Biomarker of Surgical Smoke as An Occupational Hazard for Health Care Workers in The Operating Room

Abstract

Surgical smoke generated by electrosurgical and energy-based instruments contains a complex mixture of hazardous substances, including volatile organic compounds (VOCs), polycyclic aromatic hydrocarbons (PAHs), aldehydes, ultrafine particles and viable biological materials such as bacteria and viruses. Due to its highly heterogeneous composition, comprehensive monitoring of all constituents is not feasible because of analytical limitations, cost and the absence of validated biomarkers for many compounds. Therefore, identifying dominant chemical components with available and reliable biomarkers is essential for occupational exposure assessment in operating room personnel. Evidence from multiple studies consistently indicates that benzene, toluene, ethylbenzene and xylene (BTEX) are among the most dominant and relevant VOCs present in surgical smoke. This narrative review aims to identify practical and non-invasive biomarkers for monitoring internal chemical exposure from surgical smoke by synthesizing evidence from human biomonitoring studies focusing on urinary biomarkers. Particular emphasis is placed on BTEX-derived metabolites due to their well-characterized toxicokinetic, biological relevance and the availability of standardized and validated laboratory analytical methods. Urinary S-phenyl mercapturic acid (S-PMA), O-cresol, mandelic acid and methyl hippuric acids (o-, m-, p-MHA) were consistently detected among exposed healthcare workers, especially surgical nurses, indicating systemic absorption despite airborne concentrations generally remaining below occupational exposure limits. These findings suggest that chronic low-level exposure may still pose cumulative health risks. While BTEX biomarkers do not represent the entire toxic burden of surgical smoke, their dominance in smoke composition and the feasibility of reliable laboratory testing support their use as practical biomarkers for occupational health surveillance of medical personnel working in operating rooms. Future research should focus on longitudinal assessment and integrated biomarker panels to strengthen exposure–response evaluation.

Keywords: BTEX, healthcare workers, occupational exposure, PAHs, surgical smoke, urinary biomarkers