Glove perforations during open surgery for gynaecological malignancies
Dr AP Manjunath, Department of Obstetrics and Gynecology, Kasturba Medical College and Hospital, Manipal 576 104, India. Email email@example.com
Objective To audit glove perforations at laparotomies for gynaecological cancers.
Setting Gynaecological oncology unit, cancer centre, London.
Design Prospective audit.
Sample Twenty-nine laparotomies for gynaecological cancers over 3 months.
Methods Gloves used during laparotomies for gynaecological cancer were tested for perforations by the air inflation and water immersion technique. Parameters recorded were: type of procedure, localisation of perforation, type of gloves, seniority of surgeon, operation time and awareness of perforations.
Main outcome measure Glove perforation rate.
Results Perforations were found in gloves from 27/29 (93%) laparotomies. The perforation rate was 61/462 (13%) per glove. The perforation rate was three times higher when the duration of surgery was more than 5 hours. The perforation rate was 63% for primary surgeons, 54.5% for first assistant, 4.7% for second assistant and 40.5% for scrub nurses. Clinical fellows were at highest risk of injury (94%). Two-thirds of perforations were on the index finger or thumb. The glove on the nondominant hand had perforations in 54% of cases. In 50% of cases, the participants were not aware of the perforations. There were less inner glove perforations in double gloves compared with single gloves (5/139 versus 26/154; P = 0.0004, OR = 5.4, 95% CI 1.9–16.7). The indicator glove system failed to identify holes in 44% of cases.
Conclusions Glove perforations were found in most (93%) laparotomies for gynaecological malignancies. They are most common among clinical fellows, are often unnoticed and often not detected by the indicator glove system.
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Needle stick injuries are common among healthcare workers. The risks of viral transmission have been estimated to be 12–27% for hepatitis B virus (HBV), 0.5–18% for hepatitis C virus and 0.4% for HIV.1,2 The rate of glove perforation has been investigated in various surgical specialities: 10% for open lung surgery,3 12–24% for caesarean section,4,5 28% for major gynaecological surgery,5 26% for orthopaedic surgery6 and 35% for general surgery.7 Unnoticed glove perforations represent a potential risk of infection for the surgeon by prolonged exposure to blood or other body fluids. Surgeons tend to underestimate the risk of cross-infection during surgical procedures.8 Glove perforations specific to gynaecological cancer surgery have not been investigated previously. We describe an audit of glove damage during laparotomies in a gynaecological cancer centre.
In a prospective audit conducted between July 2006 and October 2006, gloves were tested for perforations during 29 laparotomies for gynaecological malignancies. The participants wore single regular gloves (Biogel®; Mölnlycke, Gothenburg, Sweden), double regular gloves (Biogel®) or the ‘indicator’ double gloving system (Biogel® Indicator™; Mölnlycke) according to their normal preferences. The ‘indicator’ system uses a green inner glove to help identify punctures. The green inner glove becomes darker at the site of a perforation. This is due to the ingress of fluid by capillary action.9 One investigator who did not have clinical responsibilities during the operations was designated to collect the gloves and record data. Participants reported glove breaches detected by the indicator system or spontaneously with regular gloves. Once a perforation was recognised, the glove was removed. Gloves that were changed intraoperatively were also tested. Gloves were collected in plastic bags, labelled and tested for perforations at the end of each procedure. Gloves were tested for punctures by filling them with air while simultaneously twisting around the wrist margin. They were immersed in a tub containing about 3 l of water and gentle pressure was applied to the palmar surfaces. Escape of air bubbles helped to identify perforations. The glove was then turned over and resubmerged with gentle pressure on the dorsal surfaces. This method of testing has been validated by other investigators.4,10 The following parameters were documented: location of perforation, dominance of hand, grade of surgical team member, awareness of perforation, type of glove used, type of surgery and duration of operation. The observations were reported with descriptive statistics. Dichotomous data were analysed using the chi-square test.
