Evaluating the Efficacy of Smoke Management Technologies in Laparoscopic Sleeve Gastrectomy: Insights from a Prospective, Single-Centre Comparative Study

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D. Demtröder, Daniel Göhler, Kathrin Oelschlägel, Claudia Jahn-Wolf, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7003137/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 23 Mar, 2026 Read the published version in Scientific Reports → Version 1 posted 10 You are reading this latest preprint version Abstract Background Surgical power devices generate surgical smoke that may contain infectious components. Various technologies have been developed to improve surgical smoke management, but comparative performance data from human studies are limited. Method A prospective, single-centre study was performed for evaluating three smoke management technologies - continuous passive filtration (CPA), electrostatic precipitation (ESP), and continuous active filtration (CAF) - during laparoscopic sleeve gastrectomy in 15 bariatric patients. Surgical smoke concentration was monitored by condensation particle counting and single particle light scattering. Efficiency of intraoperative smoke clearance was assessed by the concentration half-life (T 1/2 ). Secondary outcomes included total CO 2 consumption, intraoperative pressure stability, and intraoperative visibility. Results ESP showed the highest smoke clearance efficiency (T 1/2 = 7.2 s), followed by CAF (18.3 s) and CPF (20.6 s) with significant differences. Total CO 2 consumption was highest for CAF (452.0 L) compared CPF (242.0 L) and ESP (80.1 L). All groups maintained a stable capnoperitoneal pressure and a good/very good intraoperative visibility. Conclusions Electrostatic precipitation showed the lowest CO 2 consumption and significantly higher smoke particle removal efficiency compared to continuous active/passive filtration. All technologies provided good/very good intraoperative visibility and capnoperitoneal pressure stability. Health sciences/Diseases Health sciences/Medical research Laparoscopy gastric sleeve surgical smoke management technologies smoke evacuation electrostatic aerosol precipitation Figures Figure 1 Figure 2 Figure 3 Figure 4 1 Introduction Modern surgery is inextricably linked to the advent of surgical power devices (SPDs), which have improved dissection and hemostasis, reduced operating times, made procedures safer and shortened hospital stays compared to classical surgical instruments ( 1 , 2 ). Unfortunately, the use of SPDs is accompanied by the formation of toxic/mutagenic surgical smoke ( 3 ). Chemical composition, particle size, and amount of surgical smoke depend on the type of operated SPD, the amount of applied energy, and the processed tissue ( 4 , 5 ). Some compounds of surgical smoke may exceed established exposure limits ( 6 – 10 ). A further concern is that surgical smoke can contain viable malignant cells, bacteria and viruses like human papillomavirus and human immunodeficiency virus ( 11 – 14 ). The relevance of the health risk by surgical smoke is reflected in data from US health authorities, which indicate that more than 500,000 US healthcare workers are regularly exposed ( 3 ). To improve intraperitoneal clearance during laparoscopic and robotic surgeries, surgical smoke is often released intentionally into the operating room ( 15 ). Unfortunately, general operating room ventilation is not sufficient to eliminate surgical smoke ( 16 ). Wearing of conventional masks ( 17 ) or masks with higher filtration efficiency like N95/FFP2 or N99/FFP3 ( 18 ) can significantly reduce exposure, but cannot provide absolute safety. Thus, there is broad consensus that the safe management of surgical smoke, particularly in laparoscopic surgery, requires the rigorous use of smoke management technologies ( 19 ). Existing smoke management technologies for laparoscopic surgery based on continuous passive filtration (CPF), continuous active filtration (CAF) or electrostatic precipitation (ESP) ( 20 , 21 ). With the onset of the COVID-19 pandemic, concerns about aerosolisation of virus-containing particles and their potential release from the capnoperitoneum into the operating room led to the suggestion that laparoscopic surgery should be replaced by open surgical interventions if patients are infected by SARS-CoV-2 or if their status is unknown ( 22 ). The lack of data on the efficacy of common smoke management technologies initiated the first comparative preclinical ex-vivo ( 23 ) and in-vivo animal ( 24 ) studies. In these studies, different laparoscopic procedures were performed in order to identify appropriate comparative parameter taking into account both smoke elimination efficiency and freedom of surgery, and rank common smoke management technologies according to their performance. To verify the preclinical findings concerning the performance of surgical smoke management technologies ( 23 , 24 ), the present clinical trial was conducted in patients undergoing laparoscopic gastric sleeve. 2 Materials and Methods 2.1 Legal background Prospective study at the Martinus Hospital, Düsseldorf, Germany, a centre of excellence for bariatric and metabolic surgery. The study was conducted in accordance with the guidelines of the Declaration of Helsinki, and each patient gave oral and written informed consent. Approval was obtained from the Ethics Committee of the Medical Chamber North Rheine, Düsseldorf, Germany (file #2022361). German Clinical Trials Register (file #DRKS00030869). The study was registered on 14 December 2022 prior to the start of the clinical trial ( 25 , 26 ). There were no changes or deviations from the study protocol during or after the end of the trial. 2.2 Patient selection and study group assignment Patients were selected for laparoscopic gastric sleeve ( 27 ) based on national guidelines ( 28 ). Patients were over 18 years of age and had not previously undergone metabolic surgery. The study was conducted on three consecutive days and patients were allocated to one of three study groups (A, B, C) independently of the blinded surgical coordination team. All procedures were performed by the same team of physicians and scrub nurses, with standardised surgical procedures and technical equipment, in accordance with the study protocol. Surgical smoke particle concentration measurements were conducted in the capnoperitoneum, as the data obtained are more valid compared to extraperitoneal measurements and are therefore also representative of the risk of extraperitoneal smoke exposure ( 24 ). The primary endpoint was the efficiency of intraoperative smoke clearance, assessed by half-life (T 1/2 ). Secondary outcomes included total CO 2 consumption, intraoperative pressure stability, visual quality, and operating time. 2.3 Operative setup, volumetry of capnoperitoneum and laparoscopic gastric sleeve Access to the abdominal cavity was obtained in the left upper quadrant by video-assisted (IMAGE1 S 4U RUBINA, OPAL1 NIR/ICG, Karl Storz, Germany) insertion of a 12 mm trocar Kii Optical Access System (T1). All trocars, except the optic trocar in group C, were from Applied Medical, CA-USA. In study groups A and B, the insufflator (Endoflator UI 500, Karl Storz, Germany) and in group C the continuous pressure insufflator (LEXION AP 50/30, Dach Medical Group GmbH, Austria) were connected to T1. During establishment of a capnoperitoneum of 15 mmHg, the intra-abdominal volume was determined for ( 5 , 10 , 15 ) mmHg. Under video-guidance, insertion of a 12 mm trocar in the midline supraumbilical (T2) and in the right upper abdomen (T3). A 15 mm trocar (T5) was placed subxyphoidal and a 5 mm trocar (T4) in the lateral left upper abdomen. In group C, the CO 2 inflow was connected to T2 (12 mm, Insuflow®Port, Dach Medical Group GmbH, Austria) and the outflow to T5 (PneuVIEW®XE, Dach Medical Group GmbH, Austria). In Group A and B, the heated CO 2 insufflation tube was connected to the side valve of T2. Insertion of a 10 mm retractor in T5 to elevate the left liver lobe. Continuous capnoperitoneal pressure monitoring by a precision pressure probe (Almemo 2590-4AS logger with FDA612SR sensor, Ahlborn, Germany) connected to the open side valve of T4. Tissue dissection with an ultrasonic cutter (Sonicision™ 7 Curved Jaw, Medtronic plc, Ireland). For further details on the surgical procedure, refer to existing literature ( 27 ). 2.4 Study groups and smoke management technologies details Intraoperative smoke management technologies were studied in three groups (A, B, C) with 5 patients each. The operational setups are shown in Fig. 1 . group A : continuous passive filtration (CPF) with integrated moisture capture system (Valleylab™ Laparoscopic Smoke Evacuation System, Medtronic plc, Ireland) at maximum flow connected to T5. group B : continuous electrostatic smoke precipitation (ESP) using the Ultravision™ generator with 5 mm Trocar accessory Ionwand TM (Alesi Surgical Ltd., UK) at T4. group C : continuous active filtration (CAF) with continuous pressure insufflator and integrated smoke evacuation (LEXION AP 50/30) in bariatric mode (40 L/min) with inflow at T2 (Insuflow ® Port) and outflow at T5 (PneuVIEW ® XE). 2.5 Aerosol-analytical setup for surgical smoke characterisation The operated aerosol analytical setup (Fig. 2 ) corresponds widely to the intra-abdominal section of a previous setup ( 24 ). Aerosol sampling from the side valve of T1 via a 1.5 m electrical-conductive hose line enveloped by a sterile tube cover (Flexasoft®, CADITEC Medical + Technical GmbH, Germany). For proper instrument operation, the sample flow rate of (0.19 ± 0.04) L/min was i) mixed first with 2.81 L/min of particle-free air for air-like conditions and ii) diluted by an aerosol dilution system (DDS 560, Topas GmbH, Germany) and by particle-free air supplied from instrument exhaust and from a flow-controlled aerosol generator (FCS 249, Topas GmbH, Germany) in idle mode. The overall aerosol dilution factor varied between 29 and 654. Monitoring of particle number concentration was realised by three aerosol-analytical instruments. A condensation particle counter (CPC 3772, TSI Inc., USA) was used for concentrations in the size range of (0.01-10) µm ( 29 ). One (LAP 323, Topas GmbH, Germany) of the two single particle light aerosol spectrometers ( 30 ) monitored concentrations in the size range of (0.15–5) µm, while the other one (OPS 3330, TSI Inc., USA) in the size range of (0.3–10) µm. 2.6 Assessment of intraoperative vision Intraoperative vision at different stages of the surgical intervention was rated by the surgical team (n = 4) using a 5-point Likert scale ( 31 ). In addition, the number of camera cleaning procedures were protocolled. 