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Surgical smoke is formed when energy‐generating devices (ie, electrosurgery units, lasers, powered instruments) raise the intracellular temperature of tissue to at least 100º C (212º F), causing tissue vaporization in the form of surgical smoke. Surgical smoke contains components that are known health hazards, such as benzene, toluene, hydrogen cyanide, formaldehyde, volatile organic compounds, viruses, and bacteria. There have been case reports of human disease tied to the inhalation of surgical smoke; therefore, it is important for perioperative team members to minimize their exposure and patient exposure. In spite of the health risks, many perioperative departments do not consistently and effectively evacuate surgical smoke. This Back to Basics article provides basic steps that perioperative team members can take to protect themselves and their patients from the harm caused by surgical smoke exposure.

BackgroundDuring minimal access surgery, surgical smoke is produced which can potentially be inhaled by the surgical team, leading to several health risks. This smoke can escape from the abdominal cavity into the operating room due to trocar leakage. The trocars and insufflator that are used during surgery influence gas leakage. Therefore, this study compares particle escape from a valveless (Conmed AirSeal iFS), and a conventional (Karl Storz Endoflator) system.Materials and methodsUsing an in vitro model, a conventional and a valveless trocar system were compared. A protocol that simulated various surgical phases was defined to assess the surgical conditions and particle leakage. Insufflation pressures and instrument diameters were varied as these are known to affect gas leakage.ResultsThe conventional trocar leaked during two distinct phases. Removal of the obturator caused a sudden release of particles. During instrument insertion, an average of 211 (IQR 111) particles per second escaped when using the 5 mm diameter instrument. With the 10 mm instrument, 50 (IQR 13) particles per second were measured. With the conventional trocar, a higher abdominal pressure increased particle leakage. The valveless trocar demonstrated a continuously high particle release during all phases. After the obturator was removed, particle escape increased sharply. Particle escape decreased to 1276 (IQR 580) particles per second for the 5 mm instrument insertion, and 1084 (IQR 630) particles per second for 10 mm instrument insertion. With the valveless trocar system, a higher insufflation pressure lowered particle escape.ConclusionsThis study shows that a valveless trocar system releases more particles into the operating room environment than a conventional trocar. During instrument insertion, the leakage through the valveless system is 6 to 20 times higher than the conventional system. With a valveless trocar, leakage decreases with increasing pressure. With both trocar types leakage depends on instrument diameter.

BackgroundDuring laparoscopy, the abdominal cavity is insufflated with carbon dioxide (CO2) that could become contaminated with viruses and surgical smoke. Medical staff is potentially exposed when this gas leaks into the operating room through the instruments and past trocar valves. No detailed studies currently exist that have quantified these leakage pathways. Therefore, the goal of this study was to quantify the gas leakages through trocars and instruments, during minimally invasive procedures.MethodsA model of the surgical environment was created, consisting of a rigid container with an interface for airtight clamping of laparoscopic equipment such as trocars and surgical instruments. The model was insufflated to 15 mm Hg using a pressure generator and a pneumotachograph measured the equipment gas leak. A protocol of several use cases was designed to simulate the motions and forces the surgeon exerts on the trocar during surgery.ResultsTwenty-three individual trocars and twenty-six laparoscopic instruments were measured for leakage under the different conditions of the protocol. Trocar leakages varied between 0 L/min and more than 30 L/min, the instruments revealed a range of leakages between 0 L/min and 5.5 L/min. The results showed that leakage performance varied widely between trocars and instruments and that the performance and location of the valves influenced trocar leakage.ConclusionsWe propose trocar redesigns to overcome specific causes of gas leaks. Moreover, an international testing standard for CO2 leakage for all new trocars and instruments is needed so surgical teams can avoid this potential health hazard when selecting new equipment.

