The Invisible Killer of the Operating Room: How Surgical Smoke Acts as a Toxic Airborne Threat to the Respiratory Fitness, Oncogenic Risk Profile and Occupational Safety of the Surgical Team
DOI:
https://doi.org/10.12775/QS.2026.62.73354Keywords
occupational hazards, surgical smoke, electrosurgery, HPV, workplace safety, smoke evacuation, energy-based devicesAbstract
Background. Surgical smoke is a hazardous byproduct generated by energy-based devices such as electrocautery, lasers, and ultrasonic scalpels during thermal tissue ablation. While water vapor accounts for most of the plume, the remaining portion contains chemical pollutants, particulate matter, and infectious biological agents that may affect the physical health of the surgical team. Operating room personnel are frequently exposed to these substances due to inconsistent safety standards.
Aim. This review analyses the chemical, physical, and biological hazards associated with surgical smoke and evaluates documented health outcomes among surgical personnel and the efficacy of modern protective and evacuation measures.
Material and methods. A review of literature was conducted using PubMed and Google Scholar, with a focus on English-language publications that addressed the chemical and biological composition of the smoke, clinical health outcomes, and the technological efficiency of various filtration and evacuation systems.
Results. Research consistently indicates that surgical plume contains carcinogenic and toxic substances, such as benzene and formaldehyde in concentrations that can exceed occupational exposure limits. Significant evidence shows the potential aerosolization of pathogens such as HPV, Hepatitis B, and coronaviruses. Chronic exposure is associated with a higher risk of severe persistent asthma and various acute symptoms, as well as specific head and neck cancers. While standard surgical masks provide inadequate filtration for submicron particles, N95 respirators and integrated smoke evacuation systems show high capture efficiency.
Conclusions. Surgical smoke represents a substantial oncogenic and infectious risk to operating room staff. To mitigate these hazards, institutional mandates for the use of smoke evacuation technology are necessary, alongside targeted education to improve staff compliance and safety behaviours.
References
1. Borowik JU, Kozak KA, Kuśmierczuk KJ, et al. The advantages and disadvantages of using a CO2 laser in endoscopic treatment of laryngeal cancer: a literature review. Journal of Education, Health and Sport. 2019;9(9):957-965.
doi: http://dx.doi.org/10.5281/zenodo.3462178
2. Lin X, Fan Q, Li R, Chen R, Yang Z, Li Y. Enhancing laparoscopic visibility: efficient surgical smoke clearance innovatively using nebulization technology. BioMedical Engineering Online. 2025;24(1). doi:10.1186/s12938-025-01395-4
3. Hara M, Oda G, Hayashi K, et al. Quantitative Analysis of Small Particles Present in Surgical Smoke Generated During Breast Surgery. Medicina (Lithuania). 2025;61(8). doi:10.3390/medicina61081422
4. Casey VJ, McNamara LM. Instrumental in Surgery: A Narrative Review on Energy-based Surgical Cutting Devices and Surgical Smoke. Annals of Surgery. 2023;278(3). doi:10.1097/SLA.0000000000005816
5. Zhou Y zhi, Wang C qun, Zhou M hua, et al. Surgical smoke: A hidden killer in the operating room. Asian Journal of Surgery. 2023;46(9). doi:10.1016/j.asjsur.2023.03.066
6. Hurst RD, Stewart CL. Hazards of surgical smoke from electrocautery: A critical review of the data. American Journal of Surgery. 2024;233. doi:10.1016/j.amjsurg.2024.02.017
7. Tomaszewska K, Majchrowicz B. Harmful factors at the workplace of an operating nurse. Journal of Education, Health and Sport. 2022;12(7):286-300. doi:10.12775/JEHS.2022.12.07.028.
8. Kocher GJ, Koss AR, Groessl M, et al. Electrocautery smoke exposure and efficacy of smoke evacuation systems in minimally invasive and open surgery: a prospective randomized study. Scientific Reports. 2022;12(1). doi:10.1038/s41598-022-08970-y
9. Benaim EH, Jaspers I. Surgical smoke and its components, effects, and mitigation: a contemporary review. Toxicological Sciences. 2024;198(2). doi:10.1093/toxsci/kfae005
10. Mazur S., Dąbrowska N, Madera M., et al. Asthma - a healthcare, environment and green transformation - associated disease. Quality in Sport. 2024;18:53276. doi:10.12775/QS.2024.18.53276.