2.7 Statistical analyses Data are presented as median values with standard deviation and as boxplots (median values with interquartile range (IQR) = Q3 – Q1). Non-parametric variables were analysed with the Kruskal-Wallis test ( 32 ). Significant differences were assessed with the Mann-Whitney test ( 33 , 34 ). A value of p < 0.05 represents for each of the mentioned tests a significant difference. 3 Results 3.1 Patient characteristics, details about surgery and postoperative outcome In total, 15 patients with a male/female ratio of 1:4 were treated. The overall median age, body weight, and body mass index (BMI) were (34 ± 15.4) a, (125 ± 29.6) kg, and (45.7 ± 6.8) kg/m 2 . There were no significant differences between the groups concerning age, and body weight and BMI. The three smoke management technologies were operated intraoperatively without issues. The median duration of surgery was (46 ± 11) min. The postoperative course was uneventful and patients were discharged at home on the third postoperative day. After one year of follow-up, the median total and excess weight loss were (27.2 ± 8.5) % and (66.1 ± 18.1) %, respectively. There was no significant difference between the three study groups. Table 1 summarises the perioperative and 12-month follow-up data. Table 1 Patient characteristics, details about surgery and postoperative outcome. property unit group A group B group C total p A/B p A/C p B/C smoke management technology - CPF ESP CAF - - - - number of patients (male/female) - 5 (0/5) 5 (0/5) 5 (3/2) 15 (3/12) - - - age of patient year 31 ± 18.4 28 ± 5.1 42 ± 18.3 34 ± 15.4 0.174 0.377 0.087 body weight, preoperative kg 116 ± 15.0 125 ± 8.0 170 ± 39.5 125 ± 29.6 0.174 0.059 0.174 body mass index, preoperative kg/m² 43.7 ± 5.5 45 ± 1.4 50.1 ± 8.3 45.7 ± 6.8 0.174 0.024 0.059 duration of surgery min 43 ± 9.2 46 ± 2.7 53 ± 15.4 46 ± 11.3 0.087 0.024 0.001 length of hospital stay day 3 ± 0 3 ± 0 3 ± 0 3 ± 0 1.000 1.000 1.000 body weight, postoperative (1 year) kg 79 ± 7.4 86 ± 7.1 105 ± 31.7 86 ± 25.3 0.232 0.014 0.038 excess body weight loss, postoperative (1 year) % 67.7 ± 10.7 71.9 ± 9.7 43.6 ± 20.7 66.1 ± 18.1 0.377 0.038 0.059 Legend Median values ± standard deviation. CPF = continuous passive filtration, CAF = continuous active filtration, ESP = electrostatic precipitation. 3.2 Capnoperitoneal volume, carbon dioxide consumption and capnoperitoneal stability A cross-group comparison of the determined capnoperitoneal volumes revealed no statistically significant difference; however, significant variations were observed in dependence of the capnoperitoneal pressure. The mean capnoperitoneal volume was determined to be (0.6 ± 0.8) L for 5 mmHg, (3.7 ± 1.5) L for 10 mmHg and (6.0 ± 1.7) L for 15 mmHg (see Fig. S.1). During the entire surgical procedure, the median CO 2 consumption (Fig. 3 a) was (242 ± 39.0) L for group A, (80.1 ± 13.7) L for group B, and (452 ± 87.9) L for group C. The consumption in group C was significantly higher than in groups A and B (p C/B < 0.001; p C/A < 0.001). The same holds true between groups A and B (p A/B < 0.001). The mean CO 2 flow rate (Fig. 3 b) was (5.49 ± 0.34) L/min for group A, (1.93 ± 0.39) L/min for group B and (7.90 ± 0.52) L/min for group C. Differences between the groups were highly significant (p C/B < 0.001, p C/A < 0.001, p B/A < 0.001). Since group B technology does not rely on evacuation, the observed flow rate originates from unintentional leakage and the sample flow rate of (0.19 ± 0.04) L/min for aerosol characterisation. The intraoperative capnoperitoneal pressure (Fig. S.2 b) was (14.3 ± 0.8) mmHg for group A, (15.8 ± 0.7) mmHg for group B and (15.2 ± 0.6) mmHg for group C. Temporal fluctuations (Fig. S.2 a) of the intraoperative capnoperitoneal pressure are an indicator for the capnoperitoneal stability and were evaluated via the coefficient of variation. The overall coefficient of variation of the capnoperitoneal pressure was 5.43% for group A, 4.12% for group B and 4.23% for group C. 3.3 Half-life of particle number concentration to assess surgical smoke elimination Figure 4 a shows the measured intraperitoneal particle number concentration over time for one trial of study group A. To assess the smoke removal efficiency, the concentration half-life T 1/2 was calculated (see Fig. 4 b) according to previous work ( 24 ) from the exponential concentration decrease after use of SPD. The lowest median concentration half-life over all instruments of T 1/2 (B) = (7.2 ± 2.6) s and thus the highest smoke removal efficiency was determined for study group B. Significantly higher (i.e., p B/A (T 1/2 ) = 0.00003, p B/C (T 1/2 ) = 0.00032) median concentration half-life values were determined for group A with T 1/2 (A) = (20.6 ± 8.6) s and group C with T 1/2 (C) = (18.3 ± 9.8) s. No significant difference in the median concentration half-life was be observed between group A and C (p A/C (T 1/2 ) = 0.36). 3.4 Quality of intraoperative visibility and intraoperative camera lens cleaning In general, the intraoperative visibility was rated between “excellent” and “good” over the whole intervention for each study group. According to Fig. S.3, the quality of visibility tended to be rated lower for group A (1.4 ± 0.5) than for group B (1.2 ± 0.4) and group C (1.3 ± 0.5). The lowest total number of camera cleaning procedures per surgical intervention was determined for group C (0.2 ± 0.4), followed by group A (1.2 ± 0.8) and group B (2.4 ± 1.3). During dissection and stapler phase no cleaning was necessary for groups A and C, while group B required 0.4 ± 0.5 procedures (see Fig. S.4). 4 Discussion In view of preclinical data ( 23 , 24 ) this clinical trial was conducted to evaluate the performance of different laparoscopic smoke management technologies. On the example of laparoscopic gastric sleeve, three different technologies were studied: continuous passive filtration (group A), electrostatic smoke precipitation (group B) and continuous active filtration (group C). Performance was evaluated based on half-life (T 1/2 ), capnoperitoneal stability, carbon dioxide consumption and intraoperative visibility. The performance of each technology was evaluated based on several key metrics, including capnoperitoneal stability, CO 2 consumption, smoke particle removal, and intraoperative visibility. A stable capnoperitoneum is imperative for ensuring the safety of laparoscopic surgery. Currently, pressure insufflators are categorized as either pulsatile or steady CO 2 supply systems. The development of steady insufflators has been driven by the need to minimize fluctuations in capnoperitoneal pressure, which can result in unintended movements of the abdominal wall, trocar, and surgical site during procedures ( 24 ). The trade-off of this is a dramatic increase in CO2 flow rate and consumption. In this study, a pulsatile insufflator was used for groups A and B, while a steady insufflator was employed for group C. Significant differences were observed between the study groups regarding both absolute capnoperitoneal pressure (target of 15 mmHg) and fluctuations. Group A exhibited the lowest capnoperitoneal pressure at 14.3 mmHg, followed by group C at 15.2 mmHg, and group B at 15.83 mmHg. Conversely, group B demonstrated the lowest fluctuations in capnoperitoneal pressure at 4.12%, with group C at 4.23% and group A at 5.43%. Despite these differences, the overall deviations between group values were minimal, indicating that capnoperitoneal stability was satisfactory across all technologies. In the context of laparoscopic surgery, the constant supply of CO 2 is of paramount importance due to the inherent losses through the trocars ( 35 ) and to optimize intraoperative visibility by effectively removing surgical smoke, particularly with evacuation-based technologies (groups A and C). The total CO 2 consumption was found to be lowest in group B (80 L), followed by group A (242 L) and group C (452 L). When the duration of each laparoscopic intervention is considered, the CO 2 consumptions can be expressed as flow rates, with group B showing the lowest flow rate at 1.9 L/min, compared to 5.5 L/min for group A and 7.9 L/min for group C. Since group B's smoke removal does not rely on CO 2 evacuation, the observed flow rate primarily reflects unintended leakage. From an economic and environmental perspective, the significantly lower CO 2 requirement for surgical smoke removal via electrostatic precipitation (group B) provides a clear and relevant differentiating factor compared to evacuation-based technologies over evacuation-based technologies (groups A and C). In order to illustrate the relevance of our findings, a simple global approximation will suffice. Assuming that each of the 15 million laparoscopic interventions reported for 2018 ( 36 ) takes at least one hour, the data from this study suggest that replacing evacuation-based surgical smoke management technologies (groups A and C) with electrostatic precipitation (group B) could result in annual savings between 6,000 and 10,000 tons of medical CO 2 . Furthermore, given that the production of 1.0 L of medical CO 2 results in the emission of 0.44 L of non-medical CO 2 , the total CO 2 savings could range from 9,000 to 15,000 tons per year. These data are highly relevant and it is reasonable to assume that the actual CO 2 savings are likely to be even higher, given the significant increase in laparoscopic surgery in recent years. The heavy dependence of the healthcare system on the supply of medical CO 2 was particularly evident during the COVID-19 crisis - an adequate supply of medical CO 2 is a significant risk factor for the safety of surgical patient care. In anticipation of shortages in the supply of medical CO 2 during the COVID-19 crisis, some authorities