The mechanisms and risks of surgical glove perforation

Comparison of Unnoticed Glove Perforations during Minimally Invasive versus Open Surgeries: A Systematic Review and Meta-Analysis

Objective: Various studies have depicted the incidence of glove perforations during open (OS) and minimally invasive surgeries (MIS). The aim of this meta-analysis was to compare the incidence of macroscopic and microscopic glove perforations during MIS and OS. Methods: The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Scientific databases (PubMed, Web of Science, Scopus, and EMBASE) were systematically searched for comparative studies depicting the glove perforation rates during MIS and OS. Risk ratios (RR) were calculated for both the outcomes (dichotomous) and the Mantel–Haenszel method was utilized for the estimation of pooled RR. The methodological quality assessment was performed by two independent investigators using the Downs and Black scale. The main outcomes of the study were the proportion of gloves with gross (macroscopic) perforations and the proportion of gloves with microscopic perforations. Results: Four comparative studies including a total of 1428 gloves (435 from the MIS group) were included. Pooling the data demonstrated no difference in the incidence of macroscopic glove perforations among the MIS and OS groups (RR 0.57, 95% CI 0.21 to 1.54, p = 0.27). On the other hand, the incidence of microscopic perforations was significantly higher in the OS group versus the MIS group (RR 0.72, 95% CI 0.55 to 0.95, p = 0.02). However, all the studies had a moderate risk of bias. Conclusions: When compared to OS, the macroscopic glove perforation rate during MIS showed no significant difference. The incidence of microscopic glove perforations was significantly higher during OS as compared to MIS. However, due to the moderate risk of bias of the available comparative studies, the level of evidence of these studies is limited.

Does Size Affect the Rate of Perforation? A Cross-sectional Study of Medical Gloves

OBJECTIVES

Healthcare workers often have unnoticed minor abrasions on their hands, putting them at risk of contracting infectious diseases from patients, if the integrity of the medical gloves is compromised. This study aimed to compare the rate and location of glove perforation between well-fitted and ill-fitted gloves.

METHODS

The participants of this cross-sectional study were 45 midwives in the maternity ward of a hospital in Shiraz city, Iran. A total of nine pairs of medical gloves including three pairs of fit size, three pairs of gloves with one size smaller (tight), and three pairs of gloves with one size larger (loose) were given to subjects, and asked them to use the gloves during episiotomy repair operations. After completing the task, all gloves were collected safely and gloves perforation was investigated based on water test (NF EN 455-1).

RESULTS

The perforation rate of the fit, tight, and loose medical gloves was 20, 37.78, and 34.81%, respectively. The results showed a significant difference between glove perforation of different glove sizes (P < 0.05). In general, there was a significant difference between the perforation rate of the fit glove and ill-fitted gloves (P = 0.013).

CONCLUSIONS

Wearing the wrong size gloves may increase the glove perforation rate. Providing a wide range of glove sizes by the hospital management, and choosing the best glove size can be very effective in reducing the glove perforation and increasing safety for healthcare workers and patients.

Perforations of tri-layer nitrile-latex and natural rubber latex gloves during ex-vivo equine intestinal anastomoses

OBJECTIVE

To compare perforation rates between tri-layer nitrile-latex and natural rubber latex surgical gloves after single-layer end-to-end jejunojejunal anastomoses in equine cadavers.

STUDY DESIGN

Prospective randomized ex-vivo study.

SAMPLE POPULATION

Pairs of surgical gloves (n = 46) worn during jejunojejunal anastomoses.

METHODS

Tri-layer nitrile-latex and rubber latex pairs of gloves were equally but randomly allocated to a right-handed surgeon performing 46 single-layer end-to-end jejunojejunal anastomoses on cadaveric material. Number and location of perforations were determined with the water leak test after each procedure. Ten unused pairs of both glove types were tested as controls.

RESULTS

At least one perforation occurred in 41% (19/46) of the pairs of gloves. Glove perforations were present in 22% (5/23; 95% CI: 9-42) of tri-layer glove pairs and 61% (14/23; 95% CI: 41-78) of the rubber glove pairs. The odds of glove perforation were 5.6 times (p = .009, 95% CI: 1.5-20.5) lower when tri-layer rather than rubber gloves were used. The duration of procedure did not affect the risk of glove perforation (p = .679). No perforations were observed in the unused gloves.

CONCLUSION

Perforations were less common when the surgeon wore tri-layer nitrile-latex gloves rather than to the natural rubber latex gloves tested in this study.

CLINICAL RELEVANCE

Tri-layer nitrile-latex gloves were more resistant to perforations in experimental settings; further studies may confirm that they are also superior in a clinical setting.

At what point during total knee arthroplasty operations are gloves most frequently torn?

PURPOSE

The aim of this study was to determine the time points during a total knee arthroplasty operation when there is the greatest possibility of tearing a surgical glove and thus the stage of the operation at which there is the greatest risk of infection.

METHODS

The study included 300 total knee arthroplasty cases performed by 10 orthopedic surgeons. Using a chronometer during the operation, the upper layer of each surgical glove was removed and inflated with sterile saline at 10-min intervals. When a tear was determined, a record was made of the time it occurred, the stage of the operation, the finger that was torn, and the side (right or left hand).

RESULTS

The mean time of the glove perforation was 40.74 ± 10.69 min. Glove tears occurred at the rate of 28.9% (n = 39) in the thumb, 63.7% (n = 86) in the index finger, 2.2% (n = 3) in the middle finger, and 5.2% (n = 7) in the ring finger. The tears occurred after the femoral cut in 8.1% (n = 11), after the tibial cut in 14.8% (n = 20), at the stage of trial component reduction in 52.6% of cases (n = 71), after placement of the prosthesis in 7.4% (n = 10), and at the closure stage in 17% (n = 23) (p < 0.001).

