It is a fascinating hypothetical question to consider what patients would say if they were given some kind of informed consent about being exposed to surgical smoke during their operation. Although the actual risk to patients may be diminishingly small, a line listing the various toxins and mutagenic materials in plume may give them pause.

“If I were lying on a surgical table, it is certainly not something I would want to be exposed to,” says Gayle Davis, director of corporate communications at the Association of periOperative Registered Nurses (AORN).

If a threat to patients was ever established, the stakes would be raised considerably to require surgical plume removal. Given that the occupational threat to healthcare workers still is subject to some lingering debate, assessing the risk to patients still is difficult. However, some researchers have tried to look at the question.

For example, a research team in Poland1 assessed the exposure of patients to organic surgical smoke during laparoscopic cholecystectomy. The selected biomarkers of exposure to surgical smoke included benzene, toluene, ethylbenzene, and xylene. The concentrations of these chemicals in the urine samples were assessed for patients before and after surgical procedures.

“Qualitative analysis of the smoke produced during laparoscopic procedures revealed the presence of a wide variety of potentially toxic chemicals such as benzene, toluene, xylene, dioxins, and other substances,” the authors reported. “Exposure of the patient to emerging chemical compounds is usually a one-time and short-term incident, yet concentrations of benzene and toluene found in the urine were significantly higher after the surgery than before it.”

Another study assessed the risk of surgical site infections, trying to determine if procedures evacuating plume resulted in lower SSI rates than those where the smoke was not removed.

The question was: Since viable bacteria and viruses can survive in the smoke, could they contaminate the surgical wound and cause infection? Clearly the burden of biomaterials was being removed in the experiment, but no statistical significance was found between the infection rates in ORs with smoke and those that removed plume, says lead author Christian DiPaola, MD, a surgeon at the University of Massachusetts Medical School in Worcester.

“Our study was underpowered,” he tells Hospital Employee Health.

The study2 included 1,312 spine surgeries, with cases divided into a control group and and an intervention group that removed surgical smoke.

“Of the 712 cases in the control group, 24 SSIs occurred (11 deep, 13 superficial), for an overall incidence of 3.4%,” DiPaola and colleagues concluded. “Of the 600 cases in the smoke evacuator group, 12 SSIs occurred (8 deep, 4 superficial), for an overall incidence of 2%. The observed difference in SSI incidence was not statistically significant (p = 0.17).”

“The idea is there, but proving it in a study is very hard to do,” he said. “This paper was a way to first consider it as a potential factor. We do all kinds of layers of infection mitigation in everything we practice. You scrub your hands, you sterilize your equipment, there are many layers of infection control practices. We wanted to think about the smoke plume as a potential source. Let’s at least include that as variable for future studies.”


  1. Wesołowski W, Kucharska M, Sapote A, et al. Chemical composition of surgical smoke formed in the abdominal cavity during laparoscopic cholecystectomy – assessment of the risk to the patient. Int J Occup Med Environ Health 2014;27(2):314-325.
  2. Krueger S, Disegna S, DiPaola C. The effect of a surgical smoke evacuation system on surgical site infections of the spine. Clin Microbiol Infect Dis 2018 3:DOI:10.15761/CMID.1000132.