developed contingency plans to ensure the supply of medical CO 2 to the healthcare system ( 37 ). The half-life T 1/2 (i.e. the time required to reduce the concentration of smoke particles by half) is an appropriate parameter for determining the effectiveness of laparoscopic smoke management technologies in preventing surgical smoke from entering the operating room atmosphere ( 23 , 24 ). The current data confirm the results of the preclinical study, namely that electrostatic precipitation in group B is the most efficient laparoscopic smoke management technology as measured by T 1/2 values. With average CO 2 flows of 5.49 ± 0.34 L/min and 7.9 ± 0.52 L/min, respectively, it is approximately three times more efficient than continuous active and passive filter technology in groups A and C. A potential limitation of this study is the lack of direct comparability between the groups in terms of body mass index (BMI) and gender distribution, which may have influenced the results. Group C was predominantly male, a population known to have more intra-abdominal visceral adipose tissue than females ( 38 , 39 ). This may suggest that the higher BMI in group C may have adversely affected capnoperitoneal pressure stability and intraoperative visibility due to increased smoke particle release from greater visceral fat. However, as the study aimed to evaluate the efficacy of different smoke management techniques and T 1/2 is independent of BMI and visceral fat, the results remain valid and are of clinically relevance. During laparoscopic surgery, CO 2 leaks of varying degrees, intentional or unintentional, occur constantly in the operating room, where the smoke poses a risk to health care workers ( 40 ). However, the rate of smoke particle release leaks into the capnoperitoneum with electrostatic precipitation is significantly lower, by several orders of magnitude, compared to filter-based technologies. This is because a significant portion of the particulate matter released into the capnoperitoneum at the surgical site is rapidly deposited by electrostatic precipitation on the peritoneum or surrounding tissues. Electrostatic precipitation is therefore less likely than filter-based techniques to contaminate the operating room through accidental surgical smoke leakage ( 24 ). It is also important to note that the effectiveness of electrostatic separation depends on the distance between the surgical site and the tip of the ion-emitting electrode. The intensity of the Gaussian field decreases as the cube of the distance increases, meaning that the effectiveness can decrease significantly as the distance from the surgical site to the electrode increases. Therefore, the electrode should be repositioned within the abdominal wall if the surgical field changes. However, if the electrode is placed too close to the surgical site, short circuits may occur if the electrode tip accidentally comes into contact with instruments or tissue. This will result in brief interruptions in smoke evacuation. 5 Conclusion All three techniques effectively eliminate smoke during laparoscopic gastric sleeve surgery while maintaining excellent visibility. Electrostatic smoke removal is the most effective method for managing smoke during the procedure, maintaining a stable capnoperitoneal pressure without extra CO 2 consumption. Abbreviations BMI Body mass index CAF Continuous active filtration COVID-19 Coronavirus disease 2019 CPC Condensation particle counter CPF Continuous passive filtration CPI Continuous pressure insufflator DDS Dynamic Dilution System EAD Electrical Aerosol Detector ESP Electrostatic smoke precipitation FCS Field Calibration System HEPA High efficiency particulate air (filter) LAP Laser Aerosol Particle Size Spectrometer LS Laparoscopic surgery MFC Mass flow controller OPS Optical Particle sizer PNC particle number concentration in air (1/cm 3 ) SARS-CoV-2 Severe acute respiratory syndrome coronavirus type 2 SMT Smoke management technology SPD Surgical power device SPI Standard pressure insufflator Declarations Acknowledgement The authors would like to thank Dach Medical GmbH for generously providing the LEXION AP 50/30 insufflator free of charge, Alesi Surgical for providing the Ultravision™ system, and Medtronic for providing the Valleylab™ smoke filters. We are especially grateful to Topas GmbH in Dresden, Germany, for generously providing and operating the aerosol analytical setup free of charge. In addition, we would like to express our sincere gratitude to the dedicated staff of the Martinus Hospital in Düsseldorf, whose invaluable support was crucial to the success of this study. Author contributions Cédric R.D. Demtröder and Daniel Göhler: conceptualization, data curation, formal analysis, funding acquisition, investigation, methodology, project administration, resources, software, validation, visualization, writing original draft Katrin Oelschlägel: data curation, formal analysis, investigation, review and editing Peter Kirchmeyer, Hülya Agarius, Fabian Kockelmann, Sébastien Roger, Mehdi Ouaissi and Claudia Jahn-Wolf: resources, supervision, review and editing Urs Giger-Pabst and Dmitrij Dajchin: conceptualization, data curation, formal analysis, investigation, methodology, resources, supervision, validation, writing original draft, review and editing Data availability statement Measurement data of the study are available from the corresponding author upon reasonable request. Competing Interests Statement The study was financed with institutional funds of the Martinus Hospital, Düsseldorf and the Association Tourangelle de Recherche en Oncologie du Val de Loire (AT-ROVL). 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Doi: 10.1136/bmj.k120 Iacobucci G Medical care will be prioritised in tackling CO 2 shortages, says government. Brit. Med. J. 2021:n2346. Doi: 10.1136/bmj.n2346 Grauer WO, Moss AA, Cann CE, Goldberg HI Quantification of body fat distribution in the abdomen using computed tomography. The American Journal of Clinical Nutrition 1984;39(4):631–7. Doi: 10.1093/ajcn/39.4.631 Nauli AM, Matin S Why Do Men Accumulate Abdominal Visceral Fat? Frontiers in Physiology 2019;10. Doi: 10.3389/fphys.2019.01486 Zhou Y-z, Wang C-q, Zhou M-h, et al. Surgical smoke: A hidden killer in the operating room. Asian J. Surg. 2023;46(9):3447–54. Doi: 10.1016/j.asjsur.2023.03.066. Additional Declarations No competing interests reported. Supplementary Files surgicalsmokemanagement03supplementaryinformation.doc Cite Share Download PDF Status: Published Journal Publication published 23 Mar, 2026 Read the published version in Scientific Reports → Version 1 posted Editorial decision: Revision requested 14 Oct, 2025 Reviews received at journal 11 Oct, 2025 Reviews received at journal 04 Oct, 2025 Reviewers agreed at journal 01 Oct, 2025 Reviewers agreed at journal 01 Oct, 2025 Reviewers invited by journal 01 Oct, 2025 Editor assigned by journal 19 Sep, 2025 Editor invited by journal 02 Jul, 2025 Submission checks completed at journal 01 Jul, 2025 First submitted to journal 29 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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06:43:22","extension":"html","order_by":13,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":118844,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7003137/v1/cbcede0e236c2eaf896a9273.html"},{"id":93557471,"identity":"951b35b9-a789-4002-a564-a4228a75096f","added_by":"auto","created_at":"2025-10-15 06:51:21","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1462415,"visible":true,"origin":"","legend":"\u003cp\u003eOperative setup and implementation of examined surgical smoke management technologies.\u003c/p\u003e\n\u003cp\u003eGroup A: T1 = aerosol sampling; T2 = CO\u003csub\u003e2\u003c/sub\u003e inflow; T4 = monitoring of capnoperitoneal pressure; T5 = continuous passive filtration (CPF); Group B: T1 = aerosol sampling; T2 = CO\u003csub\u003e2\u003c/sub\u003e inflow; T4 = trocar for electrostatic smoke precipitation (ESP); T5 = monitoring of capnoperitoneal pressure; Group C (continuous active filtration): T1 = aerosol sampling; T2 = CO\u003csub\u003e2 \u003c/sub\u003einflow; T4 = monitoring of capnoperitoneal pressure; T5 = CO\u003csub\u003e2\u003c/sub\u003e outflow.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7003137/v1/3e8b078c033a8fa6c162e4f8.png"},{"id":93558358,"identity":"ad7ff09a-6191-4296-b970-fcc029c20eb5","added_by":"auto","created_at":"2025-10-15 06:59:22","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1490850,"visible":true,"origin":"","legend":"\u003cp\u003ePhotographic image (left) and schematic diagram of the operated aerosol-analytical setup (right).\u003c/p\u003e\n\u003cp\u003eCPC = condensation particle counter; DDS = dynamic dilution system; FCS = field calibration system; LAP = laser aerosol particle size spectrometer, OPS = optical particle sizer.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7003137/v1/77c1027fcf45c5f763d97c36.png"},{"id":93556400,"identity":"9089ba33-3fc0-457f-a78c-a6dedf759a76","added_by":"auto","created_at":"2025-10-15 06:43:22","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":203622,"visible":true,"origin":"","legend":"\u003cp\u003eCumulative carbon dioxide consumption (a) and mean carbon dioxide flow rate (b).\u003c/p\u003e\n\u003cp\u003e(a) = cumulative carbon dioxide consumption during surgery; (b) = mean carbon dioxide flow rate. A = group A (continuous passive filtration); B = group B (continuous electrostatic smoke precipitation); C = group C (continuous active filtration). ** = p \u0026lt; 0.01\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7003137/v1/adb7d45f476ad3d96e95f05d.png"},{"id":93557474,"identity":"ff228b1b-6f3d-4033-980e-a89ba62c36f6","added_by":"auto","created_at":"2025-10-15 06:51:22","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":244769,"visible":true,"origin":"","legend":"\u003cp\u003eExample of the monitored intraperitoneal particle number concentration (a) and deduced concentration half-life values for each aerosol-analytical instrument (b).\u003c/p\u003e\n\u003cp\u003e(a) = monitored intraperitoneal particle number concentration; (b) =deduced concentration half-life values for each aerosol-analytical instrument. CPC = condensation particle counter; LAP = laser aerosol particle size spectrometer; OPS = optical particle sizer; CPF = continuous passive filtration; ESP = electrostatic precipitation; CAF = continuous active filtration.