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Is surgical smoke making you sick?

Think again if you think your surgical mask protects you against smoke plume and other by-products of laser and electrosurgery

December 2009 · Vol. 21, No. 12
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The operating room can be a hazardous place—and not just for the patient.

One oft-overlooked danger is exposure to surgical smoke during laser procedures, electrocautery, and electrosurgery. Contrary to widely held belief, the standard surgical mask provides minimal protection against surgical aerosols, particulates, and vapors, said Wendy K. Winer, RN, a surgical first-assistant who specializes in advanced operative laparoscopy and is the director of research and technology development at the Center for Endometriosis Care in Atlanta. Ms. Winer described the hazards of surgical smoke during a presentation at the AAGL annual meeting last month in Orlando, Fla. She is a member of the Association of Perioperative Nurses (AORN) Task Force on Surgical Smoke.

“I think if you asked health-care providers to name their number one defense against smoke in the operating room, most would say a surgical mask,” said Ms. Winer.

What they often don’t realize, she added, is that 77% of particulate matter generated during surgery is smaller than 1.1 microns, and a standard surgical mask is effective against particles 1.1 microns and larger. 1

What are the hazards of surgical smoke?

According to the US Occupational Safety and Health Administration (OSHA), “smoke plume may contain toxic gases and vapors such as benzene, hydrogen cyanide, and formaldehyde, bioaerosols, dead and live cellular material (including blood fragments), and viruses.” 2

Data suggest that the perioperative team’s exposure to a high concentration of smoke may irritate the eyes and upper respiratory tract and interfere with vision, according to OSHA. In addition, smoke may contain toxic gases that could be mutagenic and carcinogenic. 2

Health-care workers who are regularly exposed to surgical smoke may complain of bronchial problems; upper respiratory difficulties such as chronic cough; adult-onset or worsening asthma; headache; fatigue; throat irritation; and congestion, Ms. Winer said.

Energy sources that generate smoke during surgery include monopolar and bipolar electrosurgery units; CO2, Nd:YAG, KTP, and argon lasers; electrosurgery forceps; ultrasonic devices; monopolar and bipolar instrumentation; and some mechanical morcellators, Ms. Winer said.

One frequently cited study found that vaporization of 1 g of tissue using a CO2 laser exposes a health-care worker to the equivalent of three cigarettes of smoke in 15 minutes, and vaporization of 1 g of tissue using electrosurgery produces the equivalent of six cigarettes’ worth of smoke in 15 minutes. 1

Best defense is often ignored

A number of professional organizations, including the American National Standards Institute (ANSI), AORN, and the ECRI Institute, advocate the use of local exhaust ventilation (LEV) during surgical procedures in which smoke is generated. Although OSHA has recognized the hazards posed by surgical smoke, it does not specifically require LEV. Consequently, many ORs see less than universal use.

For example, in a survey of perioperative nurses conducted by researchers from Duke University, Edwards and Reiman found that many surgical facilities fail to use LEV consistently. 3 The survey indicated that smoke evacuation or wall suction was used “always or often” in only:

  • 83% of laser ablation of condyloma or dysplasia
  • 75% of CO2 laser tissue resection
  • 59% of condyloma treatment involving electrosurgery, electrocautery, or diathermy
  • 56% of Nd:YAG laser tissue resection
  • 18% of laparoscopy procedures
  • 8% of standard surgery involving electrosurgery, electrocautery, or diathermy
  • 7% of ultrasonic scalpel procedures. 3

The survey involved 623 respondents, who represented all 50 states and Canada. Respondents described their experiences in regard to surgical smoke and use of LEV for 22 types of medical procedures. Fifty-nine percent of respondents practiced in obstetrics and gynecology.

Among the reasons listed for noncompliance with LEV recommendations were resistance or refusal on the part of the surgeon and excessive noise of the equipment. 3 Intrusiveness of equipment is another frequently cited reason for failure to comply with LEV recommendations, Ms. Winer said.

“I’m in the operating room every day, and I think part of the reason these products aren’t used is because they may be cumbersome or get in the way of surgery.”

You can combat the hazards

Among the options to improve air quality in the OR are:

  • a suction or irrigation device, or both
  • an in-line filter with a suction canister
  • a trocar-attached filter (effectiveness increases with the size of the trocar)
  • a dedicated suction device that attaches to a trocar and is operated via a foot pedal or hand control
  • a device that is connected to insufflation to warm CO2 and withdraw smoke
  • a separate smoke-filtration device
  • improved ventilation in the OR.

More analysis is needed to determine the effectiveness of these devices. In addition, the AORN Task Force on Surgical Smoke “is working closely with industry to develop products that are user-friendly,” Ms. Winer said.

In regard to the surgical mask in particular, a number of companies are working to develop models that are more effective against surgical smoke, she added.

“Part of the problem is that many people don’t wear the masks that we do have appropriately. A lot of times people don’t have the mask tied properly, don’t have it secured around their face properly, or may even wear it under their nose. Even if they do wear their mask appropriately, it’s not as effective as a hood or respirator.”

Compliance is a “huge” issue

The Duke University survey of perioperative nurses indicated that compliance with smoke evacuation recommendations is a “huge issue”—as is lack of education among all health-care providers, Ms. Winer said. “People don’t realize that this is a real risk.”

“At the AAGL, I had a lot physicians come up afterwards telling me of their own personal problems with chronic cough or other respiratory problems that they believe might be because of their exposure to surgical smoke,” she added. “I’ve had gynecologists who have been in practice for many years who say they really think that exposure to surgical smoke is why they have a respiratory problem now. They’re just speculating, of course, but they think that smoke may be the primary contributing factor to their own health concerns or problems.”

“I had a lot of other people tell me, ‘Wow, this is amazing. This information is really scary.’”

Resources on the Web

The Association of Perioperative Nurses (AORN) has created a Surgical Smoke Evacuation Tool Kit that is available at The kit is free to AORN members ($100 for nonmembers) and includes:

  • a PowerPoint presentation on the hazards of surgical smoke
  • a sample competency skills checklist
  • a sample smoke evacuation policy and procedure
  • a bibliography of smoke evacuation articles and research
  • a link to a directory of vendors who sell smoke evacuation equipment, devices, and supplies
  • awareness posters.

For additional information and education, please contact:

Wendy K. Winer, RN, BSN, CNOR
Endoscopic Surgery Specialist
Director of Research and Technology Development
Center for Endometriosis Care
1140 Hammond Drive, Suite F 6220
Atlanta, GA 30328


1. Tomita Y, Mihashi S, Nagata K, et al. Mutagenicity of smoke condensates induced by CO2-laser irradiation and electrocauterization. Mutat Res. 1981;89:145-149.

2. Occupational Safety and Health Administration, US Department of Labor. Hospital eTool. Surgical suite module. Available at: Accessed Nov. 30, 2009.

3. Edwards BE, Reiman RE. Results of a survey on current surgical smoke control practices. AORN J. 2008;87:739-749.

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