CONCLUSION

The fingers requiring the most care during total knee arthroplasty are the thumb and index finger. The stages of the operation with the greatest risk for glove tears are trial component reduction and wound closure. Changing gloves after these high-risk surgical stages would help to decrease the risk of periprosthetic infections.

LEVEL OF EVIDENCE

Level IV/Case series.

Association Between the Frequency of Glove Change and the Risk of Blood and Body Fluid Exposure in Gastrointestinal Surgery

BACKGROUND

Surgical gloves are used to prevent the transmission of microorganisms from the surgeon's hands to the patient and vice versa. Little is known on the optimal frequency of glove changing. Therefore, we aimed to examine the optimal frequency of glove change during surgery by assessing the glove perforation rate in gastrointestinal surgery.

METHODS

In this observational prospective cohort study, we investigated the incidence of perforation of 5,267 gloves during gastrointestinal surgeries.

RESULTS

The overall glove perforation rate was 10.1%. There was no significant difference between single gloving (10.2%) and double gloving (10.0%; p = 0.8491). However, the perforation rate of the inner glove (5.7%) was found to be significantly lower than that of the outer glove (11.6%) (p < 0.0001). A significant difference in perforation rate was observed after wearing inner gloves for 240 min (< 240 min, 4.4%; ≤ 240 min, 7.2%; p = 0.0314), and outer gloves for 60 min (< 60 min, 7.1%; ≤ 60 min, 12.6%; p < 0.0001). We found cumulative perforation rate to rapidly increase until the wear time was 90 min.

CONCLUSION

The inner gloves and outer gloves have a higher perforation rate as the wear time increased. To reduce the risk of intraoperative blood and fluid exposure and prevent healthcare-associated infection, gloves should be changed for approximately every 60-90 min for outer gloves and approximately every 240 min for inner gloves.

A cross-sectional study of surgical glove perforation during the posterior lumbar interbody spinal fusion surgery: Its frequency, location, and risk factors

Lumbar fusion surgery was known to pose a greater risk of surgical glove perforation. However, there has been no study on the glove perforation that can transmit the blood-borne disease to the patient and surgical staff members in the posterior lumbar interbody fusion surgery (PLIFs).We performed a cross-sectional study to investigate the glove perforation during the PLIFs. The study included 37 consecutive patients (10 males and 27 females). All used gloves of surgical staff members, which included the surgeon, assistant surgeons, bone trimmer (who performed local bone trimming and interbody cage preparation), and scrub nurse were collected and were performed to the pinhole water infusion test. The characteristics (i.e., frequency and location of perforated glove) and relative risk of glove perforation were investigated for each participant. The independent risk factors influencing glove perforation were analyzed by multiple logistic regression analysis.The overall operative perforation rate which is a percentage of detected more than one glove perforated event in all cases was 51.4%. The overall glove perforation rate which is the percentage of perforated gloves in all gloves used for surgery was 3.8%. The relative risk of glove perforation by each participant was 2.38 in the surgeon (P = .002), 1.36 in the bone trimmer (P = .04), 1.36 in the scrub nurse (P = .04), and 1.19 in assistant surgeons (P = .13). And, the volume of trimmed local bone was analyzed as an independent risk factor for glove perforation (ORs = 1.310, P = .02).The overall operative perforation rate in PLIFs is higher than 50%. The surgeon, scrub nurse and bone trimmer were observed as a significant risk factor for glove perforation. And, the volume of trimmed local bone was analyzed as independent risk factor. Since the preparation of the interbody cage is essential for successful lumbar fusion surgery, the bone trimmer must pay attention to the glove perforation during this procedure.

Evaluation of surgical glove integrity and factors associated with glove defect

BACKGROUND

Surgical glove perforation may expose both patients and staff members to severe complications. This study aimed to determine surgical glove perforation rate and the factors associated with glove defect.

MATERIAL AND METHODS

This descriptive cross-sectional study was conducted between January and March 2017 at a Tunisian university hospital center in 3 different surgical departments: urology, maxillofacial, and general and digestive. The gloves were collected and tested to detect perforations using the water-leak test as described in European Norm NF EN 455-1. For percentage comparisons, the χ² test was used with a significance threshold of 5%.

RESULTS

A total of 284 gloves were collected. Of these, 47 were found to be perforated, a rate of 16.5%. All perforations were unnoticed by the surgical team members. The majority of perforated gloves (61.7%) were collected after urology procedures (P = .00005), 77% of perforated gloves were detected when the duration of the procedure exceeded 90 minutes (P = .001), and 96% were from brand A, which were the thicker gloves (P = .015).

CONCLUSIONS

This study highlighted an important problem neglected by surgical teams. The findings reaffirm the importance of double-gloving and changing gloves in surgeries of more than 90 minutes' duration.

Visible glove perforation in total knee arthroplasty

PURPOSE

The risk of superficial surgical site infection (SSI) and periprosthetic joint infection (PJI) after glove perforation is not evident. This study was to identify risk factors for glove perforation in primary TKR (total knee replacement) and the risk of subsequent superficial SSI and PJI.

METHODS AND MATERIALS

Results of visible glove perforation of both inner and outer gloves during TKR were reviewed. A case-control analysis was performed on the preoperative and operative variables to identify predictive risk factors for glove perforation. Rate of SSI and PJI was compared between perforation and non-perforation groups, including 1226 series and 183 case-control subset.

