Accessibility / Report Error

Analysis of electrocautery generated smoke by chromatographic-mass spectrometry

ABSTRACT

Objective:

to analyze the chemical components of the smoke from electrocautery from coagulating muscle and liver tissues of pigs.

Methods:

we collected smoke produced by electrocautery applied to porcine tissue in previously evacuated bottles, with qualitative and quantitative analysis of the compounds present through the hyphenated technique gas chromatography / mass spectrometry.

Results:

there was a majority of decanal aldehyde in the fumes from the subcutaneous, muscle and liver tissues. Fumes of subcutaneous and muscular tissues also showed the presence of hexanal and phenol. In the fumes of subcutaneous and liver tissues we also found toluene and limonene and, finally, nonanal smoke was present in the muscle and liver tissues.

Conclusion:

there is increasing evidence showing that smoke from electrocautery used in subcutaneous, muscle and liver tissue is harmful to human health. Thus, there is need to reduce exposure to it or wear masks with filters capable of retaining these particles.

Keywords:
Smoke. Subcutaneous Tissue. Mass Spectrometry. Chromatography; Gas. Aldehydes.

RESUMO

Objetivo:

analisar quimicamente os componentes da fumaça do eletrocautério, provenientes da coagulação de tecidos, muscular e hepático de suino.

Métodos:

coleta de fumaça produzida por eletrocauterização de tecido porcino em frascos previamente evacuados com análise qualitativa e quantitativa dos compostos presentes, através de técnica hifenada, cromatografia a gás/espectrometria de massas.

Resultados:

houve presença majoritária do aldeído decanal nas fumaças provenientes dos tecidos subcutâneo, muscular e hepático. Fumaças dos tecidos subcutâneo e muscular mostraram também a presença de hexanal e fenol. Nas fumaças dos tecidos subcutâneo e hepático foram encontrados ainda tolueno e limoneno e, por fim, nonanal estava presente nas fumaças dos tecidos muscular e hepático.

Conclusão:

há número crescente de evidências mostrando que fumaça proveniente de eletrocauterização de tecidos subcutâneo, muscular e hepático é nociva à saúde de seres humanos. Portanto, há necessidade de reduzir a exposição a ela ou usar máscara com filtro capaz de reter essas partículas.

Descritores:
Fumaça; Tecido Subcutâneo; Espectrometria de Massas; Cromatografia Gasosa; Aldeídos

INTRODUCTION

Surgical incision, dissection, coagulation and vaporization with electrocautery are widely used and recognized as a major advance in surgical technique. However, these techniques intentionally destroy tissue, creating vapors, popularly known as cautery or surgical smoke (SS)11. Bigony L. Risks associated with exposure to surgical smoke plume: a review of the literature. AORN J. 2007;86(6):1013-20.. This smoke, with characteristic odor and made up of particles with micro and / or submicron size, diffuses in the environment and is inhaled by professional medical staff present in operating rooms. It is produced when the heat reaches the cells, ruptures their membranes and vaporizes its constituents, dispersing them and generating other substances during tissue combustion22. Lewin JM, Brauer JA, Ostad A. Surgical smoke and the dermatologist. J Am Acad Dermatol. 2011;65(3):636-41..

In vitro experiments have demonstrated the smoke constituents from the use of cautery on subcutaneous and prostate tissues, in breast lifting procedures, laparotomy and TURP33. Mowbray N, Ansell J, Warren N, Wall P, Torkington J. Is surgical smoke harmful to theater staff? a systematic review. Surg Endosc. 2013;27(9):3100-7.,44. Weston R, Stephenson RN, Kutarski PW, Parr NJ. Chemical composition of gases surgeons are exposed to during endoscopic urological resections. Urology. 2009;74(5):1152-4.. It is known today that many of these components are toxic, mutagenic, such like the cigarette smoke, the smoke generated by a gram of tissue destroyed equals the one of six cigarettes without filter55. 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. J Plast Reconstr Aesthet Surg. 2012;65(7):911-6..

The constituents present in greater quantities in the smoke of subcutaneous tissue are hydrocarbons and nitrogen compounds, the hydrogen cyanide, formaldehyde, and benzene being the most toxic55. 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. J Plast Reconstr Aesthet Surg. 2012;65(7):911-6.. The number, proportion, the amount and nature of the substances present in the smoke depend on the tissue, on its condition and on the area under treatment with electrocautery, on the duration of the procedure, on the electric power and on the technique used (incision, coagulation, vaporization or dissection)66. Waldron RP, Copeland GP, Murphy AF. Surgical diathermy: a potential hazard. Br J Clin Pract. 1984;38(7-8):283..

Although there is a reasonable number of studies that analyze these constituents, the size and shape of these particles in the smoke, the interference in the surgical field visualization7 and the use of smoke suction88. Schultz L. An analysis of surgical smoke plume components, capture, and evacuation. AORN J. 2014;99(2):289-98., those analyzes were performed only on the subcutaneous tissue. However, electrocautery is widely used in other tissues such as muscle and liver, producing a lot of smoke. Thus, this study aims to comparatively demonstrate which compounds are present in the smoke from three electrocauterized tissue, subcutaneous, muscle and liver, from pigs.

