demonstrated equivalence of operating room staff exposure, and noninferiority of laparoscopic access with respect to mortality, either laparoscopic or open approaches to abdominal operations may be used in patients with SARS-CoV-2. Measures should be employed for all laparoscopic or open cases to prevent exposure of operating room staff to the surgical plume, as virus can be present in this plume.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00464-022-09133-w.

Coronavirus viability in surgical plume and methods for safe disposal: a preclinical model

Smoke generated by cautery devices used during surgery may contain infective particles and may cause transmission of airborne viruses. This study determines whether live viruses are present in surgical smoke and evaluates the effectiveness of several proposed methods of removal so as to improve safety of healthcare workers.

Clearing the air on surgical plume.

Surgical smoke or plume is produced by a variety of surgical coagulators and dissectors. A number of jurisdictions have recently introduced policies to reduce the associated occupational health risks including WorkSafe Victoria and New South Wales Health. This paper is a narrative review of potential risks, including any associated with COVID-19, and options for mitigation. Surgical smoke or plume contains potentially toxic chemicals, some of which are carcinogens. Plume may also contain live virus, notably Human Papilloma and Hepatitis B, though any possible viral transmission is limited to a few case reports. Despite identifying COVID-19 ribonucleic acid fragments in various body tissues and fluids there are no current reports of COVID-19 transmission. Although plume is rapidly removed from the atmosphere in modern operating rooms, it is still inhaled by the operative team. Mitigation should include ensuring diathermy devices have evacuators while plume extraction should be standard for laparoscopic procedures. Consideration needs to be given to the potential to compromise the operating field of view, or the noise of the extractor impairing communication. There is an increasing range of suitable products on the market. The future includes pendant systems built into the operating room. The potential risks associated with surgical plume cannot be ignored. Health services should invest in plume extraction devices with a view to protecting their staff. The conduct of the operation should not be compromised by the devices chosen. Future operating theatres need to be designed to minimize exposure to plume.

A Smoke Evacuator Equipped With a Filter Contributes Enough to Safe Gas Exhaustion From the Abdominal Cavity.

Surgical plume (SP) carries biological risks such as virus transmission. An evacuation system can remove SP from the surgical field, but is it safe to release evacuated gas into the operating room (OR) atmosphere? We examined this using a commercially available evacuator equipped with a filter under a laparoscopic porcine surgery model. SP was generated by activating an electrocautery or ultrasonic scalpel on the surface of the liver, and we evaluated whether DNA fragments derived from porcine tissue were present in the exhausted gas from the evacuation system into the atmosphere. DNA fragments were detected in the inlet gas of the evacuation system, while it was not detected in the outlet gas. As far as pathogen transmission via SP in the abdominal cavity is concerned, if the smoke evacuator ensures filter adsorption, it seems that there is little risk in releasing the suction gas into the atmosphere in the OR.

Gaseous and Particulate Content of Laser Tattoo Removal Plume.

There is increasing awareness of the potential hazards of surgical plumes. The plume associated with laser tattoo removal remains uncharacterized. To determine the gaseous, particulate, and microbiological content of the laser tattoo removal plume. Air sampling was performed during laser tattoo removal from pig skin and from patients. Measurement of metals, volatile organic compounds (VOCs), carbon monoxide (CO), hydrogen sulfide (HS), and ultrafine particulates (UPs) as well as bacterial 16S ribosomal DNA sequencing were performed. Metals were identified in the plume from both pig and human skin. Volatile organic compounds were found at similar levels within and outside the treatment room. Several bacterial phyla were detected in the treatment room, but not outside. High levels of UPs were measured throughout the treatment room during tattoo removal from pig skin. Ultrafine particulates were detected at low levels in the room periphery during tattoo removal from human skin, but at higher levels in the immediate treatment zone. HS and CO were not detected. Metals, VOCs, HS, and CO were found at levels below applicable occupational exposure limits. The presence of bacteria is of uncertain significance, but may be hazardous. High levels of UPs require further investigation.

A study to quantify surgical plume and survey the efficiency of different local exhaust ventilations

This study aimed to compare the concentration of surgical smoke produced by different tissues and electric diathermy modes and to measure the effectiveness of various local exhaust ventilations. We compared the surgical plume concentration from different tissues and settings with a porcine tissue model. We also compared the efficiency of three local exhaust ventilations: (1) a desktop unit (Medtronic Rapid Vac), (2) a central evacuation system with ENT suction, and (3) a central evacuation system with a urethral catheter (PAHSCO Urethral Catheter). In the cutting setting, the skin tissue had a higher concentration of total suspended particulates (TPS), which were 1990 ± 2000 (mean ± SD, μg/m3), 6440 ± 3000 and 9800 ± 2300 at 15, 30 and 45 s, respectively (p < 0.05). In the coagulation setting, the adipose tissue had a higher concentration of TPS, which were 3330 ± 2600, 11,200 ± 5500 and 15,800 ± 7300, respectively (p < 0.05). We found that all three smoke extractors had more than 96% efficiency in clearing surgical smoke. With electric diathermy, skin tissue in the cutting model and adipose tissue in the coagulation mode will produce higher concentration of particles within surgical plumes. An electric surgical scalpel adapted with a urethral catheter is a simple and effective way to exhaust smoke in surgical operations.

