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Surgical smoke danger: time for consistent policy and practice.



Electrosurgical units (ESU) have been used in the surgical world for almost a century with newer models being developed periodically for similar use. Many surgical procedures use the integral ESU to coagulate, cut, vaporise or ablate, generating some level of surgical plume. However, where there is use of the remarkable life-saving machinery, there will be the hazard of the surgical plume which it emits.

Questions surrounding healthcare staff's exposure to the hazards of smoke plume is seeing greater uptake. The policy of the ESU itself remains up to date with its education on par with international standards, yet a number of District Health Boards' (DHB) in New Zealand have no Surgical Smoke Evacuation Policy.

The clinical services policy on electrosurgical smoke evacuation of Mercy Hospital in Dunedin (Mercy Hospital, 2014) is reviewed in the hope that management of surgical plume will soon be presented at DHBs as an entity with its own policy, protecting staff and patients from the hazards of surgical plume.

As this is a sentinel approach in attempting to incorporate the management of Surgical Smoke in all the DHB policy manuals, a questionnaire consisting of 12 questions was developed and randomly circulated to 40 theatre staff. The statistical findings of this questionnaire will form the backbone in understanding the level of awareness of DHB staff to the hazards of surgical plume and their knowledge of existing policy with the statistics and tool used presented in this paper. A comparison is made between documented policy and practice of Mercy Hospital, (2014) and what is normal practice at the author's District Health Board.

Quality improvement

Clinical guidelines are meant to assist in decision making in patient care, ultimately achieving best patient outcome. However, there may be discrepancies between the said guidelines and day-to-day practice. Quality improvement is paramount in a perioperative setting as it improves standards of patient care. Although research in the adherence to guidelines helps us assess the possible barriers and reasons for noncompliance, informed evidence-based research will be what propels quality improvement, influencing hospitals to review and revise their approach to patient care (Hoeks, Bouw & Poldermans, 2011).

The surgical environment is constantly evolving with the development of better equipment, or the latest techniques being implemented by surgeons. With these changes there is the need to analyse the outcome of the change. The use of audit tools, questionnaires, observation and focus groups will encourage revision in clinical guidelines or even change the healthcare system and such tools indicate the efforts and engagement in quality improvement (Longenecker, Longenecker & Gering, 2014).

It has been over four decades since documentation of the hazards of surgical plume surfaced, coupled with evidence and recommendations by different organisations (Ulmer, 2008). However, to date in New Zealand there have not been any standardised requirements in surgical plume evacuation.


In 2011 the Ministry of Health in New Zealand commenced its campaign towards a smoke-free nation, the target year being 2025. This need for a safer environment with a healthier lifestyle should also be applicable to healthcare workers in their work environment. The Government's workplace health and safety strategy focuses on safe working conditions and called for improved work practices and systems (Dyson, 2005). This paper with its researched evidence on the hazards of smoke plume inhalation will ideally be a determining factor in steering policy makers to include this issue in our organisations' policy.

Ball (2010), stated that not only is smoke plume toxic gas that gives off an offensive odour, but it also includes particulate matter that may be a triggering factor to respiratory complications, carrying pathogens and transmitting them to the exposed surgical team.

The use of ESU, including laser and ultrasonic scalpel, produces gaseous by-products that may contain bio aerosol. These by-products are often termed 'surgical smoke', 'smoke plume', 'aerosol' and 'vapours'. Target cells are heated during the use of the ESU cutting or coagulating, resulting in the rupture and dispersal of fine particles of tissue.

The ultrasonic scalpel produces an aerosol which has a much higher chance of carrying viable and infectious particles as the procedures carried out are usually without the burning process as they use a much lower temperature (Alp, Bijl, Bleichrodt, Hansson & Voss 2006).

The statements

The Occupational Safe and Health Administration (OSHA 2015) states that the gaseous by-product emitted during the use of electrosurgical units may be toxic, containing vapors such as formaldehyde, benzene, cellular materials and viruses. In addition, OSHA (2015) provides recommendations in the usage of smoke evacuators and room suction systems, citing ocular and respiratory tract irritation and even possible mutagenic and carcinogenic effects from exposure to surgical plume.

Bigony (2007) questions why the use of smoke evacuating devices is not normal practice in every operating theatre, given they been shown to be effective in limiting exposure to the noxious gas.

The Association of periOperative Registered Nurses (AORN 2013) and the Australian College of Operating Room Nurses (ACORN 2014) have already produced research-based statements indicating the health risks to the surgical team exposed to surgical smoke.