\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7003137/v1/bec378b523dd02eb3811e471.png"},{"id":105755428,"identity":"5b5a78f0-21b4-4166-b9cc-06c03dcb4800","added_by":"auto","created_at":"2026-03-30 16:27:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6051452,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7003137/v1/88769c5b-2217-46dc-babc-001cab3d5e60.pdf"},{"id":93556361,"identity":"724542fe-5a29-4aa7-8156-bee94b39b5db","added_by":"auto","created_at":"2025-10-15 06:43:21","extension":"doc","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":91648,"visible":true,"origin":"","legend":"","description":"","filename":"surgicalsmokemanagement03supplementaryinformation.doc","url":"https://assets-eu.researchsquare.com/files/rs-7003137/v1/3e8fdd5c63ee54b152eef634.doc"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluating the Efficacy of Smoke Management Technologies in Laparoscopic Sleeve Gastrectomy: Insights from a Prospective, Single-Centre Comparative Study","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eModern surgery is inextricably linked to the advent of surgical power devices (SPDs), which have improved dissection and hemostasis, reduced operating times, made procedures safer and shortened hospital stays compared to classical surgical instruments (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Unfortunately, the use of SPDs is accompanied by the formation of toxic/mutagenic surgical smoke (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Chemical composition, particle size, and amount of surgical smoke depend on the type of operated SPD, the amount of applied energy, and the processed tissue (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Some compounds of surgical smoke may exceed established exposure limits (\u003cspan additionalcitationids=\"CR7 CR8 CR9\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). A further concern is that surgical smoke can contain viable malignant cells, bacteria and viruses like human papillomavirus and human immunodeficiency virus (\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe relevance of the health risk by surgical smoke is reflected in data from US health authorities, which indicate that more than 500,000 US healthcare workers are regularly exposed (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). To improve intraperitoneal clearance during laparoscopic and robotic surgeries, surgical smoke is often released intentionally into the operating room (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Unfortunately, general operating room ventilation is not sufficient to eliminate surgical smoke (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Wearing of conventional masks (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) or masks with higher filtration efficiency like N95/FFP2 or N99/FFP3 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) can significantly reduce exposure, but cannot provide absolute safety. Thus, there is broad consensus that the safe management of surgical smoke, particularly in laparoscopic surgery, requires the rigorous use of smoke management technologies (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Existing smoke management technologies for laparoscopic surgery based on continuous passive filtration (CPF), continuous active filtration (CAF) or electrostatic precipitation (ESP) (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWith the onset of the COVID-19 pandemic, concerns about aerosolisation of virus-containing particles and their potential release from the capnoperitoneum into the operating room led to the suggestion that laparoscopic surgery should be replaced by open surgical interventions if patients are infected by SARS-CoV-2 or if their status is unknown (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). The lack of data on the efficacy of common smoke management technologies initiated the first comparative preclinical ex-vivo (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e) and in-vivo animal (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) studies. In these studies, different laparoscopic procedures were performed in order to identify appropriate comparative parameter taking into account both smoke elimination efficiency and freedom of surgery, and rank common smoke management technologies according to their performance.\u003c/p\u003e\u003cp\u003eTo verify the preclinical findings concerning the performance of surgical smoke management technologies (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), the present clinical trial was conducted in patients undergoing laparoscopic gastric sleeve.\u003c/p\u003e"},{"header":"2 Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003e2.1 Legal background\u003c/h2\u003e\n \u003cp\u003eProspective study at the Martinus Hospital, D\u0026uuml;sseldorf, Germany, a centre of excellence for bariatric and metabolic surgery. The study was conducted in accordance with the guidelines of the Declaration of Helsinki, and each patient gave oral and written informed consent. Approval was obtained from the Ethics Committee of the Medical Chamber North Rheine, D\u0026uuml;sseldorf, Germany (file #2022361). German Clinical Trials Register (file #DRKS00030869). The study was registered on 14 December 2022 prior to the start of the clinical trial (\u003cspan class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e). There were no changes or deviations from the study protocol during or after the end of the trial.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003ch2\u003e2.2 Patient selection and study group assignment\u003c/h2\u003e\n \u003cp\u003ePatients were selected for laparoscopic gastric sleeve (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e) based on national guidelines (\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e). Patients were over 18 years of age and had not previously undergone metabolic surgery. The study was conducted on three consecutive days and patients were allocated to one of three study groups (A, B, C) independently of the blinded surgical coordination team. All procedures were performed by the same team of physicians and scrub nurses, with standardised surgical procedures and technical equipment, in accordance with the study protocol. Surgical smoke particle concentration measurements were conducted in the capnoperitoneum, as the data obtained are more valid compared to extraperitoneal measurements and are therefore also representative of the risk of extraperitoneal smoke exposure (\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eThe primary endpoint was the efficiency of intraoperative smoke clearance, assessed by half-life (T\u003csub\u003e1/2\u003c/sub\u003e). Secondary outcomes included total CO\u003csub\u003e2\u003c/sub\u003e consumption, intraoperative pressure stability, visual quality, and operating time.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003ch2\u003e2.3 Operative setup, volumetry of capnoperitoneum and laparoscopic gastric sleeve\u003c/h2\u003e\n \u003cp\u003eAccess to the abdominal cavity was obtained in the left upper quadrant by video-assisted (IMAGE1 S 4U RUBINA, OPAL1 NIR/ICG, Karl Storz, Germany) insertion of a 12 mm trocar Kii Optical Access System (T1). All trocars, except the optic trocar in group C, were from Applied Medical, CA-USA. In study groups A and B, the insufflator (Endoflator UI 500, Karl Storz, Germany) and in group C the continuous pressure insufflator (LEXION AP 50/30, Dach Medical Group GmbH, Austria) were connected to T1. During establishment of a capnoperitoneum of 15 mmHg, the intra-abdominal volume was determined for (\u003cspan class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e15\u003c/span\u003e) mmHg. Under video-guidance, insertion of a 12 mm trocar in the midline supraumbilical (T2) and in the right upper abdomen (T3). A 15 mm trocar (T5) was placed subxyphoidal and a 5 mm trocar (T4) in the lateral left upper abdomen. In group C, the CO\u003csub\u003e2\u003c/sub\u003e inflow was connected to T2 (12 mm, Insuflow\u0026reg;Port, Dach Medical Group GmbH, Austria) and the outflow to T5 (PneuVIEW\u0026reg;XE, Dach Medical Group GmbH, Austria). In Group A and B, the heated CO\u003csub\u003e2\u003c/sub\u003e insufflation tube was connected to the side valve of T2. Insertion of a 10 mm retractor in T5 to elevate the left liver lobe. Continuous capnoperitoneal pressure monitoring by a precision pressure probe (Almemo 2590-4AS logger with FDA612SR sensor, Ahlborn, Germany) connected to the open side valve of T4. Tissue dissection with an ultrasonic cutter (Sonicision\u0026trade; 7 Curved Jaw, Medtronic plc, Ireland). For further details on the surgical procedure, refer to existing literature (\u003cspan class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003e2.4 Study groups and smoke management technologies details\u003c/h2\u003e\n \u003cp\u003eIntraoperative smoke management technologies were studied in three groups (A, B, C) with 5 patients each. The operational setups are shown in Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n \u003cul\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003egroup A\u003c/strong\u003e: continuous passive filtration (CPF) with integrated moisture capture system (Valleylab\u0026trade; Laparoscopic Smoke Evacuation System, Medtronic plc, Ireland) at maximum flow connected to T5.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003egroup B\u003c/strong\u003e: continuous electrostatic smoke precipitation (ESP) using the Ultravision\u0026trade; generator with 5 mm Trocar accessory Ionwand \u003csup\u003eTM\u003c/sup\u003e (Alesi Surgical Ltd., UK) at T4.\u003c/p\u003e\n \u003c/li\u003e\n \u003cli\u003e\n \u003cp\u003e\u003cstrong\u003egroup C\u003c/strong\u003e: continuous active filtration (CAF) with continuous pressure insufflator and integrated smoke evacuation (LEXION AP 50/30) in bariatric mode (40 L/min) with inflow at T2 (Insuflow\u003csup\u003e\u0026reg;\u003c/sup\u003ePort) and outflow at T5 (PneuVIEW\u003csup\u003e\u0026reg;\u003c/sup\u003eXE).