RESULTS

One thousand two hundred twenty-six primary TKR from 2011 to 2014 was reviewed. Fifty-five knees had visible glove perforations. The operation perforation rate was 4.5%. Risk factors identified were body mass index (BMI) > 30, bilateral surgery, operation time >120 min and non-trainee surgeons. Superficial SSI was significantly higher in glove perforation group (9.15 vs. 0.51% and 0.55%). PJI was not significantly different (1.82% vs. 0.60% and 1.1%). The adjusted odds ratio for superficial SSI after perforation was 15.2, independent of BMI and operation time.

CONCLUSION

Visible glove perforation in TKR is associated with several risk factors. The risk of superficial SSI is higher after perforation.

Is the surgical knot tying technique associated with a risk for unnoticed glove perforation? An experimental study

BACKGROUND

The issue of safety in the surgical procedure has recently been widely and openly discussed at the World Health Organization. The use of latex gloves is the current standard of protection during surgery, as they remain intact throughout the procedure. The present study was designed to evaluate the rate of glove perforation during a two-hand technique using polyester sutures in a controlled experimental study.

METHODS

Hypothesis was that the gloves used during a two-hand technique using polyester suture suffer punctures. We used 150 pairs of gloves during the experiment. Each investigator performed 30 tests always using double gloving. They made five surgical knots on each test over a custom-made table specifically developed for the experiment. Ten tests were done at a time with a week- interval. The Control Group (CG) has 30 pairs of intact surgical gloves. The gloves were tested to impermeability by water filling and leaking was observed at three different times. Statistics relating to the perforation rate were analyzed using the chi-square test. A P value less than 0.05 was considered statistically significant.

RESULTS

During the experiment there was no loss of gloves by drilling or inadvertent error in performing the impermeability test. No perforations were detected at any time during the impermeability test with the gloves used for sutures. Also, the CG presented no leakage of the liquid used for the test. There was no statistical difference between the groups underwent suture nor between them and the GC.

CONCLUSION

Under the studied conditions, the authors' hypotheses could not be proved. There was no damage to the surgical gloves during the entire experiment. The authors believe that the skin abrasions observed in the ulnar side of the little finger, constant throughout the experiment, must be caused by friction. We feel there is no risk of perforation of surgical gloves during a two-hand technique using polyester suture.

Study of Glove Perforation during Hip Replacement Arthroplasty: Its Frequency, Location, and Timing

Objective. The aim of the study was to evaluate the location, timing, and frequency of glove perforation during hip replacement arthroplasty. Methods. Gloves worn by surgical team members in 19 primary hip replacement arthroplasties were assessed. The study was of a single gloving system. All the used gloves were collected at the end of the surgery and assessed visually and by using water inflation technique. Relevant data were collected at the time of surgery. Results. A total of one hundred and ninety-one surgical gloves were evaluated. Twenty-three glove perforations were noted in nineteen of the operations. Of these perforations 14 belonged to gloves worn by surgeon and first assistant (60.1%). Glove perforation in thumb, index finger, and palm was more common. More perforation occurred in the gloves worn in nondominant hand (52%) but was insignificant. Conclusion. Glove perforation in surgeries such as total hip arthroplasty is not uncommon. In this study of single gloving system glove perforation rate was 12.04%, whereas literature reports of glove perforation rate as low as 3.3% in elective orthopedic surgeries with double gloving system. As such emphasis should be given to wear double pair of gloves wherever this practice is uncommon.

A randomized prospective study of glove perforation in orthopaedic surgery: is a thick glove more effective?

We compared perforation rates among operative staff who were randomly assigned either thick latex surgical gloves or conventional gloves for use in performing total knee arthroplasty. A total of 1120 gloves were assessed in 70 total knee arthroplasties. Additionally, the degree of tactile sensitivity provided by the gloves was compared using a two-point discrimination (TPD) test. Perforation occurred in 27 surgeries (38.5%) and in 48 gloves (4.29%). Binary logistic regression analysis revealed that the operator was a risk factor for perforation rate (Odds ratio 14.448, P < .0.01) and that the type of glove was not (P = .896). In the TPD test, tactile sensitivity was lower for a thick outer glove than the conventional double glove (P < .001 for each site). Not only did thick surgical gloves lower tactile sensitivity, they also offered no superior protective effect over conventional gloves.

Observational study of patient and surgeon preoperative preparation in ten companion animal clinics in Ontario, Canada

Background

Surgical site infections (SSIs) are a recognized risk of any surgical procedure in veterinary medicine. One of the keys to prevention of SSIs is reducing exposure of the surgical site to endogenous and exogenous microbes, beginning in the preoperative period. While guidelines are available for preoperative preparation procedures, there has been no objective investigation of compliance with these recommendations in veterinary practices. The objectives of this pilot study were to describe preoperative patient and surgeon preparation practices in a sample of non-equine companion animal veterinary clinics, and to determine if there were any areas that consistently did not meet current guidelines.

Results

Observation of preparation practices was performed in 10 clinics over 9–14 days each using up to 3 small wireless surveillance cameras. Data were coded for 148 surgical patients, and 31 surgeons performing 190 preoperative preparations. When patient hair removal was observed, it was most commonly done using clippers (117/133, 88%), and in only one case was it performed prior to anesthetic induction. Patient contact time with soap ranged from 10-462 s (average of clinic means 75 s, average of clinic medians 67 s), and with alcohol from 3-220 s (average of clinic means 44 s, average of clinic medians 37 s). Alcohol-based hand rub (AHR) was used preoperatively in 2/10 facilities, but soap-and-water hand scrub was most commonly used at all clinics. Proximal-to-distal scrubbing was noted in 95/142 (67%) of soap-and-water scrubs. Contact time during surgeon hand preparation ranged from 7-529 s (average mean 121 s, average median 122 s) for soap-and-water and from 4-123 s (average mean 25 s, average median 19 s) for AHR. No significant changes in practices were identified over time during the observation period. Practices that did not conform to guidelines available in major companion animal surgical textbooks were commonly observed.

