A 44 year old laser surgeon presented with laryngeal papillomatosis. In situ DNA hybridization of tissue from these tumors revealed human papillomavirus DNA types 6 and 1. Past history revealed that the surgeons had given laser therapy to patients with anogenital condylomas, which are known to harbor the same viral types. These findings suggest that the papillomas in our patients may have been caused by inhaled virus particles present in the laser plume.

The possibility that the laser surgeons might inhale virus particles from the laser vapor during the removal of certain lesions has been pointed out by several authors (3,9,18). The risk, however, is regarded as being low, provided adequate precautions are taken. Safety procedures related to eye protection, smoke evacuator systems, etc. have been established (12,19,20).

Baggish, M. S. and Elbakry, M. (1987). The effects of laser smoke on the lungs of rats. Am J Ostect Gynecol , 156(no?): 1260-1265.

The sequence of long term inhalation of carbon dioxide laser smoke on ten (10) white rats was studied in a three phase experiment. The fine particulate matter resulting from tissue vaporization was deposited in the animals' alveoli, which produced congestive interstitial pneumonia, bronchiolitis, and emphysema. The pathologic findings induced by laser plume are not dissimilar to those resulting from the long term inhalation of other types of particulate matter. The use of an efficient smoke evacuator should offer substantial protection against these normal effects.

Garden, J. M. et. al. (1988). Papillomavirus in the vapor of carbon dioxide laser treated verrucae. JAMA , 259(8):1199-1202.

Hybridization with bovine papillomavirus DNA process revealed intact bovine papillomavirus DNA for all power destinies and energy fluences used. The laser vapor from seven (7) patients undergoing carbon dioxide laser therapy for planter or mosaic verrucae was also collected. Intact human papillomavirus DNA was present in the vapor from two (2) of seven (7) patients. These studies indicate that the intact viral DNA is liberated into the air with the vapor of laser treated verrucae. It would be prudent for all practitioners who use the laser in treating patients with viral infections or conditions associated with viruses to practice extreme care and safety throughout the laser procedure.

Wisniewski, P. M. et. al. (1990). Studies on the transmission of viral disease via the CO2 laser plume and ejecta. Journal of Reproductive Medicine , Vol(number):1117-1123.

While recent reports have noted the presence of viral DNA sequences in the laser plume, no significant effort has been made to study transmission of the virus in vivo via airborne laser debris. Studies were undertaken to identify potential hazards to operating room occupants in gynecologic laser surgery. The studies seem to indicate that:

1:While the surgical suits are contaminated by ejecta, viral transmission via airborne laser debris is unlikely.

2:Viral masks are ineffective in protecting the wearer from inspired virus.

3:Technical improvements aimed at eliminating most of the smoke plume are warranted.

Haskins, K. K., et. al. (1991). "Polymerase chain reaction identification of human papillomavirus DNA in CO2 laser plume from recurrent respiratory papillomatoses". Otolaryngology-Head and Neck Surgery , 191:191-195.

All but one RRP tissue specimen contained HPV-DNA and none of the non-RRF tissues contained HPV-DNA. When HPV was present in vapor, the same HPV type was found in the corresponding tissue specimen. Identification of HPV-DNA in the laser plume raises concern regarding potential risks from exposure to the plume particularly to the endoscopic surgeon and the operating team. The practical concerns and effectiveness of the plume scavenging systems are discussed. Many OR personnel agree that there may be a problem with laser smoke but are not sure if that equates to ESU smoke too.

Hallmo, P., & Naess, O. (1991). Laryngeal papillomatosis with human papillomavirus DNA contracted by a laser surgeon. European Archives of Oto-Rhino-Laryngology. 248 (7):425-7.

A 44 year old laser surgeon presented with laryngeal papillomatosis. In situ DNA hybridization of tissue from these tumors revealed human papillomavirus DNA, types 6 and 1. Past history revealed that the surgeons had conducted laser surgery on patients with anogenital condylomas, which are known to harbor the same viral types. These findings suggest that the papillomas in our patients may be transmitted in the virus particles present in laser plume.

The possibility that the laser surgeons might inhale virus particles from the laser vapor during the removal of certain lesions has been pointed out by several authors. The risk, however, is regarded as being low, provided adequate precautions are taken. Safety procedures related to eye protection, smoke evacuator systems, etc. have been established.

