Sources and components of volatile organic compounds in breast surgery operating rooms

Surgical smoke and its components, effects, and mitigation: a contemporary review

Energy-based surgical instruments produce surgical smoke, which contains harmful byproducts, such as polycyclic aromatic hydrocarbons, volatile organic compounds, particulate matter, and viable microorganisms. The research setting has shifted from the laboratory to the operating room. However, significant heterogeneity in the methods of detection and placement of samplers, diversity in the tissue operated on, and types of surgeries tested has resulted in variability in detected levels and composition of surgical smoke. State regulation limiting surgical smoke exposure through local evacuators is expanding but has yet to reach the national regulatory level. However, most studies have not shown levels above standard established limits but relatively short bursts of high concentrations of these harmful by-products. This review highlights the limitations of the current research and unsupported conclusions while also suggesting further areas of interest that need more focus to improve Occupational Safety and Health Administration guidelines.

Surgical smoke: a matter of hygiene, toxicology, and occupational health

The use of devices for tissue dissection and hemostasis during surgery is almost unavoidable. Electrically powered devices such as electrocautery, ultrasonic and laser units produce surgical smoke containing more than a thousand different products of combustion. These include large amounts of carcinogenic, mutagenic and potentially teratogenic noxae. The smoke contains particles that range widely in size, even as small as 0.007 µm. Most of the particles (90%) in electrocautery smoke are ≤6.27 µm in size, but surgical masks cannot filter particles smaller than 5 µm. In this situation, 95% of the smoke particles which pass through the mask reach deep into the respiratory tract and frequently cause various symptoms, such as headache, dizziness, nausea, eye and respiratory tract irritation, weakness, and abdominal pain in the acute period. The smoke can transport bacteria and viruses that are mostly between 0.02 µm and 3 µm in size and there is a risk of contamination. Among these viruses, SARS-CoV-2, influenza virus, HIV, HPV, HBV must be considered. The smoke may also carry malignant cells. The long-term effects of the surgical smoke are always ignored, because causality can hardly be clarified in individual cases. The quantity of the smoke changes with the technique of the surgeon, the room ventilation system, the characteristics of the power device used, the energy level at which it is set, and the characteristics of the tissue processed. The surgical team is highly exposed to the smoke, with the surgeon experiencing the highest exposure. However, the severity of exposure differs according to certain factors, e.g., ventilation by laminar or turbulent mixed airflow or smoke evacuation system. In any case, the surgical smoke must be removed from the operation area. The most effective method is to collect the smoke from the source through an aspiration system and to evacuate it outside. Awareness and legal regulations in terms of hygiene, toxicology, as well as occupational health and safety should increase.

Organic toxicants and emerging contaminants in hospital interiors before and during the SARS-CoV2 pandemic: alkanes and PAHs

Indoor pollution and deposition dust (DD), in particular, are acquiring concern, due to long exposure time and importance of intake by humans through contact and ingestion. Hospitals look a special category of sites, owing to peculiar contaminants affecting them and to presence of people prone to adverse effects induced by toxicants. Four in-field campaigns aimed at understanding the chemical composition of DD were performed in five Italian hospitals. Measurements were performed before (autumn 2019), during (spring 2021), and after (winter 2022) the peak of SARS-CoV2 and when restrictions caused by pandemic were revoked (winter 2023). Parallel measurements were made outdoors (2022), as well as in a university and a dwelling. Targeted contaminants were n-alkanes and polycyclic aromatic hydrocarbons (PAHs), while iso- and anteiso-alkanes were analyzed to assess the impact of tobacco smoking. Total n-alkanes ranged from 3.9 ± 2.3 to 20.5 ± 4.2 mg/g, with higher percentages of short chain homologs in 2019. PAHs ranged from 0.24 ± 0.22 to 0.83 ± 0.50 mg/g, with light congeners (≤ 228 a.m.u.) always exceeding the heavy ones (≥ 252 a.m.u.). According to carbon preference indexes, alkanes originated overall from anthropogenic sources. Microorganisms resulted to affect a hospital, and tobacco smoke accounted for ~ 4-20‰ of DD mass. As for PAH sources, the diagnostic concentration ratios suggested the concourse of biological matter burning and vehicle emission. Benzo[a]pyrene equivalent carcinogenic and mutagenic potencies of depositions at hospitals ranged ~ 9-39 μg/g and ~ 15-76 μg/g, respectively, which seems of concern for health. DD composition in hospitals was different from that outside the premises, as well as that found at university and at dwelling.

Comparison of surgical smoke between two approaches for endoscopic thyroidectomy and open thyroidectomy

BACKGROUND

Surgical smoke has been recognized as a potential health risk by an increasing number of researchers. Moreover, the counts of surgical smoke produced during different surgical approaches are different. This study aimed to measure and compare the particulate matter (PM) of surgical smoke generated during open thyroidectomy and two endoscopic approaches for thyroidectomy to provide guidance for safe clinical practices.

