Surgical Smoke Evacuation: An Integrative Review With Implications for Practice and Sustainment in the Military Health System

INTRODUCTION: Surgical smoke exposes approximately 500,000 perioperative personnel annually and contains ultrafine particulate matter, carcinogens, and viable biologic material that cannot be fully mitigated by surgical personal protective equipment or N95 respirators. Adequate protection requires removing smoke at the source through smoke evacuation devices and air filtration. Within the Military Health System (MHS), implementation is challenged by staff turnover, equipment variability, knowledge gaps, and competing operational demands. This integrative review synthesizes evidence to inform a quality improvement initiative aimed at optimizing smoke evacuation practices in a Military Treatment Facility.

MATERIALS AND METHODS: An integrative review was conducted using PubMed/MEDLINE, CINAHL, and Embase (2015-2025). Initial searches yielded 486 articles; after removal of duplicates and screening, 44 studies met the inclusion criteria. Two reviewers independently appraised each study using a Rapid Critical Appraisal checklist, with verification by a third reviewer. Data extraction was completed by paired reviewers and synthesized into thematic categories.

RESULTS: Evidence consistently supports source-level removal of surgical smoke using smoke evacuation devices positioned within 2 inches of the surgical site and equipped with ultra-low particulate air filtration. Key barriers included limited knowledge, inconsistent equipment availability, workflow concerns, and a lack of standardized policies. Education interventions, leadership engagement, and multidisciplinary implementation improved compliance. COVID-19 heightened awareness of aerosol hazards, influencing early increases in smoke evacuation use. Despite strong evidence of harm, compliance across healthcare settings remains low, and little research examines long-term sustainment, leadership impacts, or operational considerations unique to the MHS.

CONCLUSION: Evacuation of surgical smoke at the source is the most effective method to protect perioperative staff and patients. Standardized policies, sustained education, leadership support, and integration into MHS workflows are essential to overcoming persistent barriers. Implementing and sustaining smoke evacuation programs across the MHS will enhance force health protection and align military perioperative practice with evolving national safety standards.