The National Institute for Occupational Safety and Health (NIOSH, 1996) laid out guidelines for surgical smoke controls almost two decades ago and The International Federation of PeriOperative Nurses (IFPN, 2015) stated that organisations must have policies in place to reduce the exposure to smoke plume in theatres. So if a DHB hospital is equipped with some form of smoke evacuating tools, how diligent are they in using them? Would a policy in place mean a higher percentage of compliance? Healthcare staff are not only responsible for managing the ESU equipment during surgery but also evacuating the smoke produced, as part of ethical responsibility to the patient and to all healthcare staff (Cunnington, 2006).

The survey

The questionnaire was developed and circulated to 40 theatre nurses at a public hospital in New Zealand. No one was required to give any personal details in the survey, maintaining strict anonymity. Any interviews done to collate information for this paper had the full consent of the participants to reveal their names for this project.

The first question looked into the familiarity of staff with regards to the policy. Of the 40 returned surveys, 97.5 per cent of staff were unaware their DHB had no existing policy on surgical smoke evacuation. Only 2.5 per cent stated that they have no concerns at exposure to smoke plume and the same group had no compulsion in wanting the surgeons to use one.


However, the vast majority (97.5 per cent) of respondents were concerned about the hazards of smoke plume exposure in theatre and all in this group indicated that they would prefer the surgeons use some form of smoke evacuating tool. All of the participants felt that the usage of a mask would not be of any protection to theatre staff exposed to smoke plume.

In the survey, the nurses' specialty, the number of years in nursing and the number of years they have been working in theatre was included. With that information, the survey revealed that 95 per cent of the participants have been in theatre for over three years, 75 per cent of whom had never attended any form of teaching on surgical smoke evacuation. In addition, 75 per cent of the participants were aware of the different methods of smoke evacuation tools available.

There was also great awareness (75 per cent of respondents) of health issues regarding exposure to surgical smoke, citing potential respiratory issues, throat and ocular cancer. On possible limitations in the usage of smoke evacuating diathermy, 25 per cent cited the loud noise made by the tool as a limitation and 75 per cent stated that it was also cumbersome and not as manoeuvrable as the plain diathermy. Another perceived limitation was the high cost (50 per cent) and 50 per cent stated that the thickness of the tool obscured the vision of the user. Five per cent were unsure of any limitations.

A few of the participants voluntarily indicated there have been attempts to use the smoke evacuation diathermy by surgeons, who since had chosen to revert back to the ones without the suction ability, citing the reasons stated above.

An interview with a surgeon helped to facilitate this paper and discovered the perspective of an urologist who uses the smoke evacuating diathermy. Bax (2015), seemed surprised he was the only surgeon of six consultants and four registrars in his department who used the smoke evacuating diathermy during surgery. He explained that it was the norm in the hospitals where he worked in the United Kingdom as well as Australia. Bax (2015) recalled that the cumbrous nature of the tool and the loud sound were limiting factors, but these issues were surmountable.

A former clinical specialist at the author's DHB and now manager of perioperative services at Nelson Marlborough District Health Board (NMDHB) considers education is essential and often overlooked (Teunissen, 2016).

A Surgical Smoke Policy has recently been adopted at NMDHB and representatives of companies were sent into individual theatres to train and educate surgeons and other staff members on its use and the injurious effects of exposure to surgical plume.

Teunissen (2016) remarked how there was olfactory evidence from the theatres' common corridor, when a particular theatre had on-going surgery without the usage of the smoke evacuating diathermy. She noted how the staff response to surgical smoke included nausea, vomiting and complaints of migraine. Even patients who were wheeled or walked through the corridors were not spared the stench of burning flesh. She did note, however, that advocating and gaining staff support may be more challenging in a bigger hospital with more theatres and implementation of such a policy would inevitably equate to an increase in expenditure (Teunissen, 2016).

Mercy Hospital's policy was used as a baseline comparison with the everyday practice in the theatres of the public hospital where the survey was conducted. Although it may be a difficult task to expect the same policy to be implemented immediately, it is possible to closely duplicate this by substituting equipment currently provided.


Mercy Hospital's policy states that all theatre personnel should be trained in surgical smoke evacuation. Education around surgical plume emitted by the ESU and its hazards will help in promoting the implementation of the policy. AORN has provided generic templates for competency skills along with guideline management in the form of a Surgical Smoke tool kit (AORN, 2015). The Joint Commission (Braun, Tschurtz, Hafiz & Williams 2014) has a research-based protocol which is continuously being revised as new evidence comes to hand. Their current programme, the Hospital Respiratory Protection Program, looks into strategies regarding surgical smoke evacuation, calling for the education of all theatre healthcare staff on the hazards of surgical plume and the use of alternative tools as smoke evacuators, along with clear guidelines and education on its use.