Four hundred and sixty-two gloves were tested from 140 participants in 29 laparotomies. They comprised of 154 single gloves, 18 regular double gloves and 290 ‘indicator’ double gloves. The operations consisted of 19 ovarian cancer debulking procedures (two underwent splenectomy), 6 extrafascial hysterectomies, 2 radical hysterectomies, 1 total exenteration and 1 radical colpectomy.
Glove perforations occurred in 27 of 29 (93%) laparotomies. Perforations occurred in all (19/19) ovarian debulking procedures, five of six (83%) extrafascial hysterectomies and one of two (50%) of the radical hysterectomies (Table 1). Among 462 single and double gloves tested, 61 (13%) perforations were found. The glove perforation rate for different procedures is listed in Table 1.
Table 1. Procedure perforation rate and glove perforation rate
|Ovarian debulking||19/19 (100.0)||32/279 (11.5)|
|Extrafascial hysterectomy||5/6 (83.3)||12/78 (15.4)|
|Radical hysterectomy||1/2 (50.0)||9/47 (19.1)|
|Exenteration||1/1 (100.0)||5/37 (13.5)|
|Other||1/1 (100.0)||3/21 (14.3)|
|Total||27/29 (93.1)||61/462 (13.2)|
The median operating time was 180 minutes (interquartile range 150–275 minutes). The overall breach rate per procedure was 2.1. The mean breach rate according to duration of operation was as follows: for operating time less than 3 hours, the mean breach rate was 1.5 (25/16), for 3–5 hours was 1.8 (17/9) and when more than 5 hours was 4.7 (19/4) (r = 0.57, t = 3.6, P = 0.0013) (Table 2).
Table 2. Duration of surgery and perforation rate
The glove perforation rate for different members of the team is as follows: primary surgeon 63% (33/52), first assistant 54.5% (12/22), second assistant 4.7% (1/21) and the scrub nurse 40.5% (15/37). Forty-three percent (26/61) of perforations were in the index finger and 24.6% (15/61) were in the thumb (Table 3). The perforation rates in left and right hand were 54.4% (31/33) and 45.6% (26/28), respectively. Perforations occurred in the glove on the nondominant hand in 54% of cases whether single or double gloved. The perforation rates in male and female participants were 47.5% (26/29) and 52.5% (31/32), respectively. The glove perforation rate according to the grade and seniority of surgeon were as follows: consultant 25% (6/25), clinical fellow 94% (31/33), registrar 54.5% (6/11), senior house officer 8.8% (3/34) and scrub nurse 40.5% (15/37) (Table 4).
Table 3. Site of perforation in participants
|Palmar surface||1||0||0||1||2 (3.3)|
Table 4. Experience of participants and glove perforation rate
|Senior house officer||34||3||8.8|
The participants were unaware of perforations in 47.8% (11/23) of cases when a single glove was used and 43.7% (14/32) of cases when indicator double gloves were used. There was no significant difference in the awareness of glove perforation rate among indicator double glove system when compared with single gloves (P = 0.83; OR = 0.78, 95% CI 0.2–2.4) (Table 5). The indicator system allowed the outer glove breach to be detected in real time on 18 of 32 (56%) occasions. In two cases, the inner glove was perforated despite an intact outer glove. However, there were no needle stick injuries reported. For double gloving (regular and indicator systems), 35 glove perforations were observed, of which 30 were in the outer glove and 5 in the inner glove (Table 6). There were fewer perforations in the inner of double gloves compared with single gloves. This was 5 of 139 (3.6%) compared with 26 of 154 (16.9%) (P = 0.0004, OR = 5.44, 95% CI 1.91–16.70). Two outer glove perforations had matching inner glove perforations. This indicates that in 93% of cases, when the outer glove is perforated, the inner glove will protect the surgeon’s hand from contamination. Perforations were recognised intraoperatively due to diathermy shock by surgeon on two occasions and blood staining on the finger after removal of glove on one occasion. There was no significant difference in the frequency of perforation to the outer glove of the indicator double group 17.6% (28/159) and single-gloving group 16.8% (26/154). But there was a significant reduction in glove perforations between the inner glove of the indicator double group 3% (3/131) compared with the single-gloving group 16.8% (26/154) (P = 0.0003, OR 6.45, 95% CI 2.0–22.4).