BackgroundSurgical smoke during operation is a well-known health hazard for medical staff. This study aimed to investigate the dynamics of surgical smoke during open surgery or laparoscopic surgery for colorectal disease.MethodsThis study quantitated particulate matter (PM) counts as part of surgical smoke in 31 consecutive patients who underwent colectomy at the Niigata City General Hospital using a laser particle counter. Particles were graded by size as ≤ 2.5 μm PM (PM2.5) or > 2.5 μm PM (large PM). Operative procedures were categorized as either open surgery (n = 14) or laparoscopic surgery (n = 17).ResultsThe median patient age was 72 (range 41–89) years and 58.1% were male. The total PM2.5, PM2.5 per hour, and maximum PM2.5 per minute counts during operation were significantly higher in open surgery than in laparoscopic surgery (P = 0.001, P < 0.001, and P = 0.029, respectively). Large PM counts (total, per hour, and maximum per minute) were also higher in the open surgery group than in the laparoscopic surgery group. The maximum PM2.5 concentration recorded was 38.6 µm/m3, which is considered “unhealthy for sensitive groups” according to the U.S. Environment Protection Agency air quality index standards, if it was a 24-h period mean value.ConclusionExposure to surgical smoke is lower during laparoscopic surgery than during open surgery for colorectal diseases.

PurposeThe purpose of this study is to identify and characterize the literature on surgical smoke, visualize the data and sketch a certain trending outline.MethodsIn the Web of Science Core Collection (WoSCC), all the data were acquired from January 1st 2003 to December 31st 2022. VOSviewer and CiteSpace were employed to visualize data, based on publications, bibliographic coupling, co-citation, or co-authorship relations. Microsoft Excel 2019 was used to comb and categorize all the statistics.ResultA total 363 of journal papers were retrieved. The publication number was in a slow but steady growth between 2003 and 2019, followed by a sharp surge in 2020, and then the publication kept in a productive way. Surgical endoscopy and other interventional techniques was the most active journal on surgical smoke. USA played an important role among all the countries/regions. There were 1847 authors for these 363 papers, among whom 44 authors published more than three articles on surgical smoke. “Surgical smoke”, “covid-19” and “surgery” were the top 3 appeared keywords, while the latest hot-spot keywords were “COVID-19”, “virus”, “transmission”, “exposure” and “risk”. There were 1105 co-cited references and 3786 links appeared in all 363 articles. Among them, 38 references are cited more than 10 times. The most co-cited article was “Detecting hepatitis B virus in surgical smoke emitted during laparoscopic surgery.” Based on the titles of references and calculated by CiteSpace, the top 3 cluster trend network are “laparoscopic surgery”, “COVID-19 pandemic” and “surgical smoke”.ConclusionAccording to bibliometric analysis, the research on surgical smoke has been drawing attention of more scholars in the world. Increasing number of countries or regions added in this field, and among them, USA, Italy, and China has been playing important roles, however, more wide and intense cooperation is still in expectation.

IntroductionSurgical smoke generated through the use of electrical surgical devices poses a risk to the surgeon, medical personnel in the operating room, and the patient by exposing them to environmentally hazardous particulate matter. Previous investigation has shown that surgical smoke leads to an increased risk of pulmonary conditions, circulatory disorders, and irritation of the eyes, nose, and throat. Transmission of infectious disease can occur through inhalation of viral particles, and the presence of carcinogens are also of major concern. The deleterious effects of surgical smoke are well documented in several subspecialties, namely dermatology and general surgery, but there has been little discussion on the topic amongst orthopedic surgeons.MethodsA non-systematic review of the literature was completed with the aim of identifying the major categories of adverse health effects associated with surgical smoke inhalation and offering recommendations to reduce these hazards in the orthopedic surgical community.ResultsThree primary categories of risk associated with surgical smoke inhalation were identified: inflammation, viral/bacterial transmission, and carcinogenicity. In addition, strategies for mitigating risk and best practice recommendations were explored.ConclusionSurgical smoke is an under-recognized occupational hazard within the orthopedic surgery literature. There are several strategies which can be employed to reduce risk. Further investigation is needed to understand the long-term impact of these risks, as well as what can be done to improve the practicality and compliance with protective measures.

BackgroundConcerns regarding the aerosolized transmission of SARS-CoV-2 via SS have caused significant apprehension among surgeons related to the use of minimally invasive surgery (MIS) during the COVID19 pandemic. While a limited number of studies have previously demonstrated the presence of viral material in SS, no comprehensive systematic review exists on the subject of viral transmission in SS.MethodsA systematic review of the literature was conducted as per PRISMA guidelines. MEDLINE, EMBASE, and CENTRAL databases were searched for publications reporting the primary outcome of the presence of viral particles in SS and secondary outcomes of indices suggesting transmission of viable virus particles in SS producing clinically important infection. All human, animal, and in vitro studies which used accepted analytic techniques for viral detection were included. A meta-analysis was not complete due to methodologic heterogeneity and inconsistent reporting of outcomes of interest.Results23 publications addressed the presence of viral components in SS, and 19 (83%) found the presence of viral particles in SS. 21 publications additionally studied the ability of SS to induce clinically relevant infection in host cells, with 9 (43%) demonstrating potential for viral transmission.ConclusionEvidence exists for viral transmission via SS. However, HPV remains the only virus with documented transmission to humans via SS. While meaningful translation into practical guidelines during the COVID pandemic remains challenging, no evidence exists to suggest increased risk in MIS.