\u003c/p\u003e\n \u003c/li\u003e\n \u003c/ul\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003e2.5 Aerosol-analytical setup for surgical smoke characterisation\u003c/h2\u003e\n \u003cp\u003eThe operated aerosol analytical setup (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e) corresponds widely to the intra-abdominal section of a previous setup (\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\n \u003cp\u003eAerosol sampling from the side valve of T1 via a 1.5 m electrical-conductive hose line enveloped by a sterile tube cover (Flexasoft\u0026reg;, CADITEC Medical\u0026thinsp;+\u0026thinsp;Technical GmbH, Germany). For proper instrument operation, the sample flow rate of (0.19\u0026thinsp;\u0026plusmn;\u0026thinsp;0.04) L/min was i) mixed first with 2.81 L/min of particle-free air for air-like conditions and ii) diluted by an aerosol dilution system (DDS 560, Topas GmbH, Germany) and by particle-free air supplied from instrument exhaust and from a flow-controlled aerosol generator (FCS 249, Topas GmbH, Germany) in idle mode. The overall aerosol dilution factor varied between 29 and 654.\u003c/p\u003e\n \u003cp\u003eMonitoring of particle number concentration was realised by three aerosol-analytical instruments. A condensation particle counter (CPC 3772, TSI Inc., USA) was used for concentrations in the size range of (0.01-10) \u0026micro;m (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e). One (LAP 323, Topas GmbH, Germany) of the two single particle light aerosol spectrometers (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e) monitored concentrations in the size range of (0.15\u0026ndash;5) \u0026micro;m, while the other one (OPS 3330, TSI Inc., USA) in the size range of (0.3\u0026ndash;10) \u0026micro;m.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003e2.6 Assessment of intraoperative vision\u003c/h2\u003e\n \u003cp\u003eIntraoperative vision at different stages of the surgical intervention was rated by the surgical team (n\u0026thinsp;=\u0026thinsp;4) using a 5-point Likert scale (\u003cspan class=\"CitationRef\"\u003e31\u003c/span\u003e). In addition, the number of camera cleaning procedures were protocolled.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n \u003ch2\u003e2.7 Statistical analyses\u003c/h2\u003e\n \u003cp\u003eData are presented as median values with standard deviation and as boxplots (median values with interquartile range (IQR)\u0026thinsp;=\u0026thinsp;Q3 \u0026ndash; Q1). Non-parametric variables were analysed with the Kruskal-Wallis test (\u003cspan class=\"CitationRef\"\u003e32\u003c/span\u003e). Significant differences were assessed with the Mann-Whitney test (\u003cspan class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e34\u003c/span\u003e). A value of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 represents for each of the mentioned tests a significant difference.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Patient characteristics, details about surgery and postoperative outcome\u003c/h2\u003e\u003cp\u003eIn total, 15 patients with a male/female ratio of 1:4 were treated. The overall median age, body weight, and body mass index (BMI) were (34\u0026thinsp;\u0026plusmn;\u0026thinsp;15.4) a, (125\u0026thinsp;\u0026plusmn;\u0026thinsp;29.6) kg, and (45.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8) kg/m\u003csup\u003e2\u003c/sup\u003e. There were no significant differences between the groups concerning age, and body weight and BMI.\u003c/p\u003e\u003cp\u003eThe three smoke management technologies were operated intraoperatively without issues. The median duration of surgery was (46\u0026thinsp;\u0026plusmn;\u0026thinsp;11) min. The postoperative course was uneventful and patients were discharged at home on the third postoperative day.\u003c/p\u003e\u003cp\u003eAfter one year of follow-up, the median total and excess weight loss were (27.2\u0026thinsp;\u0026plusmn;\u0026thinsp;8.5) % and (66.1\u0026thinsp;\u0026plusmn;\u0026thinsp;18.1) %, respectively. There was no significant difference between the three study groups. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarises the perioperative and 12-month follow-up data.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatient characteristics, details about surgery and postoperative outcome.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eproperty\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eunit\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003egroup A\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003egroup B\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003egroup C\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003etotal\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003csub\u003e\u003cem\u003eA/B\u003c/em\u003e\u003c/sub\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003ep\u003csub\u003eA/C\u003c/sub\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003csub\u003e\u003cem\u003eB/C\u003c/em\u003e\u003c/sub\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003esmoke management technology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCPF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eESP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCAF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003enumber of patients (male/female)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (0/5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5 (0/5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5 (3/2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e15 (3/12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eage of patient\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eyear\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31\u0026nbsp;\u0026plusmn;\u0026nbsp;18.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e28\u0026nbsp;\u0026plusmn;\u0026nbsp;5.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e42\u0026nbsp;\u0026plusmn;\u0026nbsp;18.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e34\u0026nbsp;\u0026plusmn;\u0026nbsp;15.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.174\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.377\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.087\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ebody weight, preoperative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ekg\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e116\u0026nbsp;\u0026plusmn;\u0026nbsp;15.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e125\u0026nbsp;\u0026plusmn;\u0026nbsp;8.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e170\u0026nbsp;\u0026plusmn;\u0026nbsp;39.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e125\u0026nbsp;\u0026plusmn;\u0026nbsp;29.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.174\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.059\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.174\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ebody mass index, preoperative\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ekg/m\u0026sup2;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43.7\u0026nbsp;\u0026plusmn;\u0026nbsp;5.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e45\u0026nbsp;\u0026plusmn;\u0026nbsp;1.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e50.1\u0026nbsp;\u0026plusmn;\u0026nbsp;8.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e45.7\u0026nbsp;\u0026plusmn;\u0026nbsp;6.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.174\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.059\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eduration of surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003emin\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43\u0026nbsp;\u0026plusmn;\u0026nbsp;9.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e46\u0026nbsp;\u0026plusmn;\u0026nbsp;2.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e53\u0026nbsp;\u0026plusmn;\u0026nbsp;15.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e46\u0026nbsp;\u0026plusmn;\u0026nbsp;11.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.087\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003elength of hospital stay\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eday\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3\u0026nbsp;\u0026plusmn;\u0026nbsp;0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u0026nbsp;\u0026plusmn;\u0026nbsp;0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3\u0026nbsp;\u0026plusmn;\u0026nbsp;0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3\u0026nbsp;\u0026plusmn;\u0026nbsp;0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e1.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ebody weight, postoperative (1 year)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ekg\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e79\u0026nbsp;\u0026plusmn;\u0026nbsp;7.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e86\u0026nbsp;\u0026plusmn;\u0026nbsp;7.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e105\u0026nbsp;\u0026plusmn;\u0026nbsp;31.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e86\u0026nbsp;\u0026plusmn;\u0026nbsp;25.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.232\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.014\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.038\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eexcess body weight loss, postoperative (1 year)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e67.7\u0026nbsp;\u0026plusmn;\u0026nbsp;10.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e71.9\u0026nbsp;\u0026plusmn;\u0026nbsp;9.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e43.6\u0026nbsp;\u0026plusmn;\u0026nbsp;20.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e66.1\u0026nbsp;\u0026plusmn;\u0026nbsp;18.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.377\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.038\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.059\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eLegend\u003c/strong\u003e\u003cp\u003eMedian values\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. CPF\u0026thinsp;=\u0026thinsp;continuous passive filtration, CAF\u0026thinsp;=\u0026thinsp;continuous active filtration, ESP\u0026thinsp;=\u0026thinsp;electrostatic precipitation.