Conclusions

Some preoperative preparation practices were relatively consistent between clinics in this study, while others were quite variable. Contact times with preoperative preparatory solutions for both patients and surgeons were often shorter than recommended. Evidence-based guidelines for these procedures in veterinary medicine should be established and implemented in order to help reduce preventable SSIs, while maintaining efficiency and cost-effectiveness.

Risk of surgical glove perforation in oral and maxillofacial surgery

Oral and maxillofacial surgery, which involves several sharp instruments and fixation materials, is consistently at a high risk for cross-contamination due to perforated gloves, but it is unclear how often such perforations occur. This study aimed to address this issue. The frequency of the perforation of surgical gloves (n=1436) in 150 oral and maxillofacial surgeries including orthognathic surgery (n=45) was assessed by the hydroinsufflation technique. Orthognathic surgery had the highest perforation rate in at least 1 glove in 1 operation (91.1%), followed by cleft lip and palate surgery (55.0%), excision of oral soft tumour (54.5%) and dental implantation (50.0%). The perforation rate in scrub nurses was 63.4%, followed by 44.4% in surgeons and first assistants, and 16.3% in second assistants. The odds ratio for the perforation rate in orthognathic surgery versus other surgeries was 16.0 (95% confidence interval: 5.3-48.0). The protection rate offered by double gloving in orthognathic surgery was 95.2%. These results suggest that, regardless of the surgical duration and blood loss in all fields of surgery, orthognathic surgery must be categorized in the highest risk group for glove perforation, following gynaecological and open lung surgery, due to the involvement of sharp objects.

Concerns, attitudes, and practices of orthopaedic surgeons towards management of patients with HIV/AIDS in Nigeria

The increasing number of people living with HIV/AIDS is causing concern among surgeons over risk of occupationally acquired HIV infection. This may influence their attitude to such patients. The purpose of this study was to develop a cross-sectional survey of orthopaedic surgeons to assess their concerns, attitudes, and practices towards management of HIV-positive patients in Nigeria. All respondents were males, 55 (73.3%) of them indicated concern over the risk of occupational acquisition of HIV infection and 37 (49.3%) had examined or operated on at least one HIV/AIDS patient. Sixty (79.9%) were willing to be tested for HIV and 51 (67.9%) were previously tested. Fifty-seven (75.9%) would order preoperative HIV screening of high risk patients, and 67 (89.3%) would operate on HIV-positive patients. Most orthopaedic surgeons in Nigeria would operate on HIV-positive patients.

Glove tears during arthroscopic shoulder surgery using solid-core suture

PURPOSE

Surgeons have noticed an increased incidence of finger lacerations associated with arthroscopic knot tying with solid-core suture material. This study examines glove perforations and finger lacerations during arthroscopic shoulder surgery.

METHODS

We collected 400 surgical gloves from 50 consecutive arthroscopic shoulder repair procedures using No. 2 solid-core sutures. Two surgeons using double gloves were involved in every case, with one being responsible for tying all knots. Powder-free latex gloves were worn in all cases. Knots consisted of a sliding stitch of the surgeon's preference followed by 3 half-hitches via a knot-pusher instrument. All gloves were inspected grossly and then tested for tears with an electroconductivity meter.

RESULTS

The knot-tying surgeon had significantly more glove tears than the control (P < .01). Tears were localized to the radial side of the index finger of the glove at the distal interphalangeal joint in all cases. Of the tying surgeon's gloves, 68 (34%) were found to have tears. These included 17 inner gloves (17%) and 51 outer gloves (51%). If an inner glove was torn, the corresponding outer glove was torn in all cases. A mean of 3.96 knots were tied in each case. There was a significantly higher incidence of inner glove tears when more than 3 knots were tied (P < .03). There was no significant difference in glove tears between suture types. Finger lacerations did occur in the absence of glove tears. However, in the presence of an inner glove tear, there was a statistically significant association with a finger laceration at the corresponding level (P < .03).

CONCLUSIONS

Intraoperative glove tears and subsequent finger lacerations occur with a high frequency when arthroscopic knots are tied with solid-core suture material. Risk can potentially be minimized by frequent glove changes or use of more durable, less penetrable gloves.

CLINICAL RELEVANCE

This study addresses surgeon and patient safety during arthroscopic shoulder surgery.

Double or single gloves: which is safer in pediatric orthopedic surgery

BACKGROUND AND AIM

Surgical gloves should form an efficient barrier between surgeons and patients to prevent cross infection. Single gloves (SGs) have long been reported unsafe, and usage of double gloves (DGs) is still not universal. No study has reported the usage of DGs in pediatric orthopedic operations. The aim of this study was to assess the efficacy of DGs versus SGs in prevention of body fluid contact between patients and surgeons during pediatric orthopedic surgery.

