Originally published in the January 2016 issue of Veterinary Practice News. Did you enjoy this article? Then subscribe today!
Surgical site infections, or SSIs, are a constant concern for surgeons and surgery lovers. Infection can lead to dissatisfaction, distress and even death (spontaneous or via euthanasia). Given the rise of nosocomial infections from drug-resistant bacteria, keeping infection prevention front and center is of ever-increasing importance.
The prevention of SSIs can be visualized as a patient/pathogen/procedure triangle:
- Patient factors relate to the incision or the wound, tissue depth, systemic defenses and risk factors such as diabetes (at least theoretically) and malnutrition.
- Pathogen factors include the bacteria, their quantity and virulence.
- Procedure factors are those we should strive to control: antibiotic prophylaxis, hypothermia avoidance, gentle tissue manipulation and aseptic technique.
Using aseptic technique includes appropriate surgical attire. Caps, masks, gowns and surgical gloves are the first line of defense against SSIs. Surgical gloves, however, are not invincible and can perforate.
Unfortunately, this happens much more often than we suspect. Defects often are not noticed until the gloves are removed after surgery and blood is observed on a finger. Noticing a hole during surgery would obviously be better.
A Study on Gloves Show Surprisingly Results
A prospective study (BJ Character et al. “Postoperative Integrity of Veterinary Surgical Gloves.” JAAHA 2003, Vol. 39, No. 3, p. 311-320) was conducted to test the postoperative integrity of surgical gloves. To our knowledge, this was the first study of its kind in veterinary medicine.
To document the incidence of defects postoperatively, gloves were collected after surgical procedures at two veterinary teaching hospitals and one institution’s student surgery lab. More than 760 gloves were tested for defects using electrical resistance after procedures performed by surgeons, residents, interns and students. We will refer to this article as “the first study.” In a similar and larger study (GM Hayes et al. “Investigation of Incidence and Risk Factors for Surgical Glove Perforation in Small Animal Surgery.” Vet. Surgery 2014, Vol. 43, N. 4, pp. 400-404), more than 2,000 gloves worn in 363 small animal surgical procedures at a veterinary teaching hospital were evaluated using a water-leak test.
The surgeries ranged from minimally invasive (laparoscopy, arthroscopy) to laparotomies and arthrotomies. Operators included faculty members, surgical residents, interns and senior veterinary students. We will call this paper “the second study.”
The results were staggering.
In the first study, 23 percent of gloves had a defect at the end of surgery. Worse, 93 percent of users were not aware of the tear.
In the second study, at least one glove perforation occurred in 26 percent of procedures and went undetected by the wearer 69 percent of the time.
In both studies, about 80 percent of tears occurred during surgeries that lasted over an hour. This makes perfect sense; the longer the time spent in surgery, the greater the chances of catching a glove on an instrument or a sharp structure.
Orthopedic procedures showed a higher incidence of glove perforation in both studies. Again, this makes sense given the typically increased duration of surgery, exposure to power equipment, surgical wire and bone fragments. Yet tears occurred in almost 20 percent of soft tissue surgery cases.
In the first study, 78 percent of defects occurred in gloves worn on the nondominant hand, and 64 percent of the time on the index finger, followed by the thumb. This fact is intuitive as we typically hold the scalpel and sharp instruments with our dominant hand while usually touching or retracting tissues, including bones, with our non-dominant hand.
We also tend to grab needles with our nondominant hand (a bad habit, as the needle should be grabbed with thumb forceps).
Surprisingly, the experience level of the practitioner, whether faculty or student, did not have any bearing in either study. This proves that regardless of one’s level of expertise or years in the field, no one is immune to this risk.
While the brand of glove used had no effect on incidence, another increased risk factor assessed by the second study was the use of polyisoprene instead of latex gloves, primarily used by surgeons allergic to latex. Polyisoprene is a synthetic material that lacks protein allergens, but it also lacks stress tolerance.
The data show a high incidence of glove perforations in small animal surgery. The fact that most of these perforations go unrecognized by the user is something to keep in mind. To avoid perforations, whether noticed or unnoticed, there are a few precautions to take.
The authors recommend changing gloves every 60 minutes during long surgical procedures, especially orthopedic and neurological.
Longer surgeries invariably increase the odds of perforation, as do surgeries involving orthopedic or neurological equipment.
Surgeons allergic to latex should avoid polyisoprene gloves due to their lower stress tolerance. Alternatives to polyisoprene include neoprene or nitrile gloves, which are available from veterinary suppliers.
The Value of Double Gloving
Double gloving has been proved effective when the risk of infection would be catastrophic (e.g., in a total hip replacement). Adding an extra layer of protection reduces the incidence of perforation of the inside glove without decreasing surgical skills. Double gloving is recommended as the standard of care for surgeons performing invasive procedures in humans.
Ideally, the inner, or indicator, glove should be of a different color so a tear in the outer glove is more obvious.
Reinforced and orthopedic gloves, because of their increased thickness, are options to decrease the risk of perforation.
While proper attire such as surgical gloves is not the only factor in the epidemiology and prevention of surgical site infections, it is one aspect you can easily control. In turn, it will increase your peace of mind, pet owner satisfaction and the well-being of your patients.
History Lesson: First Surgical Gloves
History buffs may be interested to know that surgical gloves were introduced in 1893. In 1899, the benefits of rubber surgical gloves in reducing surgical site infections were first identified by Dr. Joseph Bloodgood, a student of Dr. William Halsted at Johns Hopkins Hospital in Baltimore. Halsted was the physician of “Halsted’s principles” fame.
Initially, gloves were meant to protect staff’s hands from harsh disinfectants. Then people noticed that gloves also reduced postoperative infection rates and mortality. By the early 1900s, using surgical gloves became routine.
Zee Mahmood, a veterinary student at the St. Matthew's School of Veterinary Medicine, contributed to this article.