Awareness of surgical smoke risks and assessment of safety practices during the Covid-19 pandemic

Cases of pneumonia of unknown aetiology occurred in the Wuhan city of China in December 2019.¹ It was revealed that the pathogenic agent of pneumonia in these patients was ‘severe acute respiratory syndrome coronavirus 2’ (previously known as 2019-nCoV).² In February 2020, this disease was identified by the WHO as coronavirus disease 2019 (Covid-19).³ The pandemic was declared on 11 March 2020, as the disease continued to spread rapidly and began to appear in the USA, and in parts of Europe. Covid-19 was a new virus and little was known about it. Guidelines were updated in the light of new information and experiences gained everyday. Further updates have continued in the coming months and years.

Operating theatres are high-risk areas with airway or potential splash and contact contamination. In patients with possible or definitive Covid-19, publications related to safe surgical algorithms appeared.⁴

Smoke is a harmful by-product produced using heat-producing tools such as electrocautery, laser, ultrasonic tools, high-speed drills, saws used for surgical smoke, haemostasis, excision and dissection. In the literature, it has been stated that surgical smoke contains dead and living cellular materials, blood particles, bacteria, viruses, toxic gases, vapours (benzene, toluene, carbon monoxide, etc.), and particles that damage the lung.⁵

Surgical smoke threatens the health of both patients and operating room employees due to the harmful substances it contains.⁵ Many international organizations, associations and institutes whose field of study is the safety of employees and patients have included surgical smoke and smoke protection in their core business activities. The Occupational Safety and Health Administration of the US Department of Labour states that approximately 500 000 operating room employees are exposed to surgical smoke every year and emphasizes that surgical smoke should be removed from the operating room properly.⁶ Guidelines developed by organizations such as the Association of Perioperative Registered Nurses, the American National Standards Institute, the Emergency Care Research Institute state that precautions should be taken to protect humans from surgical smoke.

In the literature, there is no evidence yet that Covid-19 can be transmitted through surgical smoke. However, previous studies have shown the presence of different viruses in surgical smoke including Corynebacterium, human papillomavirus (HPV), poliovirus, human immunodeficiency virus and hepatitis B virus.⁷ Although the possibility of disease transmission through surgical smoke exists in humans, few cases have been documented.⁸ Most commonly, HPV transmission has been reported during anogenital surgery. This is probably due to direct contact of the infected area with the electrocautery.⁸

These cases occurred in specialists performing gynaecological surgery without additional risk factors for the disease. In another study, it was revealed that 1 of 5 surgeons and 3 of 5 nurses were positive for HPV after laryngeal and urethral papilloma surgeries, and the detected HPV genotypes were the same as those of the patients.⁹ This suggests that viruses in the blood may be present in surgical smoke. Although the transmission of Covid-19 is currently thought to be mainly through respiratory droplets, there is a theoretical risk of virus aerosolization during surgery.¹⁰

The operating room ventilation system is not the only method of smoke extraction; protection from surgical smoke can also be achieved by local extraction at the site of the surgery or using personal filtration masks. Surgical masks are standard equipment used to protect against microorganisms and aerosol body fluids during the procedure. However, it can only block large droplets or particles larger than 5µ. However, it is known that surgical masks do not protect against surgical smoke because the particle size in surgical smoke is less than 0.1µ. The Covid-19 virus is 0.06–0.14µ in size, and its aerosol particle sizes range from 3–100 nm.

The use of a filtering face piece level 3 mask and face protection was recommended by the WHO for respiratory aerosol-generating procedures (AGPs) such as intubation in a Covid-19 environment. The advice for surgical AGPs, such as the use of high-speed power instruments in the operating room, was not available till the UK Public Health England released their report (PHE) on 27 March 2020.Working in a Covid-19 environment, surgeons should wear level 4 surgical gowns, face shields or goggles, double gloves and FFP2-3 or N95-99 respirator masks. A motorized air-purifying respirator is an alternative to the mask, face shield and goggles, especially if the surgeons fail the mask fit test or are doing a lengthy procedure. However, these devices have a high cost and limited availability. Due to a porous top for air intake, currently available surgical helmets and toga systems may not be the solution. During the current Covid-19 outbreak, it appears that telemedicine may be used as an electronic personal protective equipment (PPE) by minimizing the number of physical contacts and hence the danger of contamination.¹¹

Infection with Covid-19 causes direct mortality and morbidity. During the present pandemic, it is especially important to be safe from electrosurgery-related smoke. This surgical smoke evacuation device/ system is simple to operate and provides a practical and effective means of smoke evacuation during open surgery as well as all cauterization procedures.¹²

In conclusion, it is believed that the ventilation of surgical rooms and surgical masks are not enough to protect from surgical smoke. For this reason, we suggest that individual and institutional awareness should be raised regarding the use of high-filtration masks and smoke evacuation devices in operating rooms.