Surgical plume from tissue infected with human hepatitis B virus can contain viral substances

Introduction Evidence on the biological danger associated with surgical plume is lacking. We examined whether surgical plume, generated by the energy devices ultrasonically activated scalpel (US) or electrocautery (EC) contains virus-related substances. Material and methods Experiment 1, ex-vivo model: Tumor mass of a hepatocellular carcinoma line was prepared in a Nod/SCID mouse. Surgical plume generated on the mass by US or EC was collected and detection of HBs gene fragment and antigens (HBsAg or AFP) was conducted. Experiment 2, clinical specimen: Detection of HBV-DNA and HBsAg was conducted following the collection of surgical plume generated from clinically obtained liver specimens from six HBV-associated hepatocellular carcinoma patients. Results Experiment 1: HBs gene fragment was detected in the solutions regardless of the device used. HBsAg was detected in US and EC solutions and AFP was also detected in a US solution. Experiment 2: HBV-DNA was detected in both devices, in all three cases whose preoperative serum HBV-DNA was positive. In the other serum-negative cases, HBV-DNA was not detected. While serum HBsAg was positive in five of six cases, it was not detected in any solution. Conclusions DNA fragments or antigens of virus can exist in the surgical plume generated by EC or US.

Laparoscopic gynecological surgery in COVID-19 pandemic.

The major concern that has confronted surgeons during the COVID-19 pandemic is the risk of infection during surgery. So far, no studies have found SARS-CoV-2 in surgical smoke, and if it was found, whether it was infectious or not is unknown. To date, no evidence shows that respiratory viruses can be transmitted through a surgical plume or an aerosolized gas. There are various advantages of laparoscopy over laparotomy that must be kept in mind in the COVID-19 era, such as early recovery and shorter hospital stay, which can greatly help to conserve valuable hospital resources, and reduced risk of spillage of blood and body fluids, which can help to reduce transmission risk; most importantly, the distance between surgeons and between surgeons and patient is greater. Certain precautionary measures can be taken to reduce SARS-CoV-2 transmission during laparoscopy. Whenever possible, it should be the surgical option of choice.

An effective smoke evacuation system for preventing aerosolization during laparoscopy in the Covid-19 Era

Introduction: The coronavirus disease (Covid-19) pandemic has led the surgical society to new challenges in the operating theatre. Aerosolization during laparoscopic interventions in Covid-19 patients may pose an increased risk to surgical staff and patients. Methods: We briefly review the inconceivably fast emerging studies for laparoscopy during the Covid-19 era and announce our practical method of surgical plume filtration during laparoscopic procedures of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positive patients. Results: The use of minimally invasive surgery can be considered appropriate, safe and feasible in patients with Covid-19 and the use of trocar filtration systems reduces considerably the risks of infection. Conclusions: Despite the little evidence of viral transmission through laparoscopic surgical approach, modifications in surgical practice are recommended, such as the use of filtrating systems in order to minimize staff exposure to aerosolized viral particles. Copyright © Celsius Publishing House.

Could Laparoscopic Concerns During Coronavirus Pandemic Affect the Care of Women With Pregnancy of Unknown Location/Ectopic Pregnancy?

In the coronavirus pandemic elective surgery has been deferred and therefore emergency surgery for suspected ectopic pregnancy arises as the most commonly performed operation in gynecology. Laparoscopic management has traditionally been the gold standard, however recently concerns have been raised regarding severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) dissemination as aerosolized small particles are presumed to escape abdominal cavity. The rationale for this hypothesis is based on cohort studies confirming presence of blood-borne viruses such as human immunodeficiency virus (HIV) and hepatitis B virus (HBV) in the surgical plume, whereas data for airborne viruses such as SARS-CoV-2 are scarce. Remarkably, there is no solid evidence up to date to associate inhalation of pneumoperitoneum viral particles with subsequent disease of theatre staff. Reverse transcription-polymerase chain reaction (RT-PCR) on blood samples of coronavirus disease 2019 (COVID-19)-infected patients presenting with fever, confirmed viremia in only 1% of cases. The viral ribonucleic acid (RNA) was isolated in stool samples in 29% of cases but was not found in urine samples. Therefore, the use of surgical energy devices on genital tract tissues bears little chance of producing aerosolized COVID-19 particles. The optimal surgical approach should be individualized according to a variety of factors: complexity of case and bowel involvement, length of procedure, comorbidities, hospital stay, as well as the surgeon’s familiarity with each approach. When necessary precautions are taken, laparoscopy for ectopic pregnancy appears safe. Operating theatres should meet technical specifications and maintain negative pressure if possible. Only essential personnel equipped with personal protective equipment should be attending theatres. Abdominal pressure should be set under 12 mm Hg and ultrasonic/bipolar device use minimized. Smoke evacuation filtration systems and disposable trocars with insufflation taps can contain surgical smoke. As more information is emerging, trusts will adjust to evolving circumstances with standard operating procedures. Changing established practice may be premature as clinicians should “first do no harm” . J Clin Gynecol Obstet. 2020;9(3):31-36 doi: https://doi.org/10.14740/jcgo657

