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ODU Prof, EVMS Surgeon Conducting Experiments on Surgical Smoke and Its Potential Health Risks

From left to right: Dr. Khaled Sakhel, Brian Agee and Petros Katsioloudis.

A series of experiments related to surgical smoke and its effects is one of the latest collaborations between Old Dominion University and Eastern Virginia Medial School.

Petros Katsioloudis, ODU assistant professor of STEM education and professional studies and director of the department's Industrial Technology Program, has teamed with Dr. Kal Sakhel, assistant professor at the Department of Obstetrics Gynecology and coordinator for the Institute for Minimally Invasive and Robotic Surgery at EVMS, to study the production of surgical smoke by various instruments during operations, and to analyze the content of the smoke to determine what health risks this may pose to surgeons.

Surgical smoke results from the use of energy modalities such as lasers and electro-surgical instruments on human tissue. Katsioloudis and Sakhel will test a variety of instruments that employ ultrasonic, laser, and bipolar and monopolar cautery energy sources.

"Data suggest that surgical smoke can irritate the eyes, which can interfere with vision as well as the upper respiratory tract, resulting in chronic cough, worsening asthma, throat irritation and congestion. It has also been linked to headaches and chronic fatigue," said Sakhel, who is also a practicing minimally invasive gynecologic and robotic surgeon.

Katsioloudis said the collaboration with his friend Sakhel came about by accident - from a conversation about their work after church one day. When Sakhel learned of Katsioloudis' expertise in building scientific equipment, he proposed that they work together to investigate the issues related to surgical smoke, which has been a concern of his for some time. The collaboration also offered an opportunity for the ODU professor to introduce a real-world problem to the students in his STEM 221 and 231 courses, Industrial Materials, and Materials and Processes Technology.

"I told him, 'I can build something for you,'" Katsioloudis said. He then discussed the proposal with his STEM 221 class last fall, and five of the students adopted it as their final class project.

As he and Sakhel envisioned the experiments, the first phase would be to build a device to measure the amount of smoke created by different surgical instruments. Under Katsioloudis' guidance, the students jumped right in.

"We pretty much did the whole thing ourselves," he said. "The students did the brainstorming, coming up with possible solutions, and used what's known in engineering as the design process. Together we identified the limitations of each solution, decided on one, and then built a device and tested it."

One of the students, in fact, Brian Agee, took a second class with Katsioloudis in the spring so that he could continue to work on the project. The end result is a four-liter-volume Plexiglas box equipped with a system that controls vacuum and allows the insertion of pressurized carbon dioxide - to represent what is injected during surgery - a controlled temperature environment, three sites of matrix to help measure the volume of smoke created and a gel port for inserting different types of surgical tools.

Inside the box, which measures approximately 12 inches by 8 inches, is a metal clamp for holding a tissue sample. Three high-speed cameras videotape the smoke that's created when the surgical instrument makes an incision in the sample, which, together with the matrices, help record and measure the amount of smoke inside the box. Katsioloudis and Sakhel have tested the surgical instruments in a clean room at EVMS, using a small piece of chicken as the tissue sample.

The ODU researcher said that once these phase one experiments are completed, he and Sakhel will have data in hand showing which surgical instruments create the greatest - and least - amount of smoke. This information, he said, should be of interest to surgeons because it would give them options for using tools that create a smaller amount of smoke.

Phase two of the experiments involves an examination of the contents of the surgical smoke and their potential effects on surgeons.

"The composition of surgical smoke includes a long list of chemicals, but the ones that are of particular concern are acrylonitrile, hydrogen cyanide, benzene and formaldehyde," Sakhel said. "All of these are carcinogenic and can be absorbed through the skin and lungs. In other words, the donning of facemask will not protect against the harmful effects of these gasses. There have also been reports that surgical smoke can harbor Human Papilloma Virus (HPV) particles and blood fragments with the potential of viral disease transmission to the operator."

Phase two of the experiments will require a modification to the box Katsioloudis and his students built - specifically, the addition of a screen at the top of the box to trap chemicals and particles from the smoke, using a system inside the box that replicates the negative pressure created when a surgeon inhales.

"Depending on the amount and size of those particles, we will send them out to a laboratory for analysis. We want to find out, No. 1, is the amount of those molecules enough to create an issue for somebody inhaling them, and No. 2, are those particles small enough that they can go through the mask the surgeon is wearing," Katsioloudis said.

The ODU researcher said that experiments done in the 1950s indicated that particles from smoke do go through surgical masks, but that the quantity is small and thus not harmful to the surgeon. As Katsioloudis points out, however, the technology back then was limited.

"Today, we have much better microscopes and equipment so we can identify exactly what goes through the masks, and we can also estimate over the career of a surgeon - 20 or 30 years - whether inhaling surgical smoke would pose a health risk or not. Only a small amount of smoke is generated during an operation, but that adds up when you consider that a surgeon could perform as many as 5,000 surgeries over his or her career," Katsioloudis said.

"Right now, they have different fans in operating rooms that clean the air. But a lot of times the surgeon is bending over the incision, and all of that smoke goes straight up toward the face. If we can get to the point where we can show that those particles do travel through the mask, that would be big news, because the previous research is very old."

While no one is suggesting a return to the old days of scalpels and knives, which did not create surgical smoke, the researchers agree that a better method utilizing vacuum aspiration, proper ventilation and filters would be helpful in today's operating rooms.

Phase three of the research project would require additional funding to build a specific piece of equipment that could minimize surgical smoke, Katsioloudis said. For now, though, he and Sakhel are focusing on the tasks at hand. Once phase one is concluded and all the data are analyzed - as early as the end of the fall semester - the two researchers plan to submit an article to a medical journal, and perhaps an engineering journal as well.

From there, they will write a proposal to seek seed funding for phase two, which Katsioloudis hopes to start on during the spring semester. Phase three, he said, would require major funding, and could ultimately result in a patent.

"This has been a very fruitful collaboration between the two schools where health care is benefiting from the engineering know-how of ODU," Sakhel said. "We are excited to see the results of the study and how this may potentially impact operating room practices."

Katsioloudis added: "To be honest, I'm happy that we've gotten to this point. This has been great for the students. Hopefully, there will be other faculty on campus who are interested in working on this project with us."

This article was posted on: November 13, 2011

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