METHODS

Forty-eight patients with thyroid cancer admitted to our hospital from June 2020 to December 2021 and treated with different surgical approaches were enrolled in this study. The total and peak counts of PM, dynamic changes, and other characteristics of surgical smoke produced during surgery were recorded. PM was classified as PM_2.5 (size ≤ 2.5 μm) and PM₁₀ (size ≤ 10 μm).

RESULTS

In a single cut, both the peak and total counts of PM_2.5 and PM₁₀ of surgical smoke in the open thyroidectomy group (n = 15) were significantly higher than those in the breast approach endoscopic thyroidectomy with CO₂ insufflation group (n = 15) and the gasless transaxillary endoscopic thyroidectomy group (n = 18) (p < 0.001). Moreover, the latter two groups showed no significant differences in the peak and total counts of PM_2.5 and PM₁₀ (p > 0.05).

CONCLUSION

In thyroid surgery, more surgical smoke is produced during open thyroidectomy than during endoscopic thyroidectomy, while different endoscopic approaches showed no significant difference in surgical smoke production. Thus, endoscopic approaches outperform the open thyroidectomy approach with regard to surgical smoke production.

Electrocautery smoke exposure and efficacy of smoke evacuation systems in minimally invasive and open surgery: a prospective randomized study

Worldwide, health care professionals working in operating rooms (ORs) are exposed to electrocautery smoke on a daily basis. Aims of this study were to determine composition and concentrations of electrocautery smoke in the OR using mass spectrometry. Prospective observational study at a tertiary care academic center, involving 122 surgical procedures of which 84 were 1:1 computer randomized to smoke evacuation system (SES) versus no SES use. Irritating, toxic, carcinogenic and mutagenic VOCs were observed in OR air, with some exceeding permissible exposure limits (OSHA/NIOSH). Mean total concentration of harmful compounds was 272.69 ppb (± 189 ppb) with a maximum total concentration of harmful substances of 8991 ppb (at surgeon level, no SES). Maximum total VOC concentrations were 1.6 ± 1.2 ppm (minimally-invasive surgery) and 2.1 ± 1.5 ppm (open surgery), and total maximum VOC concentrations were 1.8 ± 1.3 ppm at the OR table ‘at surgeon level’ and 1.4 ± 1.0 ppm ‘in OR room air’ away from the operating table. Neither difference was statistically significant. In open surgery, SES significantly reduced maximum concentrations of specific VOCs at surgeon level, including aromatics and aldehydes. Our data indicate relevant exposure of health care professionals to volatile organic compounds in the OR. Surgical technique and distance to cautery devices did not significantly reduce exposure. SES reduced exposure to specific harmful VOC’s during open surgery.

Trial Registration Number: NCT03924206 (clinicaltrials.gov).

1,3-Butadiene: a ubiquitous environmental mutagen and its associations with diseases

1,3-Butadiene (BD) is a petrochemical manufactured in high volumes. It is a human carcinogen and can induce lymphohematopoietic cancers, particularly leukemia, in occupationally-exposed workers. BD is an air pollutant with the major environmental sources being automobile exhaust and tobacco smoke. It is one of the major constituents and is considered the most carcinogenic compound in cigarette smoke. The BD concentrations in urban areas usually vary between 0.01 and 3.3 μg/m³ but can be significantly higher in some microenvironments. For BD exposure of the general population, microenvironments, particularly indoor microenvironments, are the primary determinant and environmental tobacco smoke is the main contributor. BD has high cancer risk and has been ranked the second or the third in the environmental pollutants monitored in most urban areas, with the cancer risks exceeding 10^-5. Mutagenicity/carcinogenicity of BD is mediated by its genotoxic metabolites but the specific metabolite(s) responsible for the effects in humans have not been determined. BD can be bioactivated to yield three mutagenic epoxide metabolites by cytochrome P450 enzymes, or potentially be biotransformed into a mutagenic chlorohydrin by myeloperoxidase, a peroxidase almost specifically present in neutrophils and monocytes. Several urinary BD biomarkers have been developed, among which N-acetyl-S-(4-hydroxy-2-buten-1-yl)-L-cysteine is the most sensitive and is suitable for biomonitoring BD exposure in the general population. Exposure to BD has been associated with leukemia, cardiovascular disease, and possibly reproductive effects, and may be associated with several cancers, autism, and asthma in children. Collectively, BD is a ubiquitous pollutant that has been associated with a range of adverse health effects and diseases with children being a subpopulation with potentially greater susceptibility. Its adverse effects on human health may have been underestimated and more studies are needed.