METHODOLOGY

After 150 pediatric orthopedic operations, DGs and SGs were collected and tested for perforations. Gloves were tested for size, site, and number of perforations among principal surgeons, assistant surgeons, and scrub nurses. Gloves were not changed during long surgical procedures and were changed only if perforations were identified and recorded. The DGs used were Maxitex Duplex, powder-free indicator gloves and the SGs were of Gammex-Ansell. One hundred unused gloves of each group were tested as controls. Medical records of the patients were reviewed for age, sex, type of operation, duration of operation, and any postoperative wound infection. The data were entered in database and analyzed using SPSS package. The data were compared between double and SGs using t test with a level of statistical significance at P less than 0.05.

RESULTS

Five hundred twenty-six DGs and 316 SGs were tested. Forty-three perforations were detected in DGs (8.1%). Outer gloves were breached in 7.8% and inner in 0.3% as compared with SGs in which 28 (8.7%) were perforated. In DGs, 4% had multiple perforations compared with 11.9% in SGs. There was a statistical significance (P<0.001) when the perforations of inner gloves were compared with the SGs. None of the inner perforations were recognized during surgery, but the outer gloves of the DGs were recognized in 71% as compared with 9% in SGs (P<0.001). The majority of perforations were seen in the nondominant hand in surgeons and assistants hands, whereas scrub nurses had 85% of perforations in the dominant hand. The index finger was the site of perforations in DGs (53.4%; SGs, 43%). The inner gloves were breached only when the outer glove was found to be perforated. The duration of surgery had a direct impact on the number of perforations. There were no perforations in DGs in less than 60 minutes as compared with 3 (10.7%) in SGs. Between 60 and 120 minutes, the perforations in the DGs were 11, and in SGs, 21. During the study period, 4 patients had surgical site infection. Three were superficial and one deep-seated infection. In 3 patients with infection, the gloves were found to be perforated, and 1 patient with infection had no perforations in the gloves.

CONCLUSION

Our study confirms that DGs are safer than SGs during pediatric orthopedic operations. In the event of nonavailability of DGs, SGs should be changed on an hourly basis during long procedures. Lastly, there exists a relationship between surgical site infection and glove perforations.

Surgical gloves: perforation and protection

The risk of surgical glove perforation is affected by a number of factors including the type of surgery, length of operative procedure, hand dominance and role of the glove wearer. This article provides an overview of each of these factors and discusses protective gloving measures taken to reduce perforations based on the findings of the Cochrane review.

Unnoticed Glove Perforation During Thoracoscopic and Open Thoracic Surgery

BACKGROUND

Surgeons tend to underestimate the risk of transferring infection during thoracoscopic operations, although data on glove perforation in thoracoscopic operations have not been reported.

METHODS

Unnoticed perforations of the gloves worn by the same primary surgeon during thoracoscopic procedures and open thoracotomy were studied. Gloves with gross damage and those changed due to assumed damage were excluded. Gloves were tested by filling with water and squeezing to inflate each finger, which could detect a perforation by a 30-gauge needle.

RESULTS

Perforation was found in 25% after thoracoscopic operation, although this was significantly lower than 70% after open thoracotomy. Twelve percent of the gloves worn during thoracoscopic operation were perforated. The perforation rate was higher for gloves worn for more than 2 hours during thoracoscopic operation.

CONCLUSIONS

Glove perforation occurred without being noticed in 25% of thoracoscopic procedures, and in 12% of the gloves used during the procedure. Glove change within 2 hours is recommended.

Glove perforation and contamination in primary total hip arthroplasty

We conducted a randomised, controlled trial to determine whether changing gloves at specified intervals can reduce the incidence of glove perforation and contamination in total hip arthroplasty. A total of 50 patients were included in the study. In the study group (25 patients), gloves were changed at 20-minute intervals or prior to cementation. In the control group (25 patients), gloves were changed prior to cementation. In addition, gloves were changed in both groups whenever there was a visible puncture. Only outer gloves were investigated.

Contamination was tested by impression of gloved fingers on blood agar and culture plates were subsequently incubated at 37°C for 48 hours. The number of colonies and types of organisms were recorded. Glove perforation was assessed using the water test. The incidence of perforation and contamination was significantly lower in the study group compared with the control group. Changing gloves at regular intervals is an effective way to decrease the incidence of glove perforation and bacterial contamination during total hip arthroplasty.

Randomized Clinical Trial Comparing Blunt Tapered and Standard Needles in Closing Abdominal Fascia

Glove perforation frequently occurs during the course of surgical procedures, introducing risks for both surgeons and patients. The aim of this study was to compare the use of blunt tapered and "sharp" needles during abdominal wall closure with respect to the incidence of glove perforation and the convenience of needle handling. A series of 200 patients undergoing laparotomy in a 6-month period for general surgical disorders were randomized to two groups; in one, the abdominal fascia was closed with a blunt tapered needle; in the other, a sharp needle was used. The main outcome measures were glove perforation and convenience of handling the needle. Univariate and multivariate analyses were performed. In all, 56 glove perforations occurred during 40 (20%) surgical procedures. Perforation rates differed significantly: 12% for the blunt (n = 100) tapered needle and 28% (n = 100) for the sharp needle (p = 0.003). Only in 12 cases (21%) was the glove perforation detected at surgery. The type of needle (odds ratio 0.35, p = 0.006) and time taken to close the fascia (odds ratio 1.001, p = 0.05) significantly affected the risk of glove perforation. At multivariate logistic regression analysis the type of needle (odds ratio 0.23, p = 0.004) and the visual analog linear scale (VAS) for ease of needle handling (odds ratio 1.18, p = 0.019) were important predictive factors for glove perforation. With the blunt tapered needle, the VAS was significantly (p = 0.0003) higher at primary laparotomy than at relaparotomy. Use of the blunt tapered needle reduces the incidence of glove perforation. Laborious closure predicts glove perforation. Blunt tapered needles are less convenient in closing a scarred abdominal fascia.

