By Chase Doyle

The price for saving lives in the OR could be the healthy lungs of surgical teams.

Mounting evidence indicates that surgical smoke, the byproduct of procedures using electrocautery and other heat-producing devices, may pose a serious risk to health care workers. One study to quantify exposure found that a single day in the OR is the equivalent of smoking up to 30 unfiltered cigarettes,1 and another showed that perioperative nurses reported twice as many respiratory issues as the general population.2

It’s not just exposure to carcinogens that has providers worried. Biological substances considered to be mutagenic and possibly infectious, including malignant cells and viruses, also have been detected in surgical smoke.3 Although the long-term consequences of exposure remain unclear, in the age of COVID-19, many health care workers are finally starting to heed the signal.

It is estimated that 90% of all endoscopic and surgical procedures produce plume, and approximately a half-million health care workers are exposed to laser or electrosurgical smoke each year.4


Laws on Smoke Evacuation

Despite the potential dangers, only two states—Colorado and Rhode Island—have laws requiring that hospitals and ambulatory surgery centers adopt policies to use a smoke evacuation system for surgical procedures that generate surgical smoke. Rhode Island’s law went into effect Jan. 1, 2019, and Colorado’s will take effect May 2021.


During the 2020 Association of periOperative Registered Nurses Virtual Global Surgical Conference, Jennifer Pennock, MS, the senior manager of governmental affairs for AORN, provided an update on surgical smoke evacuation legislation in the rest of the United States.5


This year, legislation has been introduced in eight states: Connecticut, Georgia, Illinois, Iowa, Kentucky, Oregon, Tennessee and Utah. Unfortunately, Ms. Pennock said, COVID-19 had a negative impact on many of these bills, including legislation in New Jersey that was not yet introduced this year but was anticipated.

The pandemic may have delayed legislative efforts in several states, but there are lessons to be learned from the few sessions that have taken place so far, said Ms. Pennock, who noted that the primary opposition to legislation has come from state hospital associations and state chapters of the American College of Surgeons.

“One misconception expressed by policymakers and others is that surgical smoke is not a problem because they were not aware of it before,” Ms. Pennock said. “It’s difficult to introduce a solution to a problem when it’s the first time that legislators are hearing that there even is a problem, and when no complaints have previously been made.”


COVID-19 and Surgical Smoke

Although COVID-19 may have impeded surgical smoke legislation, reducing exposure to surgical smoke has become an even more pressing issue during the pandemic. Mark K. Soliman, MD, a consultant surgeon of the Florida Hospital Cancer Institute and the UF Health Cancer Center, in Gainesville, told OR Management News that although aerosolized SARS-CoV-2 has not yet been isolated in cauterized tissue or surgical smoke, the virus has been detected in peritoneal fluid. Using appropriate protection therefore is imperative until proven otherwise.

“There’s no doubt that COVID-19 [virus] has been detected in ascites, which is a big deal,” Dr. Soliman said. “A lot of this remains speculative, but for minimally invasive surgery, you have to maintain a closed circuit with proper filtrations. If you don’t have proper filtration, then you are putting people theoretically at risk.”

That does not mean minimally invasive surgery is more hazardous than traditional surgery amid the current crisis. In fact, because the operations are performed within a confined space, minimally invasive surgery may be the safer option if surgery cannot be delayed, according to Dr. Soliman.


“When a closed circuit is maintained within the intraabdominal environment, there is a chamber in which all the smoke is contained, and there are only a few points of exit called the trocar sites,” Dr. Soliman explained. “If the surgical team controls smoke evacuation, minimally invasive surgery may be the way to go.”

Although it may have taken surgeons a long time to recognize and acknowledge the risks associated with surgical smoke, the pandemic is finally giving the issue the attention it deserves, according to Dr. Soliman.

“Surgical smoke is one of those things that surgeons, myself included, have been completely blind to,” he noted. “I didn’t even consider it, truthfully. It wasn’t until COVID-19 that we actually started doing more research, discussing the issue, and being more thoughtful about the problem.”

Now, Dr. Soliman and his colleagues are taking all the necessary precautions.

“The days of casually walking into an OR as a buddy of mine is operating and chatting with a mask on are gone,” he concluded. “Until we have better data and more robust clinical trials looking at this, I think we need to proceed with maximal caution as opposed to ignorance.”



  1. Hills DS, O’Neill JK, Powell RJ. Surgical smoke a health hazard in the operating theatre: a study to quantify exposure and a survey of the use of smoke extractor systems in UK plastic surgery units. J Plast Reconstr Aesthet Surg. 2012;65(7):911-916.
  2. Ball K. Compliance with surgical smoke evacuation guidelines: implications for practice. ORNAC J. 2012;30(1):14-16, 18-19, 35-37.
  3. Liu Y, Song Y, Hu X, et al. Awareness of surgical smoke hazards and enhancement of surgical smoke prevention among the gynecologists. J Cancer. 2019;10(12):2788-2799.
  4. Steege AL, Boiano JM, Sweeney MH. Secondhand smoke in the operating room? Precautionary practices lacking for surgical smoke. Am J Ind Med. 2016;59(11):1020-1031.
  5. Pennock J. When the smoke clears: advocating for surgical smoke evacuation policy. 2020 Virtual AORN Global Surgical Conference & Expo.