An operating room nurse from the UK has asked me to comment on the burning issue of surgical smoke. [Pun intended.] I don’t think she’s going to like what I have to say.
For several years, studies have found that all kinds of chemicals and organic bits can be found in smoke plumes generated by electrocautery and lasers in the operating room. Some of the chemicals are said to be carcinogens and the organic material reportedly contains intact viral genetic material.
Many organizations have called for the establishment of government regulations regarding the amount of stuff that should be allowable in OR smoke. However, OSHA has been surprisingly reluctant to do anything and has not officially commented on the subject since 1996. The OSHA website does say that about half of the states have various regulations in place.
Some groups, particularly nursing organizations, are calling for the placement of smoke evacuators in all operating rooms. As you might suspect, these efforts are being vigorously supported by the manufacturers of smoke evacuators.
I attempted to find some real evidence about all this, but it is hard to come by. A very interesting presentation by a group from the Centre Hospitalier Universitaire de Québec (CHUQ) at the 2011 Cochrane Canada Symposium addressed the subject in a health technology assessment.
There have been no randomized trials involving surgical smoke.
For biologic and chemical substances, the CHUQ health technology assessment said the risks of transmission of diseases were unclear.
They measure the air in operating rooms and said, “[A]mbient air concentrations of carbon monoxise, volatile organic compounds, and particulate matter are very low and far below the occupational exposure limits.”
They concluded, “There is no clear evidence that surgical smoke may represent health hazard,” but hedged by saying that smoke evacuators should be restricted to specific types of cases such as breast surgery. They offered no evidence to support that recommendation.
There are only two case reports in the literature claiming transmission of viruses in surgical smoke from patients to healthcare workers. These case reports are frequently cited by advocates of smoke evacuation devices.
The first case report, cited in PubMed 16 times but many more times in other documents, is from Norway. Here is the complete abstract. I added emphasis in bold.
A 44-year-old laser surgeon presented with laryngeal papillomatosis. In situ DNA hybridization of tissue from these tumors revealed human papillomavirus DNA types 6 and 11. Past history revealed that the surgeon had given laser therapy to patients with anogenital condylomas, which are known to harbor the same viral types. These findings suggest that the papillomas in our patient may have been caused by inhaled virus particles present in the laser plume.
The second case report, cited 3 times, is from Germany. Here is its abstract.
A 28-year-old gynecological operating room nurse, who assisted repeatedly in electrosurgical and laser surgical excisions of anogenital condylomas, developed a recurrent and histologically proven laryngeal papillomatosis. The expert opinion of a virological institute confirmed a high probability of correlation between the occupational exposition and the laryngeal papillomatosis so that it was accepted as occupational disease. HPV-DNA has been repeatedly detected in laser-plume after excision of papillomas and condylomas. As of the present an exact proof that these particles are infectious has not been brought forward.
There are other ways to acquire HPV virus in one’s throat.
The CDC reports that 48 million inpatient operations were performed in the United States in 2009. In the last 25 years, not a single case of proven (or unproven) transmission of any disease by surgical smoke has been diagnosed. Had such a case been found, it no doubt would have made headlines.
The Anesthesia Quality Institute estimates that there are 35,000-45,000 operating rooms in the United States. A smoke evacuation machine costs a minimum of $1000, not including the costs of disposable tubing for every case and filters which need periodic replacement.
Let’s say 40,000 ORs X $1000/smoke evacuator = $40,000,000 to prevent exactly zero cases of disease.
In these economic times, can anyone think of a better place to spend $40,000,000? Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last two years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages 800 page views per day, and he has over 4800 followers on Twitter.