We have heard so much about smoke plume from Laser and Electrosurgery use in open procedures and the need to evacuate it. The hazards are well known and documented, however, in my 25 years in the OR, I have seen a lack of use of appropriate smoke plume evacuation in laparoscopic procedures. Why should we evacuate surgical smoke plume from laparoscopic procedures?
The obvious reason is pointed out by the surgeons daily, they can’t see. They want the surgical smoke gone. It clouds the field, builds up on the lens and makes it difficult to safely and effectively operate. Other reasons are often overlooked by the surgeon and staff and this is safety of the patient and OR staff.
To try and solve the problem of visibility, many surgeons open a valve on the trocar and let the smoke escape into the room. By doing this, they create another problem, the personnel in the room are then exposed to the smoke from the patient’s ablated tissue. Most OR nurses and Surgical Technologists know this is bad practice from a safety standpoint due to the hazardous components of surgical smoke but rarely say or do anything about it.
Another method of smoke removal is to use a suction irrigator device and simply suction the smoke out when it gets too cumbersome. This method is perceived as being safe, but keep in mind that all of the contents of the smoke are then pulled into your hospitals vacuum system. When this material enters the suction system, it builds up and eventually clogs the flow of the vacuum and can contaminate the entire system. By using a 0.1 micron, in-line filter, you can help prevent this from happening.
What happens if the smoke is left in the abdomen? The components of the smoke can be absorbed by the patient though the peritoneum. A study from Poland in 2014 showed that chemicals found in surgical smoke, during laparoscopic cholecystectomy, were absorbed by the patient and excreted through the kidneys. This means that potentially carcinogenic, toxic and mutagenic chemicals circulate through the blood stream before being filtered out in the kidneys; indicating that laparoscopic smoke evacuation is also a patient safety concern as much as it is a staff safety concern2.
In my practice and experience, an active smoke removal device has been the most effective. An active device is a filter that connects to the luer lock valve on a surgical trocar. The other end connects to a suction source off the field, either wall suction or to a fluid management device. It should contain an ULPA filter (0.1 micron at 99.999 percent efficiency), carbon filter that adsorbs the gasses and chemicals and a fluid trap to prevent liquid inundation of the filtration media. The device should also be adjustable so the surgical team can regulate the flow on the field as needed. This type of evacuation device effectively removes the smoke from the patient’s abdomen while filtering it before it enters the hospital vacuum system. It also eliminates the need to vent it out into the room where it would expose everyone to the smoke.
We know that surgical smoke contains three types of hazards, physical, chemical, and biological.
I will start with the physical hazards. This is the particulate that is found in all smoke, whether it be a cigarette, a burning pile of leaves or surgical smoke. These particles may range from 0.01 microns to greater than 200 microns in size. It is the smaller particles that are of concern to surgical staff. Particulate matter of 0.3 microns and smaller can bypass the natural defenses of the respiratory system and enter into the alveoli, where we rely on macrophage action to remove the hazard. I will leave it there for this blog because there is so much more to discuss on this alone for one entry.
The second hazard in surgical smoke is a chemical hazard. Many studies have come to the same conclusion that surgical smoke contains benzene, toluene, xylene, perchloroethylene, ethylbenzene and many others. Anyone who has ever taken a chemistry class knows that benzene is a cancer causing agent, the other chemicals are also carcinogenic, mutagenic or toxic.
The third hazard is a biologic hazard. There are several documented cases of HPV transmission to surgical personnel from surgical smoke. But the smoke also has been shown to contain HBP, HIV, Human and viral DNA as well as blood components1 3. Surgical smoke has also been suspected of transferring cancer cells as indicated in the 1999 study by Fletcher et.al.4
Based on this information, it is imperative to evacuate the surgical smoke from a patient’s abdomen without exposing the operating room personnel to the hazards of surgical smoke plume. One way to accomplish this in a safe, effective manner, is to use an active evacuation device on all laparoscopic procedures that generate surgical smoke plume.
1. Tomita T, Mihashi S, Nagata K, Ueda S, Fujiki M, Hirano M, and Hirohata T. Mutagenicity of Smoke Condensates Induced by CO2 – Laser Irradiation and Electrocauterization. Mutation Research. 1981
2. Dobrogowski et.Al., Chemical Composition of Surgical Smoke Formed in The Abdominal Cavity During Laparoscopic Cholecystectomy – Assessment of the Risk to the Patient International Journal of Occupational Medicine and Environmental Health 2014;27(2):314 – 325 http://dx.doi.org/10.2478/s13382-014-0250-3
3. Barrett, W. & Garber, S. (2004). Surgical Smoke – A Review of the Literature. Business Briefing: Global Surgery
4. Fletcher et Al. (1999). Dissemination of Melanoma Cells within Electrocautery Plume. Excerpta Medica, Inc.
Rob Scroggins is the Clinical Programs Manager for Buffalo Filter. He is a registered nurse with 25 years of operating room experience prior to joining Buffalo Filter and has a wide variety of experience in multiple specialties including orthopaedics, general surgery, vascular surgery, neurosurgery and others. He had a 21-year career in the National Guard and Army Reserve beginning as a medic at the rank of private and rising through the ranks eventually retiring as a Captain, Army Nurse Corps.