Glove perforation in outpatient dermatologic surgery

BACKGROUND

Intact surgical gloves ensure protection of health-care employees and health-care recipients. Nevertheless, glove perforation is very common and puncture rates above 50% have been published in the literature.

OBJECTIVE

It was our aim to evaluate the perforation rate of surgical gloves in outpatient dermatologic surgery.

METHODS

Six-hundred and sixty latex surgical gloves used in outpatient dermatologic surgery were evaluated for perforations using the approved water-leak method. Perforations were analyzed microscopically.

RESULTS

Twenty of the 660 gloves were found to have perforations, which corresponds to a perforation rate of 3.0%. Only 5 of these perforations (25%) were noticed by the wearer. Perforations were more numerous in nondominant-handed gloves. Microscopically, all perforations could be identified as needle stick injuries.

CONCLUSION

The risk of glove perforation in outpatient dermatologic surgery is lower than in many other medical specialties. The relatively high number of surgical procedures performed successively in outpatient dermatologic surgery, however, emphasizes the decisive relevance of an intact barrier between surgeon and patient. In view of the major fact that most perforations go unnoticed by the wearer, dermatologic surgeons must balance the improved safety of double gloving with costs and the loss of sensitivity and dexterity.

Glove perforations in open and laparoscopic abdominal surgery: the feasibility of double gloving

BACKGROUND AND AIMS

According to the traditional view, the glove protects the patient from the bacterial growth of the surgeons' hands and doing so prevents infections. Today, with growing incidences of HIV and Hepatitis B and C, surgical gloves are also important as protection for the surgeon. We compared the safety of double indicator gloves to standard single surgical gloves by investigating how often surgical gloves are punctured in laparoscopic and open gastrointestinal surgery.

STUDY

As study material we gathered all gloves that had been used in gastrointestinal surgery in Satakunta Central Hospital during two months. 814 gloves from 274 operations were tested by using standardized water filling test method.

RESULTS

In open surgery 67 gloves out of 694 had been punctured (9.6 percent). Puncture occurred in 22.5 percent of operations (53 out of 236). During open surgery 24 holes out of 35 were undetected with single gloves (69 percent). With double indicator gloves, only 3 out of 31 holes were unnoticed (10 percent). Long duration of operation increased the risk of puncture. In laparoscopic operations 4 gloves out of 120 had been perforated (3.3 percent).

CONCLUSION

Double surgical gloves give markedly better protection in surgery. This is important especially in high risk operations.

Evaluation of the rate, location, and morphology of perforations in surgical gloves worn in urological operations

Surgical perforation or intrinsic defects within the polymer membranes of surgical gloves are responsible for an increased exposure, and consequently infection risk, to HIV and HCV or other infectious diseases for the medical healthcare professional. A prospective field study was undertaken to evaluate the number and location of glove perforations, tested by the waterfill test. The morphology of these perforations was then inspected by stereo light and scanning electron microscopy. By comparing in-use defects to simulated defects created by medical instruments in unused gloves it was possible to categorize perforations caused by intrinsic defects or extrinsic mechanical stress. In six different types of surgical gloves collected from 720 urological operations the waterfill test revealed leakage rates of 6.6 percent to 12.3 percent. Further assessment of these gloves revealed intrinsic polymer material defect rates of 0.2 percent to 3.3 percent. The in-use acquired instrumental and mechanical perforation rate ranged from 4.6 percent to 12.15 percent. Perforations were mostly located at the index finger (left > right) or the thumbs. The morphology of the intrinsic defects was visualized as either incorporated membranous air bubbles or granular areas. The simulation of defects by surgical instruments in unused gloves resulted in the production of a catalog for comparison with defects seen in used gloves. This knowledge of the location and cause of these perforations highlights the need for a better avoidance strategy and/or establishment of a schedule for routine glove change by surgeons. In addition, the intrinsic polymer film quality of gloves can be improved by a lower incidence of air bubbles together with less granular sites.

Survey of the knowledge, attitude and practice of Nigerian surgery trainees to HIV-infected persons and AIDS patients

BACKGROUND

The incidence of HIV infection and AIDS is rising in Nigeria. Surgeons are at risk of occupationally acquired infection as a result of intimate contact with the blood and body fluids of patients. This study set out to determine the knowledge, attitude and risk perception of Nigerian surgery residents to HIV infection and AIDS.

METHODS

A self-administered postal questionnaire was sent to all surgery trainees in Nigeria in 1997.

RESULTS

Parenteral exposure to patients' blood was reported as occurring 92.5% times, and most respondents assessed their risk of becoming infected with HIV as being moderate at 1-5%. The majority of the respondents were not aware of the CDC guidelines on universal precautions against blood-borne pathogens. Most support a policy of routinely testing all surgical patients for HIV infection but 76.8% work in centers where there is no policy on parenteral exposure to patients' blood and body fluids. Most (85.6%) do not routinely use all the protective measures advocated for the reduction of transmission of blood borne pathogens during surgery, with the majority ascribing this to non-availability. Most want surgeons to be the primary formulators of policy on HIV and surgery while not completely excluding other stakeholders.

CONCLUSIONS

The study demonstrates the level of knowledge, attitude and practice of Nigerian surgery trainees in 1997 and the need for policy guidelines to manage all aspects of the healthcare worker (HCW), patients, and HIV/AIDS interaction.

Perforation rates for nonsterile examination gloves in routine dermatologic procedures

BACKGROUND

Low cost, nonsterile examination gloves are used routinely to perform various dermatologic procedures.