11. Meretsky CR, Mahmoodi A, Knecht EM, Popovich J, Schiuma AT. The Impact of Electrocautery Smoke on Surgical Staff and the Efficacy of Normal Surgical Masks Versus N95 Masks. Cureus. Published online 2024. doi:10.7759/cureus.58106
12. Okoshi K, Hida K, Kinoshita K, et al. Measurement of particulate matter 2.5 in surgical smoke and its health hazards. Surgery Today. 2022;52(9). doi:10.1007/s00595-022-02473-z
13. Brüske-Hohlfeld I, Preissler G, Jauch KW, et al. Surgical smoke and ultrafine particles. Journal of Occupational Medicine and Toxicology. 2008;3(1). doi:10.1186/1745-6673-3-31
14. Hardy N, Dalli J, Khan MF, Nolan K, Cahill RA. Aerosols, airflow, and airspace contamination during laparoscopy. British Journal of Surgery. 2021;108(9). doi:10.1093/bjs/znab114
15. Mahdood B, Merajikhah A, Mirzaiee M, Bastami M, Banoueizadeh S. Virus and viral components transmitted through surgical smoke; a silent danger in operating room: a systematic review. BMC Surgery. 2024;24(1). doi:10.1186/s12893-024-02514-z
16. Yokoe T, Kita M, Odaka T, Fujisawa J, Hisamatsu Y, Okada H. Detection of human coronavirus RNA in surgical smoke generated by surgical devices. Journal of Hospital Infection. 2021;117. doi:10.1016/j.jhin.2021.08.022
17. Robertson-More C, Wu T. A knowledge gap unmasked: viral transmission in surgical smoke: a systematic review. Surgical Endoscopy. 2021;35(6). doi:10.1007/s00464-020-08261-5
18. Yan L, Liu Y, Zhang J, Chen X, Li J, Zhu X. In vivo and in vitro study of the potential hazards of surgical smoke during cervical cancer treatment with an ultrasonic scalpel. Gynecologic Oncology. 2022;164(3). doi:10.1016/j.ygyno.2022.01.006
19. Palma S, Gnambs T, Crevenna R, Jordakieva G. Airborne human papillomavirus (HPV) transmission risk during ablation procedures: A systematic review and meta-analysis. Environmental Research. 2021;192. doi:10.1016/j.envres.2020.110437
20. Hallmo P, Naess O. Laryngeal papillomatosis with human papillomavirus DNA contracted by a laser surgeon. European Archives of Oto-rhino-laryngology. 1991;248(7). doi:10.1007/BF01463570
21. Rioux M, Garland A, Webster D, Reardon E. HPV positive tonsillar cancer in two laser surgeons: Case reports. Journal of Otolaryngology - Head and Neck Surgery. 2013;42(NOV). doi:10.1186/1916-0216-42-54
22. Le Moual N, Varraso R, Zock JP, et al. Are operating room nurses at higher risk of severe persistent asthma? The nurse’s health study. Journal of Occupational and Environmental Medicine. 2013;55(8). doi:10.1097/JOM.0b013e318297325b
23. Sisler JD, Shaffer J, Soo JC, et al. In vitro toxicological evaluation of surgical smoke from human tissue. Journal of Occupational Medicine and Toxicology. 2018;13(1). doi:10.1186/s12995-018-0193-x
24. Michaelis M, Hofmann FM, Nienhaus A, Eickmann U. Surgical smoke—hazard perceptions and protective measures in german operating rooms. International Journal of Environmental Research and Public Health. 2020;17(2). doi:10.3390/ijerph17020515
25. Yu CL, Hsieh SI, Lin LH, et al. Factors Associated with Surgical Smoke Self-Protection Behavior of Operating Room Nurses. Healthcare (Switzerland). 2022;10(5). doi:10.3390/healthcare10050965
26. Gao S, Koehler RH, Yermakov M, Grinshpun SA. Performance of facepiece respirators and surgical masks against surgical smoke: Simulated workplace protection factor study. Annals of Occupational Hygiene. 2016;60(5). doi:10.1093/annhyg/mew006
27. Karsai S, Däschlein G. “Smoking guns”: Hazards generated by laser and electrocautery smoke. JDDG: Journal der Deutschen Dermatologischen Gesellschaft. 2012;10(9). doi:10.1111/j.1610-0387.2012.07978.x