Table 5. Awareness of glove perforation and type of glove
|Double indicator glove||18||14|
Table 6. Perforation of inner/outer glove in relation to type of glove
|Perforations n (%)||26 (16.8)||1 (12.5)||2 (20)||4 (3)||28 (17.6)|
The use of sterile surgical gloves has become the standard of care in the perioperative environment. With increasing awareness of the risk of transmission of pathogens, particularly HBV and HIV, there is increasing interest in protecting the surgeon from the contaminated body fluid and tissues of patient. Often, surgeons have unnoticed abrasions on their hands that place them at risk if the integrity of the surgical glove is compromised. A surgeon’s breached glove not only indicates the potential for infection to the operating surgeon but also to the patient.11,12 Hence, both patients and the surgical team need to be protected from this risk. Moreover, there is immunosuppression and increased risk of communicable diseases in patients with malignancies, especially with cervical cancer. Therefore, it is of paramount importance for healthcare professionals in oncology to ensure they are protected from such diseases during surgery.
Primary surgeons had more perforations than assistants. This is probably because assistants do not use the knife or needles as much. In our audit, scrub nurses had a high glove perforation rate also. Similar findings have been noted by other investigators.4,13 Scrub nurses use the same set of gloves for sharps disposal after surgery, and the high perforation rate may not represent intraoperative perforation. Clinical fellows had the greatest risk of perforation (94%). This may be because they were most often the primary surgeon and less experienced than the supervising consultants. However, other investigators have reported that the level of training did not affect the frequency of glove perforations.4,5,13 Our findings confirm those of other investigators with two-thirds of perforations in the index finger or thumb.4,5,14 This suggests that some perforations were due to direct manipulation of sharps with these digits and using the electrocaurtery unit. Strict use of tissue forceps would reduce such perforations. Reinforcement of the glove in these areas during manufacture may help reduce sharp injuries but might reduce tactile sensation. The nondominant hand is at increased risk of injury. That is because the surgeon usually holds the instruments in his dominant hand and holds the tissue with the nondominant hand. The needle may accidentally puncture the glove of the opposite hand. Similar observation is made by other studies.4,5,13,14
The procedure perforation rate in our audit was 93%. The glove perforation rate varies from 11 to 19% with different gynaecological operations. The highest perforation rate was in radical hysterectomy with bilateral pelvic lymphadenectomy. This high incidence of perforations in gynaecological oncology may be due to long operating hours requiring more dissection, suturing, knot tying and extended use of sharp instruments in the bony pelvis. Moreover, gynaecological oncologic surgery requires subspecialty training with more complex cases being operated at our institution, which acts as a tertiary referral centre. The glove perforation rate is higher as the operating time increases. Fay and Dooher15 also noted that the glove failure rate was more frequent in longer procedures (1–3 hours, 27% failure rate; 3–5 hours, 47% failure rate; more than 5 hours, 58% failure rate). Our results show that double gloving reduces the risks of exposure to blood and body fluids during gynaecological oncology by 93% when the outer glove is breached. Several studies have shown the value of double gloving in different surgical specialities also.16–19 Pre-existing perforations have been reported in unused gloves. The rate varies from 2–7.5%.20–22 Surgeons using single gloves are more likely to have contamination from patient’s body fluids because of this background risk. Furthermore, the perforation rate of the inner of double gloves is lower than that of single gloves. There was penetration of both gloves in four instances, representing 6.5% of the total glove perforations. Therefore, the possibility of blood contamination during the operation is increased when the surgeon uses single compared with double gloves. In two cases, the inner glove was perforated despite an intact outer glove. This could have resulted from overstretching when donning or pre-existing glove perforations. Only two outer glove perforations had matching inner glove perforations, thus indicating that in 93% of cases when the outer glove is perforated, the inner glove will protect the surgeon. The indicator system has been developed to assist detection of glove punctures. Early intraoperative identification and changing of damaged gloves may also reduce the duration of exposure to body