\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Capnoperitoneal volume, carbon dioxide consumption and capnoperitoneal stability\u003c/h2\u003e\u003cp\u003eA cross-group comparison of the determined capnoperitoneal volumes revealed no statistically significant difference; however, significant variations were observed in dependence of the capnoperitoneal pressure. The mean capnoperitoneal volume was determined to be (0.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8) L for 5 mmHg, (3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5) L for 10 mmHg and (6.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7) L for 15 mmHg (see Fig. S.1).\u003c/p\u003e\u003cp\u003eDuring the entire surgical procedure, the median CO\u003csub\u003e2\u003c/sub\u003e consumption (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea) was (242\u0026thinsp;\u0026plusmn;\u0026thinsp;39.0) L for group A, (80.1\u0026thinsp;\u0026plusmn;\u0026thinsp;13.7) L for group B, and (452\u0026thinsp;\u0026plusmn;\u0026thinsp;87.9) L for group C. The consumption in group C was significantly higher than in groups A and B (p\u003csub\u003eC/B\u003c/sub\u003e \u0026lt; 0.001; p\u003csub\u003eC/A\u003c/sub\u003e \u0026lt; 0.001). The same holds true between groups A and B (p\u003csub\u003eA/B\u003c/sub\u003e \u0026lt; 0.001).\u003c/p\u003e\u003cp\u003eThe mean CO\u003csub\u003e2\u003c/sub\u003e flow rate (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eb) was (5.49\u0026thinsp;\u0026plusmn;\u0026thinsp;0.34) L/min for group A, (1.93\u0026thinsp;\u0026plusmn;\u0026thinsp;0.39) L/min for group B and (7.90\u0026thinsp;\u0026plusmn;\u0026thinsp;0.52) L/min for group C. Differences between the groups were highly significant (p\u003csub\u003eC/B\u003c/sub\u003e \u0026lt; 0.001, p\u003csub\u003eC/A\u003c/sub\u003e \u0026lt; 0.001, p\u003csub\u003eB/A\u003c/sub\u003e \u0026lt; 0.001). Since group B technology does not rely on evacuation, the observed flow rate originates from unintentional leakage and the sample flow rate of (0.19\u0026thinsp;\u0026plusmn;\u0026thinsp;0.04) L/min for aerosol characterisation.\u003c/p\u003e\u003cp\u003eThe intraoperative capnoperitoneal pressure (Fig. S.2 b) was (14.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8) mmHg for group A, (15.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7) mmHg for group B and (15.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6) mmHg for group C. Temporal fluctuations (Fig. S.2 a) of the intraoperative capnoperitoneal pressure are an indicator for the capnoperitoneal stability and were evaluated via the coefficient of variation. The overall coefficient of variation of the capnoperitoneal pressure was 5.43% for group A, 4.12% for group B and 4.23% for group C.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch2\u003e3.3 Half-life of particle number concentration to assess surgical smoke elimination\u003c/h2\u003e\n\u003cp\u003eFigure \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003ea shows the measured intraperitoneal particle number concentration over time for one trial of study group A. To assess the smoke removal efficiency, the concentration half-life T\u003csub\u003e1/2\u003c/sub\u003e was calculated (see Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003eb) according to previous work (\u003cspan class=\"CitationRef\"\u003e24\u003c/span\u003e) from the exponential concentration decrease after use of SPD.\u003c/p\u003e\n\u003cp\u003eThe lowest median concentration half-life over all instruments of T\u003csub\u003e1/2\u003c/sub\u003e(B) = (7.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6) s and thus the highest smoke removal efficiency was determined for study group B. Significantly higher (i.e., p\u003csub\u003eB/A\u003c/sub\u003e(T\u003csub\u003e1/2\u003c/sub\u003e)\u0026thinsp;=\u0026thinsp;0.00003, p\u003csub\u003eB/C\u003c/sub\u003e(T\u003csub\u003e1/2\u003c/sub\u003e)\u0026thinsp;=\u0026thinsp;0.00032) median concentration half-life values were determined for group A with T\u003csub\u003e1/2\u003c/sub\u003e(A) = (20.6\u0026thinsp;\u0026plusmn;\u0026thinsp;8.6) s and group C with T\u003csub\u003e1/2\u003c/sub\u003e(C) = (18.3\u0026thinsp;\u0026plusmn;\u0026thinsp;9.8) s. No significant difference in the median concentration half-life was be observed between group A and C (p\u003csub\u003eA/C\u003c/sub\u003e(T\u003csub\u003e1/2\u003c/sub\u003e)\u0026thinsp;=\u0026thinsp;0.36).\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003e3.4 Quality of intraoperative visibility and intraoperative camera lens cleaning\u003c/h2\u003e\n \u003cp\u003eIn general, the intraoperative visibility was rated between \u0026ldquo;excellent\u0026rdquo; and \u0026ldquo;good\u0026rdquo; over the whole intervention for each study group. According to Fig. S.3, the quality of visibility tended to be rated lower for group A (1.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5) than for group B (1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4) and group C (1.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5).\u003c/p\u003e\n \u003cp\u003eThe lowest total number of camera cleaning procedures per surgical intervention was determined for group C (0.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4), followed by group A (1.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8) and group B (2.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3). During dissection and stapler phase no cleaning was necessary for groups A and C, while group B required 0.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5 procedures (see Fig. S.4).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eIn view of preclinical data (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) this clinical trial was conducted to evaluate the performance of different laparoscopic smoke management technologies. On the example of laparoscopic gastric sleeve, three different technologies were studied: continuous passive filtration (group A), electrostatic smoke precipitation (group B) and continuous active filtration (group C). Performance was evaluated based on half-life (T\u003csub\u003e1/2\u003c/sub\u003e), capnoperitoneal stability, carbon dioxide consumption and intraoperative visibility.\u003c/p\u003e\u003cp\u003eThe performance of each technology was evaluated based on several key metrics, including capnoperitoneal stability, CO\u003csub\u003e2\u003c/sub\u003e consumption, smoke particle removal, and intraoperative visibility. A stable capnoperitoneum is imperative for ensuring the safety of laparoscopic surgery. Currently, pressure insufflators are categorized as either pulsatile or steady CO\u003csub\u003e2\u003c/sub\u003e supply systems. The development of steady insufflators has been driven by the need to minimize fluctuations in capnoperitoneal pressure, which can result in unintended movements of the abdominal wall, trocar, and surgical site during procedures (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The trade-off of this is a dramatic increase in CO2 flow rate and consumption. In this study, a pulsatile insufflator was used for groups A and B, while a steady insufflator was employed for group C. Significant differences were observed between the study groups regarding both absolute capnoperitoneal pressure (target of 15 mmHg) and fluctuations. Group A exhibited the lowest capnoperitoneal pressure at 14.3 mmHg, followed by group C at 15.2 mmHg, and group B at 15.83 mmHg. Conversely, group B demonstrated the lowest fluctuations in capnoperitoneal pressure at 4.12%, with group C at 4.23% and group A at 5.43%. Despite these differences, the overall deviations between group values were minimal, indicating that capnoperitoneal stability was satisfactory across all technologies.\u003c/p\u003e\u003cp\u003eIn the context of laparoscopic surgery, the constant supply of CO\u003csub\u003e2\u003c/sub\u003e is of paramount importance due to the inherent losses through the trocars (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e) and to optimize intraoperative visibility by effectively removing surgical smoke, particularly with evacuation-based technologies (groups A and C). The total CO\u003csub\u003e2\u003c/sub\u003e consumption was found to be lowest in group B (80 L), followed by group A (242 L) and group C (452 L). When the duration of each laparoscopic intervention is considered, the CO\u003csub\u003e2\u003c/sub\u003e consumptions can be expressed as flow rates, with group B showing the lowest flow rate at 1.9 L/min, compared to 5.5 L/min for group A and 7.9 L/min for group C. Since group B's smoke removal does not rely on CO\u003csub\u003e2\u003c/sub\u003e evacuation, the observed flow rate primarily reflects unintended leakage. From an economic and environmental perspective, the significantly lower CO\u003csub\u003e2\u003c/sub\u003e requirement for surgical smoke removal via electrostatic precipitation (group B) provides a clear and relevant differentiating factor compared to evacuation-based technologies over evacuation-based technologies (groups A and C).