METHODS

The tissue used for the research was from a pig of the Large White breed, which is closest to human tissue55. 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. J Plast Reconstr Aesthet Surg. 2012;65(7):911-6.. The animal had its used approved for teaching and research by the Ethics Committee on Animal Use of the Biology Institute of the Universidade Estadual de Campinas.

The collection was performed at the Experimental Surgery Center of the Universidade Estadual de Campinas, with fresh tissues, using a monopolar electrocautery with 30w power, long enough to produce smoke.

The samples were collected in four vials, previously evacuated and hermetically sealed. One of the vials was used to collect air in the operating room prior to cautery use, serving as a control. In the three other vials we collected smoke from the cautery use, in pure coagulation mode, at the site of its production in the subcutaneous, muscle and liver tissues.

These previously evacuated vials are made from Pyrex glass, provided with a teflon high vacuum tap with a tap screw cap containing silicone septa for the introduction of the needle containing the gas absorbing fiber, and then introduced into the gas chromatograph using helium as the carrier gas. Before the introduction of the samples we performed the chromatogram / mass spectra of the reference (only the fiber) to verify that the peaks relating to the chromatograph eluted samples were not due to the reference. The chromatogram / mass spectra were compared with the chromatogram / mass spectra of the samples library existing in the equipment to identify the substances responsible for chromatographic peaks present in the samples collected.

The equipment used in the analysis was the gas chromatograph (Agilent 7890A model) coupled to the mass spectrometer (Agilent, 5975C model). The technique for sampling was Solid Phase Micro Extraction (SPME) using a needle with SUPELCO, gas-absorbing triple fiber: 50/30mm DVB/CAR/PDMS (polydimethylsiloxane), heated at 100oC for 40 minutes to release the adsorbed compounds.

We tabulated and presented data in a qualitative way, with no statistical study.

RESULTS

The results of each sample components analysis are shown in Tables 1, 2, 3 and 4, being, respectively, the ambient air control sample, subcutaneous, muscle, and liver tissues. Tables indicate chemicals, the percentage area of the chromatographic peak for each compound, its elution time (in minutes), and quality. This last parameter refers to the degree of similarity between the detected substance and the existing compounds in the mass spectrometer database.

Table 1
Compounds present in the ambient air sample.

Table 2
Compounds present in subcutaneous tissue sample.

Table 3
Compounds present in the muscle sample.

Table 4
Compounds present in the liver sample.

We found decanal in all three tissues; common substances in the smokes from subcutaneous and muscle tissues were hexanal and phenol; common compounds in the smokes from subcutaneous and liver tissues were toluene and limonene; and the common compound in the smokes from muscle and liver tissues was nonanal.

DISCUSSION

The aromatic hydrocarbon toluene has been widely found in subcutaneous tissue smoke33. Mowbray N, Ansell J, Warren N, Wall P, Torkington J. Is surgical smoke harmful to theater staff? a systematic review. Surg Endosc. 2013;27(9):3100-7.. However, there was no evidence in the literature of its presence in the smoke from liver tissue. Aldehydes have also been widely cited in the literature as present in subcutaneous tissue smoke and, as shown in this study, are not restricted to it, being also present in the smoke from muscle and liver, in the forms of hexanal, nonanal and decanal. The presence of d-limonene has not been reported in other studies in subcutaneous tissue smoke.

Wenig et al.99. Wenig BL, Stenson KM, Wenig BM, Tracey D. Effects of plume produced by the Nd:YAG laser and electrocautery on the respiratory system. Lasers Surg Med. 1993;13(2):242-5. evaluated cautery smoke exposure in rats and noticed that they were stunned during the exposure period, returning to normal after an exposure-free period. Furthermore, when analyzing the rats' lungs, they observed vessels hypertrophy, cellular congestion and emphysematous changes. They supported the idea that these changes were from exposure to benzene, formaldehyde and acrolein, substances present in the subcutaneous tissue, muscle and liver smoke.

The presence of volatile organic compounds within the smoke, as mentioned by Moot et al.1010. Moot AR, Ledingham KM, Wilson PF, Senthilmohan ST, Lewis DR, Roake J, et al. Composition of volatile organic compounds in diathermy plume as detected by selected ion flow tube mass spectrometry. ANZ J Surg. 2007;77(1-2):20-3., although in low concentrations, can chronically inflict the same health hazards of passive smoking. Furthermore, two compounds identified by this group, hydrogen cyanide and butadiene, are implicated as cardiotoxic and carcinogenic, respectively. They also showed that benzene, butadiene and decene are carcinogenic substances1010. Moot AR, Ledingham KM, Wilson PF, Senthilmohan ST, Lewis DR, Roake J, et al. Composition of volatile organic compounds in diathermy plume as detected by selected ion flow tube mass spectrometry. ANZ J Surg. 2007;77(1-2):20-3..