Theatre staff at Mercy Hospital are required to complete an electrosurgical smoke competency annually, which includes watching a PowerPoint presentation on electrosurgical safety, reading the guidelines for electrosurgical plume evacuation as well as completing an online package with an accompanied quiz (Mercy Hospital Policy, 2014). Such an education package could readily be included in the regular teaching sessions for nursing staff in DHB theatres. Interventional strategies may be needed to address staff attitudes toward diathermy plume exposure and the use of protective measures and education may be the key element (Mellor & Hutchinson, 2013).

The objectives of Mercy's policy are to ensure the use of approved evacuation systems when surgical plume is generated. This is clearly in line with the guidelines of Occupation Safety and Health Administration (OSHA) 2015, where it states that all smoke generated has to be evacuated regardless of the amount.

A few theatres in the author's DHB are equipped with ducted surgical smoke evacuating systems, with the remainder armed with access to the portable system, so while education may change the mindset of the surgeons towards compliance, there is no real excuse for the inability to use the system.

For surgeries that emit small amounts of plume like biopsies and skin lesions, Mercy's policy states that a hand-held suction device, with tubing no longer than two metres be positioned no further than 5cm from the site of plume production. This should be used in conjunction with an inline filter with 0.1 micron filtration capability, positioned between the wall suction and the suction canister, to capture odour and any particulate matter. These concur with the standards written by AORN (2013) as well as the guidelines set by OSHA (2015). The IFPN, 2015 also supports this and adds that wall suction of the said filtration capability is to be used if it is the only option available--a position supported by Ulmer (2008) and Mellor and Hutchinson (2013).

The Mercy policy also covers smoke emitted during laparoscopic surgeries, calling for the release of the smoke-filled insufflated gas to be through a filtered system. Many surgeons in the author's DHB find it more convenient to open the tap attached to the laparoscopic trocar devices to release the gas into the environment and clear their vision, rather than to ask for a filter to be connected. This may be due to the fact that the filters are generally not in a surgeon's preference sheet. This is an area which DHB policy makers can look into and perhaps have it listed as part of a laparoscopic setup.

The studies

Ulmer (2008), noted that the risks of surgical smoke exposure for nurses, anaesthetists and anaesthetic technicians by far outweigh that of surgeons due to the number of hours spent in the theatre.

A study of 750 Perioperative Nurses in the United States of America revealed a marked increase in the prevalence of upper respiratory tract infections and asthma amongst the nurses as compared to an average person (Ball, 2008).

Rioux, Garland, Webster & Edward, (2013) presented a case report of Human Papilloma Virus (HPV) positive cancer in two laser surgeons. Both gynaecologists had no evident risk factors--except for the exposure to laser plumes during their years of performing laser ablations as well as loop electrosurgical excision procedures of cervical and vulvar lesions. Both surgeons presented with oropharyngeal squamous cell carcinoma and the report strongly suggests that HPV is transmittable through surgical plume, resulting in subsequent development of squamous cell carcinomas.

A study and analysis of smoke samples emitted during electrosurgery by Al Salaf, Vega-Carrascal, Cunningham, Bloofield & McGrath (2007) demonstrated the presence of carcinogenic and neurotoxic compounds in surgical smoke. Lewin, Brauer & Ostad (2011) stated that their reviewed studies indicated potential for infection and respiratory damage resulting from surgical smoke exposure, recommending diligent use of a high-filtration mask over and above the use of smoke evacuating systems when performing laser surgery or electrocautery.


This paper provides convincing evidence of the hazards of surgical plume produced by the usage of ESU. The Mercy Hospital surgical smoke policy has provided a baseline for comparison to the steps taken in my own DHB. Guidelines by international organisations have been in place for almost two decades and a range of sample surgical smoke policies are available to create change within our organization. Ignorance of the hazards may prove to be the limiting factor in the uptake of smoke evacuation, making education the key. We should not wait for one of our staff to be diagnosed with respiratory disease as a direct consequence of exposure to surgical smoke before bringing the issue into the policy arena.


If risks are highlighted and some form of protective equipment is at hand, an implemented policy and auditing of practice would ensure best practice is followed. Employee safety is paramount within any organisation and is both a moral and legal obligation.

About the author:

Juliana Binte Osman moved to New Zealand from Singapore in 2008. She has more than two decades of nursing experience with eight years in operating theatres. She feels fortunate to be able to balance her two loves; work and her children. However, writing has always been Juliana's passion and this included a compiled account of her first few years as a 'migrant nurse in theatre' on her experiences in volunteer work in Cambodia and Thailand and the years as an Aeromedical nurse. All of these accounts were circulated amongst close friends mainly for amusement. If Juliana isn't with her family or in theatre she can be found doing legal or medical interpreting work. Her first published article appeared in a midwife's journal, Home Birth Matter, in 2009.


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Title Annotation:clinical
Author:Osman, Juliana Binte
Publication:The Dissector: Journal of the Perioperative Nurses College of the New Zealand Nurses Organisation
Article Type:Report
Date:Mar 1, 2016
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