\u003c/p\u003e\u003cp\u003eIn order to illustrate the relevance of our findings, a simple global approximation will suffice. Assuming that each of the 15\u0026nbsp;million laparoscopic interventions reported for 2018 (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e) takes at least one hour, the data from this study suggest that replacing evacuation-based surgical smoke management technologies (groups A and C) with electrostatic precipitation (group B) could result in annual savings between 6,000 and 10,000 tons of medical CO\u003csub\u003e2\u003c/sub\u003e. Furthermore, given that the production of 1.0 L of medical CO\u003csub\u003e2\u003c/sub\u003e results in the emission of 0.44 L of non-medical CO\u003csub\u003e2\u003c/sub\u003e, the total CO\u003csub\u003e2\u003c/sub\u003e savings could range from 9,000 to 15,000 tons per year. These data are highly relevant and it is reasonable to assume that the actual CO\u003csub\u003e2\u003c/sub\u003e savings are likely to be even higher, given the significant increase in laparoscopic surgery in recent years. The heavy dependence of the healthcare system on the supply of medical CO\u003csub\u003e2\u003c/sub\u003e was particularly evident during the COVID-19 crisis - an adequate supply of medical CO\u003csub\u003e2\u003c/sub\u003e is a significant risk factor for the safety of surgical patient care. In anticipation of shortages in the supply of medical CO\u003csub\u003e2\u003c/sub\u003e during the COVID-19 crisis, some authorities developed contingency plans to ensure the supply of medical CO\u003csub\u003e2\u003c/sub\u003e to the healthcare system (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe half-life T\u003csub\u003e1/2\u003c/sub\u003e (i.e. the time required to reduce the concentration of smoke particles by half) is an appropriate parameter for determining the effectiveness of laparoscopic smoke management technologies in preventing surgical smoke from entering the operating room atmosphere (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The current data confirm the results of the preclinical study, namely that electrostatic precipitation in group B is the most efficient laparoscopic smoke management technology as measured by T\u003csub\u003e1/2\u003c/sub\u003e values. With average CO\u003csub\u003e2\u003c/sub\u003e flows of 5.49\u0026thinsp;\u0026plusmn;\u0026thinsp;0.34 L/min and 7.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.52 L/min, respectively, it is approximately three times more efficient than continuous active and passive filter technology in groups A and C.\u003c/p\u003e\u003cp\u003eA potential limitation of this study is the lack of direct comparability between the groups in terms of body mass index (BMI) and gender distribution, which may have influenced the results. Group C was predominantly male, a population known to have more intra-abdominal visceral adipose tissue than females (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). This may suggest that the higher BMI in group C may have adversely affected capnoperitoneal pressure stability and intraoperative visibility due to increased smoke particle release from greater visceral fat. However, as the study aimed to evaluate the efficacy of different smoke management techniques and T\u003csub\u003e1/2\u003c/sub\u003e is independent of BMI and visceral fat, the results remain valid and are of clinically relevance.\u003c/p\u003e\u003cp\u003eDuring laparoscopic surgery, CO\u003csub\u003e2\u003c/sub\u003e leaks of varying degrees, intentional or unintentional, occur constantly in the operating room, where the smoke poses a risk to health care workers (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). However, the rate of smoke particle release leaks into the capnoperitoneum with electrostatic precipitation is significantly lower, by several orders of magnitude, compared to filter-based technologies. This is because a significant portion of the particulate matter released into the capnoperitoneum at the surgical site is rapidly deposited by electrostatic precipitation on the peritoneum or surrounding tissues. Electrostatic precipitation is therefore less likely than filter-based techniques to contaminate the operating room through accidental surgical smoke leakage (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIt is also important to note that the effectiveness of electrostatic separation depends on the distance between the surgical site and the tip of the ion-emitting electrode. The intensity of the Gaussian field decreases as the cube of the distance increases, meaning that the effectiveness can decrease significantly as the distance from the surgical site to the electrode increases. Therefore, the electrode should be repositioned within the abdominal wall if the surgical field changes. However, if the electrode is placed too close to the surgical site, short circuits may occur if the electrode tip accidentally comes into contact with instruments or tissue. This will result in brief interruptions in smoke evacuation.\u003c/p\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003eAll three techniques effectively eliminate smoke during laparoscopic gastric sleeve surgery while maintaining excellent visibility. Electrostatic smoke removal is the most effective method for managing smoke during the procedure, maintaining a stable capnoperitoneal pressure without extra CO\u003csub\u003e2\u003c/sub\u003e consumption.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBMI Body mass index\u003c/p\u003e\n\u003cp\u003eCAF Continuous active filtration\u003c/p\u003e\n\u003cp\u003eCOVID-19 Coronavirus disease 2019\u003c/p\u003e\n\u003cp\u003eCPC Condensation particle counter\u003c/p\u003e\n\u003cp\u003eCPF Continuous passive filtration\u003c/p\u003e\n\u003cp\u003eCPI Continuous pressure insufflator \u003c/p\u003e\n\u003cp\u003eDDS Dynamic Dilution System\u003c/p\u003e\n\u003cp\u003eEAD Electrical Aerosol Detector\u003c/p\u003e\n\u003cp\u003eESP Electrostatic smoke precipitation\u003c/p\u003e\n\u003cp\u003eFCS Field Calibration System\u003c/p\u003e\n\u003cp\u003eHEPA High efficiency particulate air (filter)\u003c/p\u003e\n\u003cp\u003eLAP Laser Aerosol Particle Size Spectrometer\u003c/p\u003e\n\u003cp\u003eLS Laparoscopic surgery\u003c/p\u003e\n\u003cp\u003eMFC Mass flow controller\u003c/p\u003e\n\u003cp\u003eOPS Optical Particle sizer\u003c/p\u003e\n\u003cp\u003ePNC particle number concentration in air (1/cm\u003csup\u003e3\u003c/sup\u003e)\u003c/p\u003e\n\u003cp\u003eSARS-CoV-2 Severe acute respiratory syndrome coronavirus type 2\u003c/p\u003e\n\u003cp\u003eSMT Smoke management technology\u003c/p\u003e\n\u003cp\u003eSPD Surgical power device\u003c/p\u003e\n\u003cp\u003eSPI Standard pressure insufflator\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgement\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank Dach Medical GmbH for generously providing the LEXION AP 50/30 insufflator free of charge, Alesi Surgical for providing the Ultravision\u0026trade; system, and Medtronic for providing the Valleylab\u0026trade; smoke filters. We are especially grateful to Topas GmbH in Dresden, Germany, for generously providing and operating the aerosol analytical setup free of charge. In addition, we would like to express our sincere gratitude to the dedicated staff of the Martinus Hospital in D\u0026uuml;sseldorf, whose invaluable support was crucial to the success of this study.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Author contributions\u003c/p\u003e\n\u003cp\u003eC\u0026eacute;dric R.D. Demtr\u0026ouml;der and Daniel G\u0026ouml;hler: conceptualization, data curation, formal analysis, funding acquisition, investigation, methodology, project administration, resources, software, validation, visualization, writing original draft\u003c/p\u003e\n\u003cp\u003eKatrin Oelschl\u0026auml;gel: data curation, formal analysis, investigation, review and editing\u003c/p\u003e\n\u003cp\u003ePeter Kirchmeyer, H\u0026uuml;lya Agarius, Fabian Kockelmann, S\u0026eacute;bastien Roger, Mehdi Ouaissi and Claudia Jahn-Wolf: resources, supervision, review and editing\u003c/p\u003e\n\u003cp\u003eUrs Giger-Pabst and Dmitrij Dajchin: conceptualization, data curation, formal analysis, investigation, methodology, resources, supervision, validation, writing original draft, review and editing\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Data availability statement\u003c/p\u003e\n\u003cp\u003eMeasurement data of the study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Competing Interests Statement\u003c/p\u003e\n\u003cp\u003eThe study was financed with institutional funds of the Martinus Hospital, D\u0026uuml;sseldorf and the Association Tourangelle de Recherche en Oncologie du Val de Loire (AT-ROVL). All authors have no conflicts of interest or financial ties to declare. We explicitly emphasize, that all authors declare no financial ties or any other conflicts of interest with Dach Medical Group GmbH (Ostermiething, Austria), Alesi Surgical Ltd., (Cardiff, United Kingdom) or Medtronic plc (Dublin, Ireland).\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTou S, Malik AI, Wexner SD, Nelson RL. Energy source instruments for laparoscopic colectomy. Cochrane Db. Syst. Rev. 2011. Doi: 10.1002/14651858.CD007886.pub2\u003c/li\u003e\n\u003cli\u003eBotteri E, Podda M, Arezzo A, et al. Current status on the adoption of high energy devices in Italy: An Italian Society for Endoscopic Surgery and New Technologies (SICE) national survey. Surg. Endosc. 2021;35(11):6201\u0026ndash;11. Doi: 10.1007/s00464-020-08117-y\u003c/li\u003e\n\u003cli\u003eOSHA. (2016). Laser/Electrosurgery Plume. https://www.osha.gov/SLTC/laserelectrosurgeryplume.\u003c/li\u003e\n\u003cli\u003eOtt DE, Moss E, Martinez K Aerosol exposure from an ultrasonically activated (Harmonic) device. J. Am. Assoc. Gynecol. Laparosc. 1998;5(1):29\u0026ndash;32. Doi: 10.1016/S1074-3804(98)80007-8\u003c/li\u003e\n\u003cli\u003eKarjalainen M, Kontunen A, Saari S, et al. The characterization of surgical smoke from various tissues and its implications for occupational safety. PloS ONE 2018;13(4). Doi: 10.1371/journal.pone.0195274\u003c/li\u003e\n\u003cli\u003eHollmann R, Hort CE, Kammer E, Naegele M, Sigrist MW, Meuli-Simmen C. Smoke in the Operating Theater: An Unregarded Source of Danger. Plastic and Reconstructive Surgery 2004;114(2):458\u0026ndash;63. Doi: 10.1097/01.prs.0000131886.72932.c3\u003c/li\u003e\n\u003cli\u003ePierce JS, Lacey SE, Lippert JF, Lopez R, Franke JE Laser-Generated Air Contaminants from Medical Laser Applications: A State-of-the-Science Review of Exposure Characterization, Health Effects, and Control. J. Occup. Environ. Hyg. 2011;8(7):447\u0026ndash;66. Doi: 10.1080/15459624.2011.585888\u003c/li\u003e\n\u003cli\u003eDobrogowski M, Wesolowski W, Kucharska M, et al. Health risk to medical personnel of surgical smoke produced during laparoscopic surgery. Int. J. Occup. Med. Env. 2015;28(5):831-840. Doi: 10.13075/ijomeh.1896.00374\u003c/li\u003e\n\u003cli\u003eHa HI, Choi MC, Jung SG, et al. Chemicals in Surgical Smoke and the Efficiency of Built-in-Filter Ports. J. Soc. Laparoendosc. Surg. 2019;23(4):e2019. Doi: 10.4293/JSLS.2019.00037\u003c/li\u003e\n\u003cli\u003eDixon K, Dasgupta P, Vasdev N. A systematic review of the harmful effects of surgical smoke inhalation on operating room personnel. Health Sciences Review 2023, 6:100077. Doi: 10.1016/j.hsr.2023.100077\u003c/li\u003e\n\u003cli\u003eBaggish MS, Polesz BJ, Joret D, Williamson P, Refai A. Presence of human immunodeficiency virus DNA in laser smoke. Lasers Surg. Med. 1991;11(3):197\u0026ndash;203. Doi: 10.1002/lsm.1900110302\u003c/li\u003e\n\u003cli\u003eSood AK, Bahrani-Mostafavi Z, Stoerker J, Stone IK. Human Papillomavirus DNA in LEEP Plume. Infect. Dis. Obstet. Gynecol. 