Heinsohn, P., et. al. (1991). Aerosols Created by Some Surgical Power Tools: Particle Size Distribution and Qualitative Hemoglobin Content. Applied Occupational Environmental Hygiene , 6:773-776.

Prompted by the concerns about exposure to blood and other body substances, the possible generation of blood containing aerosols in orthopedic surgical practice was investigated. Common surgical power tools were operated in the laboratory to simulate the aerosols typically generated in common orthopedic procedures. A bone saw, a Hall Air drill, a Shea drill, and electrosurgery were used on bone or tendon while blood was slowly dripped over the operative surface. Particle size distribution was evaluated with a low pressure cascade impactor. Hemoglobin was detected in all samples. Personal sampling is indicated to determine whether inspirable blood aerosols are present in the surgeon's breathing zone during an operation. More studies need to be undertaken because of: The increased incidence of STD's, the epidemic of cancer now infecting one out of every four people, and the inclusive data demanding an answer to:

1. Can viruses be reproduced after traveling on smoke?

2. How much does it take to infect a health care worker?

Chen, C., et. al. (1992). Aerosol penetration through surgical masks. American Journal of Infection Control , 20:177-184.

This study concluded that the mask that has the highest collection efficiency is not necessarily the best mask from the perspective of the filter quality factor, which considers not only the capture efficiency but also the air resistance. Although surgical mask media may be sufficient to remove bacteria exhaled or expelled by health care workers, they may not be sufficient to remove the submicrometer sized aerosols containing pathogens to which these health care workers are potentially exposed.

Many surgeons have realized that blood does aerosolize with whatever else is in the blood and more studies are warranted in this area.

Gatti, J. E., et. al. (1992). The mutagenicity of electrocautery smoke. Plastic and Reconstructive Surgery , 89(5):781-784.

The smoke produced with the electrosurgery knife during reduction mammaplasty was found to be mutagenic to the TA98 strain. The Ames test, an established technique for evaluating the mutagenicity of a substance, was convincingly positive for the smoke collected during the breast surgery. Whether the smoke represents a serious health risk to operating personnel is not known. Development of techniques to limit electrosurgery smoke exposure in the operating room appears to be needed, and surgeons should attempt to minimize their exposure.

American Health Consultants. (1993). Electrosurgical Plume More Dangerous. (1993). Clinical Laser Monthly , 11(3):33-48.

The laser often is criticized because of its plume, yet the plume produced during electrosurgery is more hazardous, emits the same quantity of smoke particles, and isn't scrutinized by regulatory agencies, say laser specialists. Eugene Moss, health physicist at the National Institute for Occupational Safety and Health in Cincinnati, says both laser and electrosurgical smoke contain the same types of mutagenic compounds. "Electrosurgery heats up the tissue more than lasers, so it creates more char," he says. "Although it's the same tissue component, overheating (the tissue) makes it more mutagenic and more dangerous as far as breathing it in."

Researchers in Japan did a study in 1981 which showed that smoke produced during electrosurgery was twice as mutagenic as laser smoke. In the study, the authors compared smoke to laser and electrosurgery smoke. One gram of tissue was treated with the CO2 laser. When smoke was evacuated, it was found to have the same mutagenic potential as smoking three (3) unfiltered cigarettes. With electrosurgery smoke, however, that same gram of tissue was equivalent to six (6) cigarettes.

Gloster, H. M. et. al. (1995). Rish of acquiring human papillomavirus from the plume produced by the carbon dioxide laser in the treatment of warts. Journal of the American Academy of Dermatology, 23(3):436-440.

When warts are grouped together without specification of anatomic site, CO2 laser surgeons are no more likely to acquire warts than a person in the general population. However, human papillomavirus types that cause genital warts seem to have a predilection for infecting the upper airway mucosa, and laser plume containing these viruses may represent more of a hazard to the surgeon.

Bureau of National Affairs, Inc. Blood containing aerosols could expose surgeons to HIV, hepatitis: study. Government Employee Relations Report , 31(1527):1076.

While studies have shown Hepatitis B can be transmitted by aerosol, it is not known whether HIV can, but it is theoretically possible, according to the study. "Data collected in this study indicate that the primary and assistant surgeons are exposed to blood containing aerosols in the operating room," the researchers concluded.