El Ghawabi et al.1111. El Ghawabi SH, Gaafar MA, El-Saharti AA, Ahmed SH, Malash KK, Fares R. Chronic cyanide exposure: a clinical, radioisotope, and laboratory study. Br J Ind Med. 1975;32(3):215-9. and Chandra et al.12 showed that chronic exposure to low concentrations of hydrocarbons - hexanal, heptanal, octanal, nonanal and decanal - cause headache, weakness, touch and smell changes, lacrimation, salivation, abdominal colic pain and nervous instability. Moreover, Blanc et al.1313. Blanc P, Hogan M, Mallin K, Hryhorczuk D, Hessl S, Bernard B. Cyanide intoxication among silver-reclaiming workers. JAMA. 1985;253(3):367-71. showed that hydrocarbons can lead to deficiency of vitamin B12 and folate and increase in thyroid stimulating hormone (TSH), leading to goiter. Laugesen et al.1414. Laugesen M, Fowles J. Scope for regulation of cigarette smoke toxicity according to brand differences in published toxicant emissions. N Z Med J. 2005;118(1213):U1401., in a review study, stated that in cigarette smoke, the butadiene amounted to 45% of the cancer risk, hydrocarbons corresponded to 89% risk of cardiovascular disease, and acrolein (aldehyde, like the others found in all three tissues) corresponded to 97% risk of lung disease.

There is growing body of evidence that the smoke produced by electrocautery used in biological tissues, be them subcutaneous, muscle or liver, is harmful to the human health. The need to reduce such exposure is evident, whether by suction of this smoke by means of suitable devices or by using surgical instruments that do not generate heat, like some kinds of laser.

ACKNOWLEDGEMENTS

We thank Dr. José Henrique Silveira Virgili for the contribution during the experimental surgery, and the staff of the Experimental Surgery Center.

REFERENCES

  • 1
    Bigony L. Risks associated with exposure to surgical smoke plume: a review of the literature. AORN J. 2007;86(6):1013-20.
  • 2
    Lewin JM, Brauer JA, Ostad A. Surgical smoke and the dermatologist. J Am Acad Dermatol. 2011;65(3):636-41.
  • 3
    Mowbray N, Ansell J, Warren N, Wall P, Torkington J. Is surgical smoke harmful to theater staff? a systematic review. Surg Endosc. 2013;27(9):3100-7.
  • 4
    Weston R, Stephenson RN, Kutarski PW, Parr NJ. Chemical composition of gases surgeons are exposed to during endoscopic urological resections. Urology. 2009;74(5):1152-4.
  • 5
    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. J Plast Reconstr Aesthet Surg. 2012;65(7):911-6.
  • 6
    Waldron RP, Copeland GP, Murphy AF. Surgical diathermy: a potential hazard. Br J Clin Pract. 1984;38(7-8):283.
  • 7
    Weld KJ, Dryer S, Ames CD, Cho K, Hogan C, Lee M, et al. Analysis of surgical smoke produced by various energy-based instruments and effect on laparoscopic visibility. J Endourol. 2007;21(3):347-51.
  • 8
    Schultz L. An analysis of surgical smoke plume components, capture, and evacuation. AORN J. 2014;99(2):289-98.
  • 9
    Wenig BL, Stenson KM, Wenig BM, Tracey D. Effects of plume produced by the Nd:YAG laser and electrocautery on the respiratory system. Lasers Surg Med. 1993;13(2):242-5.
  • 10
    Moot AR, Ledingham KM, Wilson PF, Senthilmohan ST, Lewis DR, Roake J, et al. Composition of volatile organic compounds in diathermy plume as detected by selected ion flow tube mass spectrometry. ANZ J Surg. 2007;77(1-2):20-3.
  • 11
    El Ghawabi SH, Gaafar MA, El-Saharti AA, Ahmed SH, Malash KK, Fares R. Chronic cyanide exposure: a clinical, radioisotope, and laboratory study. Br J Ind Med. 1975;32(3):215-9.
  • 12
    Chandra H, Gupta BN, Bhargava SK, Clerk SH, Mahendra PN. Chronic cyanide exposure--a biochemical and industrial hygiene study. J Anal Toxicol. 1980;4(4):161-5.
  • 13
    Blanc P, Hogan M, Mallin K, Hryhorczuk D, Hessl S, Bernard B. Cyanide intoxication among silver-reclaiming workers. JAMA. 1985;253(3):367-71.
  • 14
    Laugesen M, Fowles J. Scope for regulation of cigarette smoke toxicity according to brand differences in published toxicant emissions. N Z Med J. 2005;118(1213):U1401.
  • Source of funding:

    none.

Publication Dates

  • Publication in this collection
    Mar-Apr 2016

History

  • Received
    29 Nov 2015
  • Accepted
    28 Mar 2016
Colégio Brasileiro de Cirurgiões Rua Visconde de Silva, 52 - 3º andar, 22271- 090 Rio de Janeiro - RJ, Tel.: +55 21 2138-0659, Fax: (55 21) 2286-2595 - Rio de Janeiro - RJ - Brazil
E-mail: revista@cbc.org.br