University Hospital of Tampere, Finland
Professor of Surgery
University of Turku
Chief of Surgery
Central Hospital of Satakunta, Finland
Surgical gloves were originally invented to protect the hands from strong disinfectant agents. Ever since the sterilisation of gloves, the use of surgical gloves has been mainly aimed at protecting the patient from wound infection. With the emergence and spread of blood-borne diseases such as hepatitis B (HBV), hepatitis C (HCV) and human immunodeficiency virus (HIV), the importance of protecting both patient and surgeon from blood exposure has been emphasised.
Surgical gloves are often perforated during surgery, exposing the surgeon’s skin to body fluids that may transmit lethal diseases. In the same way, the patient can be exposed to the surgeon’s blood, and there are known cases of HBV, HCV and HIV transmission from surgeon to patient. In addition, the patient is also faced with the risk of wound infection, which leads to loss of resources and suffering for the patient, and which may also jeopardise the whole operation.
Different types of gloves
Gloves currently used in surgery are mainly made of latex, which is a refined product of natural rubber. High-quality latex gloves are thin, durable and elastic. They should resist chemical deterioration and hydration to a high degree, despite the natural porosity of latex. Low-quality gloves can have pores large enough to let skin bacteria and viruses through, although they may seem intact to the eye.(1–3)
Several other types of gloving systems exist in addition to single-use gloves. Using two pairs of (latex) gloves on top of each other – which is known as double gloving – gives significantly better protection against blood exposure of the skin compared with single gloving. However, surgeons are often reluctant to use them, because of their interference with dexterity and tactility.(4,5)
The use of double gloves with an inner, coloured glove – the indicator glove – offers protection similar to or better than that of regular double gloving and also markedly increases the intraoperative detection rate for breaches in the glove barrier.(6–8) The indicator gloving system consists of two pairs of gloves worn on top of each other; an inner dark green and an outer cream-coloured glove. The inner glove is a half-size larger than the outer one. The colour of the inner glove becomes visible only if fluid penetrates the air-filled space between the two gloves.
Consequently, a leak of the outer glove causes a clearly visible, rapidly spreading green patch if the surface of the outer glove is in contact with some fluid, which is drawn in through perforation by capillary action.
Orthopaedic gloves are thicker than regular latex gloves for additional protection. However, when used in orthopaedic procedures, a thick glove does not diminish the frequency of perforation.(9) Cloth gloves, worn on top of regular latex gloves or between two latex gloves, reduce the perforation rate of the inner glove compared with double latex gloving.
Different kinds of reinforced gloves have been introduced on the market. Steel wire weave glove liners are extremely cut-resistant in laboratory settings but do not offer better protection when worn on top of a single latex glove during surgery, compared with double latex gloving.(10) Gloves made of Kevlar, a material used in ballistic vests for law enforcement, offer similar protection as outer gloves constructed from cotton, high-strength polyethylene or steel/nylon wires when worn on top of latex gloves. The perforation rates of the inner glove are similar to those obtained when using double latex gloving, but the detection rate is poor.
An alternative technique to detect perforation is electronic monitoring, which causes an alarm signal if the insulating effect of protective wear is lost during surgery. The monitoring unit is connected to the patient and to a conductive surface, on which the surgeon stands. The strength of this method is that it also detects other breaches of protective equipment, such as wetting of gowns or hydration of latex glove porosities. The weakness of this method is that up to 13% of alarms are false- positives – for example, when the operator accidentally touches the base of the operation table or steps away from the conductive surface. Therefore, surgeons do not always respond appropriately to the alarm.(11–13)
Different types of glove perforations
The type of glove perforation mainly depends on the quality of the gloves used, the type of surgery being carried out and the individual surgeon. The reported amount of perforations per operation is 18% in general surgery, 23–25% in orthopaedic procedures and 83% in heart surgery.(14–18) Perforations are found in 14.6–48% of single gloves in postoperative testing, and there is no difference in perforations of single or outer double glove compared with double gloving.(4,8,16,19)
The importance of double gloving is seen when comparing the perforation rates of single and inner double gloving. Several studies show that only 2–4% of inner gloves have matching perforations with the outer ones.(4,6,8,14) Only 12.3–50% of perforations in single and 21–58% in outer double gloving are recognised during or immediately after the operation.(7,14,16,19,20)
The use of indicator gloves increases the detection rate to 78–97.4% of perforations in surgeons’ gloves.(6–8,21,22) Perforation frequency is higher for the principal surgeon than for the assistant.(14,19,23,24) Risk of perforation rises in emergency surgery and for long operations (risk increases by 1.115 times for every 10 minutes of surgery). (16,17,25) The use of indicator gloves significantly increases detection of perforations.(6–8,17,21,22)
The majority of punctures are located on the nondominant hand (58–73%), mostly in the nondominant index finger (30–50%), thumb and middle finger. These injuries are mainly related to suturing and to the use of wires. (7,8,14,15,19,23,26) Wedding rings under the gloves cause a significant increase in glove perforations.(27)
Percutaneous injuries occur in 0.9–9.3% of operations, (7,23,28–30) and evidence of superficial hand injuries – which had caused bleeding or could be made to bleed – has been reported after 20% of operations.(26) This risk varies among different surgeons and surgical procedures.(29)
More than 36% of glove perforations cause visible bloodstaining of the hands.(13) Wearing double instead of single gloving can lead to a reduction of 88–93.6% with regard to the surgeon’s risk of exposure to blood.(6,8,20)
The use of double gloving reduces the inner glove perforation rate by more than 60% (and prevents cutaneous hand exposure to blood). More than 50% of cutaneous hand exposures in the single glove group could be prevented by double gloving.(28) Double gloving reduces the amount of blood exposure but does not reduce the risk for sharp percutaneous injuries.(30) Nevertheless, it offers better protection in some cases; for example, if a needle passes through two layers of latex instead of one, the amount of inoculated blood is smaller. Consequently, the risk for disease transmission is probably also reduced. (2,31,32)
Surgical site infection
In the event of perforation, preoperative hand disinfection combined with use of sterile gloves minimises wound contamination from the surgeon’s hands. A recent study failed to show that intraoperative glove perforation increased the risk of surgical site infections.(33)
Risks of blood exposure can be reduced by using high-quality gloves and surgical equipment, and by avoiding passing sharp objects from hand to hand. Double gloving significantly diminishes the risk of blood exposure for the surgeon.
It is recommended that double indicator gloving be used in surgery. Surgeons must weigh the benefits and drawbacks of wearing double gloving systems for sufficient protection.
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