surgical smoke: operating room with doctors around operating table
Surgical smoke is a clear, vapor-like substance that is produced when human tissue is deconstructed by common surgical instruments used in almost every operation. (gpointstudio/Shutterstock)

ATLANTA – The Georgia Legislature is considering a bill that would mandate the use of technology in operating rooms that removes the presence of a by-product known as surgical smoke.

Senate Minority Leader Gloria Butler introduced the legislation last year but did not find enough support to advance it through the chamber. The Senate opted instead to create a study committee on the issue, and following the testimonies and findings of the committee, Butler is once again pushing for the bill to pass.

Surgical smoke is a clear, vapor-like substance that is produced when human tissue is deconstructed by common surgical instruments used in almost every operation. During a surgery, the smoke can permeate an operating room, and equipment is not typically used to remove its presence. The proposed bill would require the use of such equipment in all procedures producing surgical smoke.

The legislation is the result of growing concerns from nursing organizations that surgical smoke poses health risks to those who are exposed. The movement, led by the Association of periOperative Registered Nurses (AORN), has resulted in the adoption of similar legislation in Colorado and Rhode Island already, and Georgia could become the next.

“It’s a hazard, we have known it’s a hazard since the mid ‘70s, and we haven’t done anything about it,” said Doreen Wagner, a member of the AORN and a nurse for over 30 years.

Among the concerns voiced by Wagner and others include an assortment of respiratory issues, including asthma and bronchitis, as well as general irritation, headaches and discomfort after long hours of exposure. Studies have demonstrated these potential hazards, but they have been unable to establish a link between surgical smoke and the more serious outcomes sometimes suggested, such as the development of cancer.

Fierce debate

The Georgia Nursing Association and the local chapters of the AORN feel the data is sufficient to support the mandate of surgical smoke evacuation equipment, but the push has stirred up a fierce debate between nurses and surgeons. Dr. Joe Sharma, vice chair of quality, patient safety and care innovation at the Emory department of surgery and president-elect of the Georgia chapter of the American College of Surgeons, has emerged as a vocal opponent of the legislation.

“We need to be data driven, and we have a tremendous amount of data, but it is being skewed and inappropriately used,” Sharma said.

He specifically cites the lack of randomized controlled trials on the risks of surgical smoke that would constitute level one evidence. Wagner, however, feels that documented risks associated with surgical smoke would make such randomized trials unethical.

Sharma testified against the legislation in the Senate study committee, and has remained staunchly opposed to its advancement this year. Beyond his issues with the available research, he is concerned that the evacuation equipment on the market is clunky, unstandardized and not properly studied.

“We should evaluate this with the same stringency that we would evaluate a device that we put into a patient of mine, or a device I would use to perform surgery,” Sharma said. “And we have not. We have not done that.”

Sharma worries that the smoke evacuation devices currently available do not deliver on advertised results, and could potentially pose a risk to patients because of distracting noises or less precise movements afforded by the surgical tools. While he sees value in understanding any underlying risks, he points to mask usage as an already established method for dealing with the problem.

In response, Wagner refers to studies showing that masks are not 100% effective at preventing the very small particles associated with viruses from entering a person’s respiratory system. Special research attention has been dedicated to the transmission of HPV through surgical smoke after anecdotal reports of it occurring, but the data has been inconsistent, and Sharma contends that his team uses smoke evacuation tools with HPV patients regardless.

“It’s harmful, we’ve known it for a long time, and we’re finally stepping outside of the hospital setting and saying that everybody needs to be protected,” Wagner said.

Still, Wagner feels that thousands of health care workers and nurses exposed to surgical smoke each year are being denied control over their own health by surgeons who won’t adapt to new technology.

“It’s harmful, we’ve known it for a long time, and we’re finally stepping outside of the hospital setting and saying that everybody needs to be protected,” Wagner said.

Views at the national level largely reflect the ongoing debate between Georgia’s surgical and nursing groups. The American College of Surgeons recommended the use of surgical smoke evacuation for procedures involving COVID-19 patients, but has remained unwilling to recommend it generally. Meanwhile, the AORN continues to advocate strongly for broad evacuation mandates in many states across the country, and the National Institute for Occupational Safety and Health has so far supported the use of smoke evacuators.

This is not the first time these two organizations have clashed. In 2016, following the AORN recommendation that disposable bouffant caps be used instead of traditional surgical caps, the American College of Surgeons issued a statement in response claiming that “the skullcap is symbolic of the surgical profession.” That back-and-forth closely resembles the ongoing surgical smoke debate, with similar arguments being made about the level of evidence and the safety of operating room workers.

But while the debate has raged on, the legislation has stalled in the General Assembly. Despite the report of the study committee and the benefit of a Republican cosponsor, the bill has not yet been scheduled for a hearing in the Senate Health and Human Services Committee. As crossover day in the Legislature approaches, which represents the last day bills can be sent from one chamber to another and still hope to pass this year, it becomes more likely that surgical smoke legislation may have to wait a little longer.

Wagner, who had hoped this would be the year, is concerned that continued delays of the bill’s passage will lead to more health problems for nurses and a weakened ability to recruit people to the profession. As a professor of nursing at Kennesaw State University, she believes that protecting nurse’s health is essential to keeping more students interested in the career, especially considering the well-documented nursing shortage in the state.

But Sharma sees the delay as an opportunity to continue expressing his concerns and working toward what he hopes will be a collaborative approach on the issue.

“My strongest recommendation coming out of this is that before we pass any law, do any mandates, let’s sit as a group,” Sharma said. “Let the surgical organizations and the nursing organizations sit as a group and do the analysis together, and I think it will be illuminating for everybody.”

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