The characterization and removal of surgical smoke produced by electrosurgical and laser devices
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The main focus of this study was to characterize the physical and chemical make-up of ESU and diode laser surgical smoke produced from different tissue types, and the efficacy of the Turbo smoke extractor in reducing smoke particle concentration and bacterial contamination. In characterizing the surgical smoke, germanium prisms impacted with different smoke samples were analyzed using several methods, including scanning electron microscopy (SEM), multiple attenuated internal reflection infrared spectroscopy (MAIR-IR), and contact angle data. Surgical smoke, generated during tissue cutting by electrosurgical (ESU) and laser devices within a static fume hood volume was sampled with an impactor (one-cubic-meter or 35.3 cubic feet was collected in 3.5 minutes). Microbiology analysis was also applied with one-cubic-meter volume of smoke impacted on agar plate samples and incubated for 24 and 48 hours. Particle concentration during smoke production was routinely monitored with particle counting devices, such as the PCM 228 and Aircuity. Representative values for generated surgical smoke peak values were 1.7 billion particles/ft 3of all sizes, with 17 million of these (per ft 3 ) being in the small-particle (PM 2.5 ) respirable range, comprising 98% of the suspended particulate mass of about 200mg/m 3and 5 million particles/ft 3 in the larger respirable range up to 10μm diameter (PM 10 ). Approximately 100,000 particles/ft 3 larger than 10μm diameter were also produced. Operation of the cutting instruments within a 100%RH enclosure, simulating intra-peritoneal surgeries, increased the average particle sizes. Infrared spectroscopy of impactor- collected respirable aerosols revealed these to be predominantly biological lipid (oil) droplets with some accompanying protein content, generally more oil-rich from stomach tissue and more protein-rich from heart tissue. Contact angle analyses showed the collected respirable particle fractions to be surface active, significantly depressing the surface tension of water. Histologically prepared and stained ESU-cut heart tissue sections revealed the smoke source to be mainly from explosive bursting of cellular contents, leaving behind connective tissue fragments surrounding the cut paths. SEM revealed the capability for damaged erythrocytes to also be aerosolized into the PM10 respirable fraction. Only very small numbers of viable bacteria were ejected and detected from the ESU or laser-cut sites of demonstrably bacteria-laden tissues. In experiments employing either ESU at 50W or laser cutting at 1.5W to stomach, heart, and jaw tissues, it was found that there was usually a statistically significant difference in the generation of fewer smoke particles during laser cutting than during ESU cutting, but no statistically significant differences with regard to tissue types. An exception was the increased smoke generation from laser cutting of periosteal jawbone tissue, where application of the cutting laser beam was more direct than for the bulky ESU blade. Across all experiments, it was found that concurrent operation of the commercial surgical smoke filtration unit at the manufacturer's recommended 50% setting was capable of reducing the circulating surgical smoke by 60-90%, depending on placement of the smoke collection tube adjacent to the cutting site. Without statistical significance, it was observed that operation of turbulence-producing filtration units, as well as aerosol impactor units, led to collection of more environmental microbes on sampling agar plates and on adjacent sterile operating instruments, suggesting an influence of increased turbulence on particle deposition. Some residual fine oil and carbon particles, but no viable microbes, emanated from the filtration device itself.
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