1994;2(4):167\u0026ndash;70. Doi: 10.1155/S1064744994000591\u003c/li\u003e\n\u003cli\u003eFletcher JN, Mew D, DesC\u0026ocirc;teaux J-G. Dissemination of melanoma cells within electrocautery plume. The American Journal of Surgery 1999;178(1):57\u0026ndash;9. Doi: 10.1016/s0002-9610(99)00109-9.\u003c/li\u003e\n\u003cli\u003eLiu Y, Song Y, Hu X, Yan L, Zhu X Awareness of surgical smoke hazards and enhancement of surgical smoke prevention among the gynecologists. Journal of Cancer 2019;10(12):2788\u0026ndash;99. Doi: 10.7150/jca.31464.\u003c/li\u003e\n\u003cli\u003eLimchantra IV, Fong Y, Melstrom KA Surgical Smoke Exposure in Operating Room Personnel: A Review. JAMA Surgery 2019;154(10):960\u0026ndash;7. Doi: 10.1001/jamasurg.2019.2515\u003c/li\u003e\n\u003cli\u003eNational Institute for Occupational Safety. Health Control of smoke from laser/electric surgical procedures. National Institute for Occupational Safety and Health. Applied Occupational and Environmental Hygiene 1999;14(2):71. Doi: 10.1080/104732299303205.\u003c/li\u003e\n\u003cli\u003eBenson SM, Novak DA, Ogg MJ Proper Use of Surgical N95 Respirators and Surgical Masks in the OR. AORN Journal 2013;97(4):457\u0026ndash;70. Doi: 10.1016/j.aorn.2013.01.015.\u003c/li\u003e\n\u003cli\u003eRegli A, Sommerfield A, von Ungern?Sternberg BS The role of fit testing N95/FFP2/FFP3 masks: a narrative review. Anaesthesia 2020;76(1):91\u0026ndash;100. Doi: 10.1111/anae.15261\u003c/li\u003e\n\u003cli\u003eFrancis N, Dort J, Cho E, et al. SAGES and EAES recommendations for minimally invasive surgery during COVID-19 pandemic. Surg. Endosc. 2020, 34(6):2327\u0026ndash;31. Doi: 10.1007/s00464-020-07565-w\u003c/li\u003e\n\u003cli\u003eAnsell J, Warren N, Wall P, et al. Electrostatic precipitation is a novel way of maintaining visual field clarity during laparoscopic surgery: a prospective double-blind randomized controlled pilot study. Surg. Endosc. 2014, 28, 2057-2065. Doi: 10.1007/s00464-014-3427-8\u003c/li\u003e\n\u003cli\u003eMowbray NG, Ansell J, Horwood J, et al. Safe management of surgical smoke in the age of COVID-19. Br. J. Surg. 2020;107(11):1406\u0026ndash;13. Doi: 10.1002/bjs.11679\u003c/li\u003e\n\u003cli\u003eVigneswaran Y, Prachand VN, Posner MC, Matthews JB, Hussain M What Is the Appropriate Use of Laparoscopy over Open Procedures in the Current COVID-19 Climate? J. Gastrointest. Surg. 2020;24(7):1686\u0026ndash;91. Doi: 10.1007/s11605-020-04592-9\u003c/li\u003e\n\u003cli\u003eBuggisch J, G\u0026ouml;hler D, Le Pape A, et al. Experimental model to test electrostatic precipitation technology in the COVID-19 era: A pilot study. J. Am. Coll. Surg. 2020;231(6):704\u0026ndash;12. Doi: 10.1016/j.jamcollsurg.2020.08.759\u003c/li\u003e\n\u003cli\u003eG\u0026ouml;hler D, Aslanyan L, Oelschl\u0026auml;gel K, et al. Performance of intraoperative surgical smoke management technologies for laparoscopic surgery: A comparative in-vivo pig study. J. Aerosol Sci. 2024, 177(3):106309. Doi: 10.1016/j.jaerosci.2023.106309\u003c/li\u003e\n\u003cli\u003ehttps://drks.de/search/de/trial/DRKS00030869/details\u003c/li\u003e\n\u003cli\u003ehttps://trialsearch.who.int\u003c/li\u003e\n\u003cli\u003eDhahri A, Verhaeghe P, Hajji H, et al. Sleeve gastrectomy: Technique and results. Journal of Visceral Surgery 2010;147(5):e39\u0026ndash;46. Doi: 10.1016/j.jviscsurg.2010.08.016.\u003c/li\u003e\n\u003cli\u003eDeutsche Gesellschaft f\u0026uuml;r Allgemein- und Viszeralchirurgie (DGAV). S3-Leitlinie Chirurgie der Adipositas und metabolischer Erkrankungen. Version 2018; https://register.awmf.org/de/leitlinien/detail/088-001, 03.03.2023.\u003c/li\u003e\n\u003cli\u003eSem GJ Design and performance characteristics of three continuous-flow condensation particle counters: a summary. Atmos. Res. 2002;62(3-4):267\u0026ndash;94. Doi: 10.1016/S0169-8095(02)00014-5\u003c/li\u003e\n\u003cli\u003eISO 21501-1:2009 Determination of particle size distribution - Single particle light interaction methods - Part 1: Light scattering aerosol spectrometer.\u003c/li\u003e\n\u003cli\u003eLikert R. A technique for the measurement of attitudes. Arch. Psychol. 1932;22(140):5\u0026ndash;55.\u003c/li\u003e\n\u003cli\u003eKruskal WH, Wallis WA. Use of Ranks in One-Criterion Variance Analysis. J. Amer. Statist. Assoc. 1952;47(260):583\u0026ndash;621. Doi: 10.2307/2280779\u003c/li\u003e\n\u003cli\u003eWilcoxon F Individual Comparisons by Ranking Methods. Biometrics Bull. 1945;1(6):80. Doi: 10.2307/3001968\u003c/li\u003e\n\u003cli\u003eMann HB, Whitney DR. On a test of whether one of two random variables is stochastically larger than the other. Ann. Math. Stat. 1947;18(1):50\u0026ndash;60. Doi: 10.1214/aoms/1177730491\u003c/li\u003e\n\u003cli\u003eCahill RA, Dalli J, Khan M, Flood M, Nolan K Solving the problems of gas leakage at laparoscopy. Br. J. Surg. 2020;107(11):1401\u0026ndash;5. Doi: 10.1002/bjs.11977\u003c/li\u003e\n\u003cli\u003eBlencowe NS, Waldon R, Vipond MN Management of patients after laparoscopic procedures. BMJ: British Medical Journal 2018:k120. Doi: 10.1136/bmj.k120\u003c/li\u003e\n\u003cli\u003eIacobucci G Medical care will be prioritised in tackling CO 2 shortages, says government. Brit. Med. J. 2021:n2346. Doi: 10.1136/bmj.n2346\u003c/li\u003e\n\u003cli\u003eGrauer WO, Moss AA, Cann CE, Goldberg HI Quantification of body fat distribution in the abdomen using computed tomography. The American Journal of Clinical Nutrition 1984;39(4):631\u0026ndash;7. Doi: 10.1093/ajcn/39.4.631\u003c/li\u003e\n\u003cli\u003eNauli AM, Matin S Why Do Men Accumulate Abdominal Visceral Fat? Frontiers in Physiology 2019;10. Doi: 10.3389/fphys.2019.01486\u003c/li\u003e\n\u003cli\u003eZhou Y-z, Wang C-q, Zhou M-h, et al. Surgical smoke: A hidden killer in the operating room. Asian J. Surg. 2023;46(9):3447\u0026ndash;54. Doi: 10.1016/j.asjsur.2023.03.066.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Laparoscopy, gastric sleeve, surgical smoke management technologies, smoke evacuation, electrostatic aerosol precipitation","lastPublishedDoi":"10.21203/rs.3.rs-7003137/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7003137/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eSurgical power devices generate surgical smoke that may contain infectious components. Various technologies have been developed to improve surgical smoke management, but comparative performance data from human studies are limited.\u003c/p\u003e\u003ch2\u003eMethod\u003c/h2\u003e\u003cp\u003eA prospective, single-centre study was performed for evaluating three smoke management technologies - continuous passive filtration (CPA), electrostatic precipitation (ESP), and continuous active filtration (CAF) - during laparoscopic sleeve gastrectomy in 15 bariatric patients. Surgical smoke concentration was monitored by condensation particle counting and single particle light scattering. Efficiency of intraoperative smoke clearance was assessed by the concentration half-life (T\u003csub\u003e1/2\u003c/sub\u003e). Secondary outcomes included total CO\u003csub\u003e2\u003c/sub\u003e consumption, intraoperative pressure stability, and intraoperative visibility.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eESP showed the highest smoke clearance efficiency (T\u003csub\u003e1/2\u003c/sub\u003e = 7.2 s), followed by CAF (18.3 s) and CPF (20.6 s) with significant differences. Total CO\u003csub\u003e2\u003c/sub\u003e consumption was highest for CAF (452.0 L) compared CPF (242.0 L) and ESP (80.1 L). All groups maintained a stable capnoperitoneal pressure and a good/very good intraoperative visibility.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eElectrostatic precipitation showed the lowest CO\u003csub\u003e2\u003c/sub\u003e consumption and significantly higher smoke particle removal efficiency compared to continuous active/passive filtration. All technologies provided good/very good intraoperative visibility and capnoperitoneal pressure stability.\u003c/p\u003e","manuscriptTitle":"Evaluating the Efficacy of Smoke Management Technologies in Laparoscopic Sleeve Gastrectomy: Insights from a Prospective, Single-Centre Comparative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-15 06:43:17","doi":"10.21203/rs.3.rs-7003137/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-14T10:47:15+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-11T19:19:45+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-05T03:39:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"82588334853687001704921296347563583914","date":"2025-10-01T23:23:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"325036415784364112381787805268648850133","date":"2025-10-01T11:35:58+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-01T11:25:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-19T05:48:52+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-02T11:36:48+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-01T10:03:41+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-06-29T13:57:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cf7271c3-5949-4a6c-99d2-ec89139845c5","owner":[],"postedDate":"October 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":56142433,"name":"Health sciences/Diseases"},{"id":56142435,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2026-03-30T16:23:24+00:00","versionOfRecord":{"articleIdentity":"rs-7003137","link":"https://doi.org/10.1038/s41598-026-43227-y","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2026-03-23 16:08:57","publishedOnDateReadable":"March 23rd, 2026"},"versionCreatedAt":"2025-10-15 06:43:17","video":"","vorDoi":"10.1038/s41598-026-43227-y","vorDoiUrl":"https://doi.org/10.1038/s41598-026-43227-y","workflowStages":[]},"version":"v1","identity":"rs-7003137","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7003137","identity":"rs-7003137","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}