Surgical plume in dermatology: an insidious and often overlooked hazard.

Dermatologists performing surgical procedures face occupational and health hazards when exposed to surgical plume released during electrosurgical and ablative laser procedures. These hazardous fumes have toxic, infectious and carcinogenic effects. Understanding this risk is of particular importance during the COVID‐19 pandemic as the understanding of the transmissibility and infectious nature of the virus is still evolving rapidly. In this article, we present the hazards from laser and surgical plumes, and discuss possible preventative measures aimed at reducing these risks.

Safe surgery during the coronavirus disease 2019 crisis.

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has created a global pandemic. Surgical care has been impacted, with concerns raised around surgical safety, especially in terms of laparoscopic versus open surgery. Due to potential aerosol transmission of SARS-CoV-2, precautions during aerosol-generating procedures and production of surgical plume are paramount for the safety of surgical teams. A rapid review methodology was used with evidence sourced from PubMed, Departments of Health, surgical colleges and other health authorities. From this, a working group of expert surgeons developed recommendations for surgical safety in the current environment. Pre-operative testing of surgical patients with reverse transcription-polymerase chain reaction does not guarantee lack of infectivity due to a demonstrated false-negative rate of up to 30%. All bodily tissues and fluids should therefore be treated as a potential source of COVID-19 infection during operative management. Caution must be taken, especially when using an energy source that produces surgical plumes, and an appropriate capture device should also be used. Limiting the use of such devices or using lower energy devices is desirable. To reduce perceived risks association with desufflation of pneumoperitoneum during laparoscopic surgery, an appropriate suction irrigator system, attached to a high-efficiency particulate air filter, should be used. Additionally, appropriate use of personal protective equipment by the surgical team is necessary during high-risk aerosol-generating procedures. As a result of the rapid review, evidence-based guidance has been produced to support safe surgical practice.

Simple Device Design for Plume Management after Pneumoperitoneum in Laparoscopy in COVID-19 Outbreak.

The impact of COVID-19 on surgical practice is worldwide. Controversy is there regarding dissemination of coronavirus by surgical smoke during laparoscopic surgery; hence, laparoscopic surgeries are being used with great cautions. We propose the use of a simple device, which can be prepared cheaply with material readily available in our hospitals, to manage the surgical plume generated during laparoscopic procedures. With proper management of the surgical plume with the above-proposed device, the concerns regarding aerosol generation can be alleviated and all the benefits of laparoscopy can be extended to our patient in need of a surgery that cannot be delayed.

Electrocautery, Diathermy, and Surgical Energy Devices: Are Surgical Teams at Risk During the COVID-19 Pandemic?

The aim of the study was to provide a rapid synthesis of available data to identify the risk posed by utilizing surgical energy devices intraoperatively due to the generation of surgical smoke, an aerosol. Secondarily it aims to summarize methods to minimize potential risk to operating room staff. Continuing operative practice during the coronavirus disease-19 (COVID-19) pandemic places the health of operating theatre staff at potential risk. SARS-CoV2 is transmitted through inhaled droplets and aerosol particles, thus posing an inhalation threat even at considerable distance. Surgical energy devices generate an aerosol of biological particular matter during use. The risk to healthcare staff through use of surgical energy devices is unknown. This review was conducted utilizing a rapid review methodology to enable efficient generation and dissemination of information useful for concurrent clinical practice. There are conflicting stances on the use of energy devices and laparoscopy by different surgical governing bodies and societies. There is no definitive evidence that aerosol generated by energy devices may carry active SARS-CoV2 virus. However, investigations of other viruses have demonstrated aerosolization through energy devise use. Measures to reduce potential transmission include appropriate personal protective equipment, evacuation and filtration of surgical plume, limiting energy device use if appropriate, and adjusting endoscopic and laparoscopic practice (low CO2 pressures, evacuation through ultrafiltration systems). The risk of transmission of SARS-CoV2 through aerosolized surgical smoke associated with energy device use is not fully understood, however transmission is biologically plausible. Caution and appropriate measures to reduce risk to healthcare staff should be implemented when considering intraoperative use of energy devices.