fluids when a puncture has occurred. In our study, nearly 50% of perforations were not recognised by the surgical team. Therefore, the barrier between the patient’s blood and the surgeon’s skin may be breached unknowingly for prolonged periods. Although an indicator system for identifying perforations with accuracy of 97% has been reported,8,23 our observation is that the indicator system identified holes only in 56% cases. One of the explanations given by Avery et al.24 is that the ‘indicator’ system works effectively only if adequate fluid is present in the operative site. Therefore, a wet operating field is necessary for a colour change to occur with ingress of fluid by capillary action between the gloves, which can be easily noticed by the wearer. Our rate of immediately detected perforations in the indicator glove system of 18/32 is higher than that observed by Caillot et al.25 in visceral surgery (3/16) but lower than the rate observed by Laine and Aarnio26 in orthopaedic surgery (37/41). It is likely that the breaches occurring during orthopaedic surgery are larger than those during visceral surgery. This suggests that an adequate size of breach (as in orthopaedic surgery) is required to allow detection of the perforation. Thus, the indicator glove indicator system may fail to change colour if the surgical field is either dry or only slightly moistened by body fluids, and this could occur if the breach is not large enough to allow the fluid to come into contact with the inner glove. The most important factor that influences the surgeon in choosing double gloving is the loss of tactile sensation, reduced sensitivity and dexterity.13,27 Although a larger inner glove is usually recommended, many surgeons find gloves of equal sizes or a larger outer glove more comfortable.8 The main concern about double gloving is whether the wearers of two pairs of gloves are more prone to accidental perforations as a result of impaired sensitivity and compromised dexterity. However, double gloving did not result in significantly more outer glove perforations than single gloves, suggesting that the dexterity of the glove wearer is not sufficiently compromised leading to additional perforations.28 In the 2006 Cochrane review28 of double gloving, findings were summarised from 31 randomised controlled trials. The review, which covers a variety of surgical environments and addresses several double gloving options, indicates that the addition of a second pair of surgical gloves significantly reduces perforations to innermost gloves. Perforation indicator systems result in significantly more innermost glove perforations being detected during surgery. Although the Cochrane review concludes that there is no direct evidence that additional glove protection worn by the surgical team reduces surgical site infections in patients, the review has insufficient power to show for this outcome.
As there are no published data for glove perforation rates in gynaecological oncology surgery, it is difficult to define an acceptable standard. However, the important message from our data is that gynaecological oncosurgeons are at high risk for blood and body fluid exposure during operations. Use of double gloving may reduce the risk. As the majority of glove perforations go unnoticed, we recommend the routine use of double gloves. This audit only assessed a small number of surgical teams. However, it is likely that this is representative of gynaecological oncology surgery nationally. A large randomised controlled trial of infection rates when using different gloving methods would be necessary to identify the real impact of double gloving and methods for reducing the risk of glove perforation.
Contribution to authorship
T.E.J.I. and A.P.M.: study conception and design; A.P.M.: acquisition of data and checking the perforations of glove; T.E.J.I., A.P.M., D.P.J.B.: analysis and interpretation of data; A.P.M., T.E.J.I.: drafting of manuscript; T.E.J.I., D.P.J.B., J.H.S., J.E.B., A.P.M.: critical revision; T.E.J.I., A.P.M.: statistical expertise; T.E.J.I., D.P.J.B., J.H.S., J.E.B., A.P.M.: final approval of the version to be published; T.E.J.I.: supervision.
Details of ethics approval
The ethical committee clearance was not required for this audit as there was no patient participation or involvement of animal subjects, or medical records.
This publication is made as a result of International Federation of Gynecology and Obstetrics and International Gynaecologic Cancer Society (FIGO-IGCS) Gynaecologic Oncology Fellowship programme 2005–06. The authors thank FIGO-IGCS for the contribution and support. The authors thank Dr NS Nair, Professor and Head, Department of Statistics, and Dr Vani Ramkumar, Professor and Unit IV Chief, Department of Obstetrics and Gynecology, Manipal University, Manipal, India, for helping with statistical analysis and typographical errors.