Surgical Smoke in the Era of the COVID-19 Pandemic—Is It Time to Reconsider Policies on Smoke Evacuation?

Abstract

You have accessJournal of UrologyJU Forum1 Oct 2020Surgical Smoke in the Era of the COVID-19 Pandemic—Is It Time to Reconsider Policies on Smoke Evacuation? Jonathan Pavlinec and Li-Ming Su Jonathan PavlinecJonathan Pavlinec Department of Urology, University of Florida College of Medicine, Gainesville, Florida and Li-Ming SuLi-Ming Su Department of Urology, University of Florida College of Medicine, Gainesville, Florida View All Author Informationhttps://doi.org/10.1097/JU.0000000000001142AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail The novel coronavirus outbreak (2019-nCOV) has profoundly impacted surgical practice including urology. Performing surgeries during this pandemic presents risks to the surgical team given the unclear incidence of asymptomatic COVID-19 carriers in the absence of widespread testing. Surgical smoke has long been studied as a potential occupational hazard, with aerosolized isolates including viral particles and carcinogens.1 As COVID-19 has been identified in the respiratory and gastrointestinal system, saliva, sputum and blood, as well as the genitourinary tract, aerosol production during surgery on these tissues is especially relevant given the highly contagious transmissibility of COVID-19. Although viral shedding appears to be limited in urine, viral RNA was detected by reverse transcriptase-polymerase chain reaction in 4 of 58 (6.9%) convalescent COVID-19 positive cases in a recent study.2 There are implications across many common urological operations, particularly those involving bowel (eg bowel reconstruction during cystectomy) and oral access (buccal mucosa graft harvesting for urethroplasty). Specific to minimally invasive procedures, the buildup of surgical smoke in the pneumoperitoneum can concentrate particulates that can be released into the operating room during removal of trocars, specimen extraction or open conversion. Many surgical societies including the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), European Society for Gynaecological Endoscopy, Society of European Robotic Gynaecological Surgery and EAU Robotic Urology Section (ERUS) have acknowledged this potential risk and have released recommendations. In considering the safety of operating room personnel during this pandemic, it is timely to review the impact of surgical smoke not only as a possible route of COVID-19 transmission, but also as an occupational risk. What is the Composition of Surgical Smoke? Surgical smoke represents gaseous byproducts related to tissue cauterization and subsequent thermal necrosis caused by thermal devices (eg lasers, electrocautery, ultrasonic devices). It consists of 95% water/steam and 5% cellular particulate matter (chemicals, blood and tissue particles, viruses and bacteria). Size of particulate produced is dependent upon the thermal device with electrocautery producing the smallest particulate size (0.07 microns) and lasers producing the largest (0.31 microns). Ultrasonic energy can be problematic due to the relatively large volume of surgical smoke produced and the relatively low temperature generated, which may be insufficient to inactivate viruses.3 Different tissue types also vary in the number and size of aerosolized particles generated when cauterized.1 What is the Evidence Suggesting a Risk? Upper and lower airway deposition of aerosolized particulate has been linked to chronic respiratory conditions. Symptoms include headaches, watery eyes, cough, burning throat, nausea, drowsiness, dizziness, sneezing and rhinitis. Particles 5 microns or larger are deposited on the walls of the upper airways and bronchus, while those smaller than 2 microns are deposited in the bronchioles and alveoli. Of note, COVID-19 particles range between 0.06 and 0.14 microns. Standard surgical masks can filter particles only as small as 5 microns, with high filtration laser masks filtering particles as small as 0.1