28. Dobrogowski M, Wesołowski W, Kucharska M, Sapota A, Pomorski LS. Chemical composition of surgical smoke formed in the abdominal cavity during laparoscopic cholecystectomy - Assessment of the risk to the patient. International Journal of Occupational Medicine and Environmental Health. 2014;27(2). doi:10.2478/s13382-014-0250-3
29. Liu Y, Zhao M, Shao Y, Yan L, Zhu X. Chemical composition of surgical smoke produced during the loop electrosurgical excision procedure when treating cervical intraepithelial neoplasia. World Journal of Surgical Oncology. 2021;19(1). doi:10.1186/s12957-021-02211-8
30. Ha HI, Choi MC, Jung SG, et al. Chemicals in surgical smoke and the efficiency of built-in-filter ports. Journal of the Society of Laparoendoscopic Surgeons. 2019;23(4). doi:10.4293/JSLS.2019.00037
31. Cheng MH, Chiu CH, Chen CT, Chou HH, Pao LH, Wan GH. Sources and components of volatile organic compounds in breast surgery operating rooms. Ecotoxicology and Environmental Safety. 2021;209. doi:10.1016/j.ecoenv.2020.111855
32. Markowska M, Krajewski A, Maciejewska D, Jeleń H, Kaczmarek M, Stachowska E. Qualitative analysis of surgical smoke produced during burn operations. Burns. 2020;46(6). doi:10.1016/j.burns.2020.02.014
33. Li CI, Chou YH, Pai JY, Chen CH, Chiang MC. Investigating surgical smoke in otolaryngology operating rooms. Scientific Reports. 2022;12(1). doi:10.1038/s41598-022-05701-1
34. Kameyama H, Otani T, Yamazaki T, et al. Comparison of surgical smoke between open surgery and laparoscopic surgery for colorectal disease in the COVID-19 era. Surgical Endoscopy. 2022;36(2). doi:10.1007/s00464-021-08394-1
35. Li CI, Pai JY, Chen CH. Characterization of smoke generated during the use of surgical knife in laparotomy surgeries. Journal of the Air and Waste Management Association. 2020;70(3). doi:10.1080/10962247.2020.1717675
36. Hsu FLT, Ho TW, Chang C, Wu JM, Lin MT. Chemical composition of smoke produced by open versus laparoscopic surgery for cholecystectomy. HPB. 2022;24(8). doi:10.1016/j.hpb.2022.02.002
37. Yeganeh A, Hajializade M, Sabagh AP, Athari B, Jamshidi M, Moghtadaei M. Analysis of electrocautery smoke released from the tissues frequently cut in orthopedic surgeries. World Journal of Orthopedics. 2020;11(3). doi:10.5312/WJO.V11.I3.177
38. Morimoto G, Kawahira H, Takayama S, Lefor AK. Chemical Components of Smoke Produced From Versatile Training Tissue Models Using Electrocautery. Simulation in Healthcare. 2022;17(1). doi:10.1097/SIH.0000000000000578
39. Merajikhah A, Imani B, Khazaei S, Bouraghi H. Impact of Surgical Smoke on the Surgical Team and Operating Room Nurses and its Reduction Strategies: A Systematic Review. Iranian Journal of Public Health. 2022;51(1). doi:10.18502/ijph.v51i1.8289
40. Hu X, Zhou Q, Yu J, Wang J, Tu Q, Zhu X. Prevalence of HPV infections in surgical smoke exposed gynecologists. International Archives of Occupational and Environmental Health. 2021;94(1). doi:10.1007/s00420-020-01568-9
41. Zhou Q, Hu X, Zhou J, Zhao M, Zhu X, Zhu X. Human papillomavirus DNA in surgical smoke during cervical loop electrosurgical excision procedures and its impact on the surgeon. Cancer Management and Research. 2019;11. doi:10.2147/CMAR.S201975
42. Cheruiyot I, Sehmi P, Ngure B, et al. Laparoscopic surgery during the COVID-19 pandemic: detection of SARS-COV-2 in abdominal tissues, fluids, and surgical smoke. Langenbeck’s Archives of Surgery. 2021;406(4). doi:10.1007/s00423-021-02142-8