OBJECTIVE

To evaluate the perforation rate of nonsterile examination gloves in routine dermatologic procedures.

METHODS

Three hundred fifty nonsterile latex examination gloves used to perform shave biopsies were evaluated for perforations using an air inflation/water submersion method. Ninety gloves, which were intentionally perforated with a 30-gauge needle, were used as controls to assess our evaluation method.

RESULTS

Eight of the 350 gloves were found to have a perforation, which corresponds to a 2.3% perforation rate. Seven of the eight perforations were found in the web space between the second and third finger sleeves, with one being an obvious manufacturing error. All 90 perforations of the control group were correctly identified.

CONCLUSION

There appears to be a very low risk of glove perforation when nonsterile examination gloves are used in routine dermatologic procedures.

Surgeon-patient barrier efficiency monitored with an electronic device in three surgical settings

Blood-borne viral pathogens are an occupational threat to health care workers (HCWs), particularly those in the operating room. A major risk is posed by accidental penetrating injury, but skin contamination with body fluids from an infected patient, with prolonged intimate cutaneous contact, is a frequent occurrence during surgery, carrying further risk of transdermal infection. We have monitored barrier failure in three surgical settings (microsurgery, orthopedic surgery, general surgery) by means of an electronic surveillance device. A total of 111 surgical procedures were monitored: 67 microsurgeries, 22 orthopedic surgeries, and 22 general surgeries. Of the 278 electronic alarms signaling barrier failure, 44 (15.8%) were associated with glove perforation, 39 of which (88.6%) were not perceived by the operator. In 16 of those, the skin was visibly stained with the patient's blood. Altogether, 76 of the alarms (27.3%) were consequent to contacts caused by soaked gowns/sleeves, and 121 (43.5%) were attributed to hydration of latex porosities; 37 alarms (13.4%) were unexplained false positives. On only one occasion did a surgeon observe blood stains on his hands without a previous alarm; this event was classified as a device failure due to incorrect wiring. Double-gloving offered satisfactory protection against skin contamination during microsurgery but not during orthopedic surgery. The data presented here indicate that electronic monitoring of the surgical barrier enables prompt detection of barrier failure, especially at the level of the gloves, thereby limiting skin contamination with patients' body fluids during surgery.

How often does glove perforation occur in surgery? Comparison between single gloves and a double-gloving system

BACKGROUND

In surgery, intact gloves protect the surgeon from bloodborne pathogens and the surgical wound from microorganisms on the skin of the surgeon. However, glove perforation is very common, and puncture rates as high as 61% are published in the literature. One objective of this study was to compare puncture rates between a unique double-gloving puncture indication system and single-use gloves, and another was to determine the extent to which glove perforations remain undetected during surgery.

METHODS

The study material comprised all gloves used in surgical operations at our hospital for a period of 2 months. The analysis was made by the glove type in a prospective and randomized manner. Gloves were tested immediately after the surgical procedure using the approved standardized water-leak method for 2 minutes to detect any holes. The gloves used in this study were either a double-gloving puncture indication system or the standard glove used at our hospital.

RESULTS

In 885 operations altogether, 2,462 gloves were tested; 1,020 single gloves, 1,148 double-glove systems, and 294 combination gloves were studied. The overall perforation rate was 192 out of 2,462 gloves (7.80%), and 162 out of 885 operations (18.3%). The detection of perforation during surgery was 28 out of 76 (36.84%) with single gloves, 77 out of 89 with the double-gloving system (86.52%), and 9 out of 27 with combination gloves (33.33%; P <0.001). The inner glove of the double-gloving system was punctured in 6 out of 88 outer glove perforations (6.82%).

CONCLUSIONS

In view of the critical importance of safety at work by having a sterile barrier between surgeon and patient, it is very important to use a double-gloving puncture indication system, at least in operations where there is a high risk of glove perforation.

New advances in electronic devices for hole detection

Holes in surgical gloves are considered to be an important source of transmission of pathogens between surgeon and patient. Two new glove hole detectors have been devised to alert the surgeon to the presence of holes. These devices have been evaluated using six powder-free and seven powdered varieties of surgical gloves that were either dry or exposed to hydration. Eight of the 13 surgical gloves hydrated rapidly with water, altering their resistance to the conduction of electricity. Because the Barrier Integrity Monitor¿ only has a hydration monitor, 68 false positives occurred during the evaluation, indicating to the surgeon that he/she should change gloves unnecessarily because the glove had no hole. In contrast, the Surgic Alert Monitor¿ (SAM¿) had a hydration alarm as well as a glove hole detection alarm. During the 104 tests, the SAM¿ device showed no false positives. In the testing of five of the rapidly hydrating types of surgical gloves, the SAM¿ device could not reliably detect holes. On the basis of this study, the SAM¿ device, in conjunction with gloves that resist hydration, appeared to be a reliable hole detection monitor.

Glove perforation rate in open lung surgery

OBJECTIVE

In open lung surgery the surgical access is encircled by the ribs, which should result in a high glove perforation rate compared with other surgical specialities.

METHODS

Prospectively the surgeon, first and second assistant and the scrub nurse wore double standard latex gloves during 100 thoracotomies. Parameters recorded were: procedure performed, number of perforations, localization of perforation, the seniority of the surgeon, manoeuvre performed at the moment of perforation, immediate cause of perforation, operation time, performance of rib resection during thoracotomy and time of occurrence of the first three perforations.

