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No Smoking In Theatre Please

No Smoking In Theatre Please

almost 3 years ago by Julie McEwan

smoke plume

Whilst updating myself on industry news I have found an abundance of articles discussing the problem and potential solutions to ‘surgical smoke’. This was an alien term to me so I began to read on with interest.

Surgical smoke is the gaseous by-product produced by electro-surgery, laser tissue ablation, ultrasonic scalpel dissection, high speed drilling or burring, or indeed any procedure completed by means of a surgical device that cuts, coagulates, desiccate, fulgurate or vaporises tissue. 

Advances in technology means these types of instruments are widely available and increasingly utilised across a wider range of operations and the alarming thing is the content of the smoke produced and its effects on the patient, but due to repeated exposure, healthcare professionals. Studies have bench marked the adverse effect of exposure with that of cigarette smoking and the results are worrying. The surgical smoke generated during only one day of plastic surgery procedures was equated to smoking 27-30 cigarettes! It has been concluded by another study that vaporising one gram of tissue by a carbon dioxide laser and using electrosurgical current, produces smoke containing the same harmful chemical by-products that were equivalent to smoking three and six unfiltered cigarettes respectively. The British Journal of Anaesthesia recorded, between April 1st, 2009 and 31st March 2014 39,631,801 surgical procedures and with an estimate that approximately 95% of all surgical procedures produce some degree of surgical smoke, the problem becomes even more serious.

Denmark implemented legislation, way back in 2001 with regards to surgical smoke and the protection of healthcare professionals, dictating that surgical smoke must be promptly removed from the operating room environment, but more importantly from the site of surgery.

This blog will discuss the component parts of surgical smoke, its dangers, current solutions and the stance currently taken by regulatory bodies such as the MHRA, COSHH and BOHS.

Studies have concluded that 95% of the smoke plume produced is simply water, however the other 5% is more insidious. Of this 5% there are 3 different, harmful components; biological, chemical and physical.


The smoke has been shown to contain a variety of biological matter including viable cells, viruses, bacteria, hair particles and blood; and with this the risk of infection. The water vapour in the plume acts as the carrier in the transfer and studies have identified HIV-1, staphylococcus aureus – which can cause skin and respiratory infections and the pathogenic bacteria mycobacterium tuberculosis, within surgical smoke, alongside a confirmed case of human papillomavirus (HPV) being transferred between patient and surgeon, with the exact same DNA viral type being identified in both.


The jury seems to be out on quite how many different chemicals are found within surgical smoke, although a conservative estimate is anywhere from 80 to 150, dependent on study and procedure.

Among these are 16 chemicals that on their own are labelled, ‘priority pollutants’. This list includes known carcinogens benzene and toluene, carbon monoxide and hydrogen cyanide – a poison that is used in chemical weapons. Proximity to these chemicals is not ideal and they are known to have harmful effects. These include respiratory irritation/illness, coughing, head ache and nausea. Not to mention the possibility of aggravating existing respiratory conditions such as asthma. Many of the hazardous chemicals present can also be absorbed through the skin.


The particles within the smoke are so small that once settled they form a dust that can coat instruments within the operating theatre. When the plume is generated it can also affect the visibility in the operating theatre impairing the intricate surgical procedure that is taking place. The main hazard is inhalation and as the particles are so fine they are not obstruction by the lungs filter– overtime this will cause problems more commonly associated with tobacco smokers such as destruction and paralysis of the cilia (minute hairs that line the trachea and move mucus and foreign bodies from the lungs) and related respiratory weaknesses.

Surgical smoke has been found in operating theatres for many years, however it is thought that the visible and fetid smoke that is produced by laser surgery has brought this subject to the fore.

Currently healthcare professionals are opting to use surgical masks to deal with the inhalation of smoke during procedures. It is clear, due to the size of the particles, that to be efficient they will need to be high performance. However, as Denmark has highlighted in their regulations, the most important procedure to have is one to evacuate the smoke as swiftly as possible and for this to begin as close to the surgery site as possible. A mechanical system that uses high strength filters, is endorsed by the Centres for Disease Control and Prevention (CDC) in conjunction with a device to capture smoke at its source. The difficulty with this is the space available at the source and that such a device may impair the surgeon’s ability to manoeuvre as necessary. Other options include a change in the technology and the re-design of laser and electrosurgical equipment to include suction at the tip, or a suction device that can be utilised for the removal of liquids and gases simultaneously to avoid an additional tool in the already crowded space.

Resistance is expected to come in one of two forms; either the resistance to change – whether that be equipment or procedure but also cost. Hopefully the resistance can be overcome once the dangers are fully investigated and understood. Changes to the status quo will be more readily accepted due to the benefits to them personally and even more so if it is spearheaded by them.

The long-term effects will not be understood for some time; however, it is good to see that regulatory bodies are become involved in this issue. Guidance is currently brief, as there are only a small number of peer reviewed studies, but both the Medical and Healthcare Products Regulatory Agency (MHRA) and British Occupational Hygiene Society (BOHS) advocate that exposure to smoke of this kind is best avoided. In the UK, all workers are legally protected from unnecessary exposure to hazardous materials, however it will take time for evidence to be gathered to classify surgical smoke as such.

More Blogs from Julie McEwan

Julie has written numerous interesting and well researched blogs on a wide range of topics related to Medical Devices and Human Factors.  Please click here to read more of Julie's blogs and here to find out more about Julie.