Purpose In robot-assisted minimally invasive surgery (RMIS), smoke produced by laser ablation and cauterization causes degradation in the visual quality of the operating field, increasing the difficulty and risk of surgery. Therefore, it is important and meaningful to remove fog or smoke from the endoscopic video to maintain a clear visual field. Methods In this paper, we propose a novel method for surgical smoke removal based on the Swin transformer. Our method firstly uses convolutional neural network to extract shallow features, then uses the Swin transformer block to further extract deep features and finally generates smoke-free images. Results We conduct quantitative and qualitative experiments on the proposed method, and we also validate the desmoking results in the surgical instrument segmentation task. Extensive experiments on synthetic and real dataset show that the proposed approach has good performance and outperforms the state-of-the-art surgical smoke removal methods. Conclusion Our method effectively removes surgical smoke, improves image quality and reduces the risk of RMIS. It provides a clearer visual field for the surgeon, as well as for subsequent visual tasks, such as instrument segmentation, 3D scene reconstruction and surgery automation.

Background Particulate matter (PM) in surgical smoke is known to influence operative vision and poses safety risks to operating personnel. Nebulization, which is effective in promoting the deposition of PM, has not been used to clear laparoscopic surgical smoke. Methods The novel nebulizer was tested for mechanical characteristics and applied to evaluate its feasibility for surgical smoke clearance. Nebulization ( n  = 6) or elimination ( n  = 6) procedures were performed to manage surgical smoke produced by electrocautery hook or ultrasonic scalpel on various tissues of twelve rabbits. Levels of PM in surgical smoke, including the PM1.0, PM2.5, PM10, and total suspended particulate were compared to evaluate emissions from both surgical instruments. In addition, pre-treatment, post-treatment and reduction in PM concentrations were compared between the nebulization and elimination groups. Results The spray cone angle was approximately 70°, and the median particle size was around 25 µm. Laparoscopic visibility was restored with clearance of surgical smoke within 8 s after nebulization. The electrocautery hook produced significantly higher levels of PM compared to the ultrasonic scalpel. The PM concentrations generated by electrocautery hook varied across different tissues, whereas only PM1.0 level differed with the ultrasonic scalpel. The pre-treatment PM concentrations were comparable between both groups. The nebulization group showed a greater reduction in PM concentrations compared to the elimination group, with statistical significance in PM1.0 levels. Consequently, post-treatment PM concentrations were significantly lower in the nebulization group. Similar trends were observed across all target tissues except for omentum. Conclusions Nebulization was an effective method for clearing laparoscopic surgical smoke thereby improving surgical vision and potentially mitigating risks associated with surgical smoke exposure.

In surgery, the surgical smoke generated during tissue dissection and hemostasis can degrade the image quality, affecting tissue visibility and interfering with the further image processing. Developing reliable and interpretable computational imaging methods for restoring smoke‐affected surgical images is crucial, as typical image restoration methods relying on color‐texture information are insufficient. Here a computational polarization imaging method through surgical smoke is demonstrated, including a refined polarization difference estimation based on the discrete electric field direction, and a corresponding prior‐based estimation method, for better parameter estimation and image restoration performance. Results and analyses for ex vivo, the first in vivo animal experiments, and human oral cavity tests show that the proposed method achieves visibility restoration and color recovery of higher quality, and exhibits good generalization across diverse imaging scenarios with interpretability. The method is expected to enhance the precision, safety, and efficiency of advanced image‐guided and robotic surgery. A computational polarization image restoration method that exploits refined polarization difference is proposed and validated through in vivo animal experiments and human oral cavity tests, using a compatible polarization‐resolved endoscope system. The method demonstrates superiority in interpretability, generalizability, visibility, and color restoration, holding the potential to improve the precision, safety, and efficiency of surgical procedures.