Surgeons are constantly exposed to surgical fumes and noxious vapours in the operating theatre. Although theatres are equipped with ventilation and masks are worn, surgeons, anaesthetists and staffs are inevitably exposed to a certain amount of fumes.

The production of surgical fumes

Surgical fumes are produced by electrocautery tools used to dissect tissue and provide haemostasis. Drills, burrs saws, lasers and ultrasonic scalpels are also sources of surgical smoke.

Anaesthetic gases such as nitrous oxide and isoflurane have also been known to cause hepatic, renal and pulmonary toxicity. Surgical fumes have been found to contain a myriad of gases, namely, carbon monoxide, acrylonitrile, hydrogen cyanide and benzene.

Out of these, levels of carbon monoxide have been found to be at levels of 100-1900 parts per million (ppm), which is much higher than the stipulated 35ppm per hour exposure set by the Environmental Agency Protection. The rest are found at levels that reach the safe exposure limits.

Inhalation of surgical smoke may pose a biological hazard

Studies have also shown the growth of viable bacteria from laser plume smoke. One case study reports of a surgeon developing laryngeal papillomatosis after performing a laser procedure on a patient who had anogenital condyloma.

Further studies show that the serotypes of HPV in the surgeon and patient were identical. There is concern regarding the transmission of HIV DNA via surgical smoke when culture cells were able to be infected after exposure. Nevertheless, these cases are rare and further investigation is needed before conclusive evidence can be formulated.

Surgical smoke an unavoidable component in the healthcare environment

Many countries around the world have recognised the issue of air quality in operating theatres. The Nordic countries are amongst the strictest in terms of guidelines in managing surgical smoke.

The UK and Canada both also have guidance documents on the effects of surgical smoke. International associations such as the Association of Operating Room Nurses and the American Society for Laser Medicine and Surgery have both produced position statements that recommend the application of local exhaust ventilation. In Hong Kong, actual legislation is yet to materialise.

Despite that, it is prudent to carry out preventive measures such as minimising the production of surgical smoke, increasing the efficacy of smoke evacuation (ventilation, suction within two inches of surgical site) and utilising effective surgical masks. Furthermore, surgical smoke in the peritoneal cavity produced during laparoscopic surgery may pose a risk to patients. It is recommended that regular ventilation is used to reduce intra-abdominal levels of carbon monoxide and other toxins.

In conclusion, little evidence is available on the long-term effects of surgical smoke for healthcare workers; but it is imperative to take preventive action before permanent effects are encountered. MIMS

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