RESULTS

One thousand, six hundred and seventy-three gloves (902 outer, 771 inner) were tested. In 78 operations perforations occurred. There were 150 outer glove perforations (8.9%, 0-8, mean 1.23), 19 inner glove perforations (1.13%, 0-2, mean 0.19). Cutaneous blood exposure was prevented in 78% of all operations and in 87% of all perforations. The perforation rate for the surgeon, the scrub nurse, the first and the second assistant were 61.2, 40.4, 9.7 and 3.1% of all operations, respectively. Rib resection and a duration of more than 2 h resulted in a significant rise of glove perforation rate (P<0.05). The personal experience of the surgeon and the type of operation did not correlate with glove perforation. The immediate cause leading to perforation was named in only 17 cases (13.7%) and comprised contact with bone (seven), a needle stitch (seven) and a production flaw (three). Leaks were localized mostly on the first finger (18%),second finger, (39%) palm and dorsum of the hand (16%). The average occurrence of all first perforations was 38.7 min (range 3-190) after the beginning of surgery, the second after 63.2 min (range 10-195). Fifty-four first perforations (50.5%) were found during the first 30 min of the operation.

CONCLUSIONS

The reported perforation rate of 78% lies in the highest range of reported perforation rates in different surgical specialities. Double gloving effectively prevented cutaneous blood exposure and thus should become a routine for the thoracic surgeon to prevent transmission of infectious diseases from the patient to the surgeon.

Loss of glove integrity during emergency department procedures

STUDY OBJECTIVE

We sought to assess the loss of integrity of the latex-glove barrier during use in the ED setting.

METHODS

We conducted a prospective observational study in an urban ED and Level I trauma center. Procedures performed by ED health care workers (HCWs) were directly observed, timed, and categorized. The gloves used by the HCWs were collected and subjected to the standard US Food and Drug Administration leak test.

RESULTS

Ninety-nine (7.9%) of 1,254 pairs of gloves used for observed procedures leaked, compared with 2 of 200 unworn control pairs (1.0%) and 12 of 300 pairs that were worn but not used (4.0%). Leak rates varied by manufacturer and were higher for gloves worn 20 minutes or longer (13.7%, P = .015), used for four or more procedures (50%, P < .01), or used for critical care procedures (23.5%, P < .01). Sixty-six of an additional 325 pairs of gloves collected from unobserved critical care procedures (20.3%) leaked.

CONCLUSION

Loss of glove integrity occurs during the performance of ED procedures, subjecting the HCW to possible infectious-fluid exposure. Risk of glove perforation increases with duration of wear, number of procedures performed, and the performance of critical care procedures.

Surgical glove failures in clinical practice settings

Health care personnel often pay little attention to the barrier effectiveness of the surgical gloves they use in clinical settings. They may assume that all surgical gloves provide adequate protection against the transfer of bloodborne pathogens, chemicals, or mutagenic substances. Perioperative staff members frequently are unaware that their surgical gloves have failed until they find blood on their hands after operative procedures are completed. In this first article of a three-part series, the authors review current surgical glove testing standards, define surgical glove failure, and describe the reasons that surgical glove failure occurs in clinical practice settings.

Needle puncture resistance of surgical gloves, finger guards, and glove liners

New puncture resistant materials are being developed for health professional use as protection against disease and needle stick injuries. The needle puncture resistance of protective gloves and glove liners from DePuy DuPont Orthopaedics and of finger guards from Zimmer was evaluated using a computerized needle penetration system to determine maximal penetration forces and the penetration work required for taper point and for cutting edge needles to penetrate these membranes. The Medak portion of the Life Liner glove liner and the Spectra portion of the FingGuard finger guard offered remarkable resistance against needle penetration as compared to the other glove liners and gloves tested. The cutting edge needles required considerably less penetration force and work to penetrate the FingGuard and Life Liner than that required with comparable size taper point needles. Because these unique protective materials had a limited distribution over the hand, the surgeon's hand remained susceptible to inadvertent needle puncture. While this protection against needle penetration in the Life Liner and the FingGuard represents an exciting advance in surgery, it is important to emphasize that this development is only one consideration in the selection of surgical gloves.

A survey of glove preferences of general and orthopaedic surgeons in North West Thames Regional Health Authority

The glove preferences of all the consultant surgeons and consultant orthopaedic surgeons in North West Thames were surveyed by questionnaire. Responses were received from 59 of 78 general surgeons and 47 of 55 orthopaedic surgeons. Twenty-two percent of general surgeons never double gloved compared with 4% of orthopaedic surgeons (P < 0.01). Seventy-three percent of general surgeons double gloved for 'high risk' patients compared with 17% of orthopaedic surgeons (P < 0.001). When double gloving the majority of surgeons (67%) used their normal sized glove inside and half a size larger on the outside.

A comparative study of two types of latex surgical gloves in elective orthopaedic surgery

Glove perforation during surgery represents a potential risk of infection for the surgeon. The authors postulated that thicker latex gloves may offer greater protection. The perforation rates for the Ansell Gammex glove and the thicker Baxter Triflex gloves were compared in single- and double-glove usage and no difference was found between the two brands, in either usage. The authors recommend double-gloving for all orthopaedic operations with regular glove changes during major procedures.

A new glove puncture detection system

A new glove detection system has been developed for early and accurate detection of a hole in the glove. It consists of an inner glove colored by a green dye and outer glove. When a breach in the outer glove occurs, the inner glove develops a dark patch around the needle puncture hole, a visible indicator for immediate glove change. Using a computerized needle penetration system, the immediate and maximal penetration forces as well as the work required for needle penetration of this new double glove was significantly greater than those encountered with either the inner or outer glove tested separately. In addition to hole detection, this double glove provides increased protection against needle penetration.