43. Ball K, Gilder RE. A Mixed Method Survey on the Impact of Exposure to Surgical Smoke on Perioperative Nurses. Perioperative Care and Operating Room Management. 2022;26. doi:10.1016/j.pcorm.2021.100232
44. Canicoba ARB, Poveda V de B. Surgical Smoke and Biological Symptoms in Healthcare Professionals and Patients: A Systematic Review. Journal of Perianesthesia Nursing. 2022;37(1). doi:10.1016/j.jopan.2021.06.106
45. Tseng HS, Liu SP, Uang SN, et al. Cancer risk of incremental exposure to polycyclic aromatic hydrocarbons in electrocautery smoke for mastectomy personnel. World Journal of Surgical Oncology. 2014;12(1). doi:10.1186/1477-7819-12-31
46. Atar Y, Salturk Z, Kumral TL, et al. Effects of Smoke Generated by Electrocautery on the Larynx. Journal of Voice. 2017;31(3). doi:10.1016/j.jvoice.2016.05.012
47. Hill DS, O’Neill JK, Powell RJ, Oliver DW. 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. Journal of Plastic, Reconstructive and Aesthetic Surgery. 2012;65(7). doi:10.1016/j.bjps.2012.02.012
48. Gioutsos K, Nguyen TL, Biber U, Enderle MD, Koss A, Kocher GJ. Surgical smoke: Modern mobile smoke evacuation systems improve occupational safety in the operating theatre. Interactive Cardiovascular and Thoracic Surgery. 2022;34(5). doi:10.1093/icvts/ivac024
49. Choi SH, Choi DH, Kang DH, et al. Activated carbon fiber filters could reduce the risk of surgical smoke exposure during laparoscopic surgery: application of volatile organic compounds. Surgical Endoscopy. 2018;32(10). doi:10.1007/s00464-018-6222-0
50. Hahn KY, Kang DW, Azman ZAM, Kim SY, Kim SH. Removal of Hazardous Surgical Smoke Using a Built-in-Filter Trocar: A Study in Laparoscopic Rectal Resection. Surgical Laparoscopy, Endoscopy and Percutaneous Techniques. 2017;27(5). doi:10.1097/SLE.0000000000000459
51. Liu N, Filipp N, Wood KB. The utility of local smoke evacuation in reducing surgical smoke exposure in spine surgery: a prospective self-controlled study. Spine Journal. 2020;20(2). doi:10.1016/j.spinee.2019.09.014
52. Benson SM, Novak DA, Ogg MJ. Proper Use of Surgical N95 Respirators and Surgical Masks in the OR. AORN Journal. 2013;97(4). doi:10.1016/j.aorn.2013.01.015
53. Carr MM, Patel VA, Soo JC, Friend S, Lee EG. Effect of Electrocautery Settings on Particulate Concentrations in Surgical Plume during Tonsillectomy. Otolaryngology - Head and Neck Surgery (United States). 2020;162(6). doi:10.1177/0194599820914275
54. Liu Y, Song Y, Hu X, Yan L, Zhu X. Awareness of surgical smoke hazards and enhancement of surgical smoke prevention among the gynecologists. Journal of Cancer. 2019;10(12). doi:10.7150/jca.31464
55. Chavis S, Wagner V, Becker M, Bowerman MI, Jamias MS. Clearing the Air About Surgical Smoke: An Education Program. AORN Journal. 2016;103(3). doi:10.1016/j.aorn.2016.01.007
56. Edwards BE, Reiman RE. Results of a Survey on Current Surgical Smoke Control Practices. AORN Journal. 2008;87(4). doi:10.1016/j.aorn.2007.11.001
57. York K, Autry M. Surgical smoke: Putting the pieces together to become smoke-free. AORN Journal. 2018;107(6). doi:10.1002/aorn.12149
58. Golda N, Huber A, Gole H. Determining the impact of intraoperative smoke evacuation on the patient experience during outpatient surgery: A randomized controlled trial. Journal of the American Academy of Dermatology. 2018;78(5). doi:10.1016/j.jaad.2017.11.020
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Copyright (c) 2026 Martyna Szepietowska, Dominika Janik, Zuzanna Zapart, Agata Sochocka, Nina Nowicka, Oliwia Zuzanna Gańska, Alicja Sikorska, Jakub Bundyra, Emil Mian, Julia Parda
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