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Citation: Medhioub F, Jaber E, Hamrouni A, Gharbi L. Unnoticed surgical gloves intraoperative perforation: A multicentric study of
the leading factors. Jr. med. res. 2020; 3(3):9-12. Medhioub et al © All rights are reserved.
https://doi.org/10.32512/jmr.3.3.2020/9.12
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Medhioub Fatma
1,2, *
, Jaber Eya
1,2
, Hamrouni Anouar
1,2
, Gharbi Lassad
1,2
.
Unnoticed surgical gloves perforation: A multicentric study of the
leading factors.
of the associated factors.
Background
Surgical gloves act as protective barrier against blood-borne pathogens
transmission from patients to healthcare workers and vice versa. The aim
of this study was to assess the rate of surgical gloves intraoperative
perforation and to highlight its leading factors.
Methods
A descriptive cross-sectional multicentric study was conducted at three
different Tunisian university hospitals: Charles Nicolle, La Rabta and Mongi
Slim. Four different surgical departments were involved: cardiovascular
surgery, urology, general surgery and otorhinolaryngology. The gloves
were collected and tested immediately at the sterilization units using the
leak test as described in European Norm EN 455-1.19. Results were
produced using the statistical package for social sciences version 19.0 and
the X2 was used with a significance threshold of 5%.
Results
A total of 320 gloves were collected. Seventy-two were found to be
perforated (22.5%). The majority of the perforated gloves were collected
after cardiovascular procedures (40%, p=0.001), on the non-dominant
hand (71%, p=0.0001), when the duration of the procedure exceeded 90
minutes (p=0.0001) and for thinner gloves (61%,p=0.018). The left index
finger of the surgeon’s glove is more likely to be perforated (38%).
Conclusion
This study showed considerable gloves perforation rate during surgical
procedures that could indicate the implementation of new rules and
policies in the operating theater practices.
Key words
Perforation, surgical gloves, operating theater, associated factors.
1: Department of general surgery Mongi Slim
Hospital Tunis, Tunisia.
2: College of Medicine Tunis, Tunis el Manar
University, Tunisia.
* Corresponding author
Correspondence to:
f.medhioub@gmail.com
Publication data:
Submitted: August 23, 2020
Accepted: October 14, 2020
Online: November 30, 2020
This article was subject to full peer-review.
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Abstract:
Original Article
Unnoticed surgical gloves intraoperative perforation: A multicentric study of the leading factors.
Citation: Medhioub F, Jaber E, Hamrouni A, Gharbi L. Unnoticed surgical gloves intraoperative perforation: A multicentric study of
the leading factors. Jr. med. res. 2020; 3(3):9-12. Medhioub et al © All rights are reserved.
Submit your manuscript: www.jmedicalresearch.com
Introduction
Gloves were first recommended for medical staff as a protection
from chemical products [1]. Since early 80
S
surgical gloves were
recognized as protective barrier against blood-borne pathogen
transmission and their single use was recommended [2].
Gloves perforation occurs frequently during surgical procedures
[3]. This incident may expose both patient and the surgical staff
to various infections. As perforation may not be apparent, it
seems useful to understand its mechanisms and the leading
circumstances. This could minimize the infection risk for the
patients and the health practitioners.
Our study aims to determine the rate of glove perforation and the
contributing factors.
Bibliographic review
We reviewed literature using several search engines and databases:
Pub Med, Science Direct, EM consult, google scholar using these
keywords: Perforation, surgical gloves, operating theater, associated
factors. Twenty-eight relevant papers published over the past
fifteen years were collected from the literature.
Ethical considerations
This study was approved by all the ethical committees of the
participating centers.
Results
Our study included 320 gloves. The participants (n=87) were
residents in 38% of cases, senior surgeons in 29%, operating room
technicians in 26% and scrub nurses in 7%. There was a male
predominance with a sex ratio of 2.5. Most of the participants were
<30 years old. The professional experience was <5 years in 47% of
cases. Most of the participants were right-handed (94%). (Table 1).
Table 1: socio-demographic characteristics of the participants
Characteristics
n
%
Gender
Male
63
72.4
Female
24
27.6
Age
20-30
47
54
31-40
12
13.8
41-50
17
19.5
>50
11
12.6
Surgical specialty
Cardio-vascular
20
23
General and digestive
26
29.9
Urology
17
19.9
Otorhinolaryngology
24
27.6
Position
Surgeon
25
28.7
Resident
33
37.9
Surgical technician /scrub nurse
29
33.4
Years of experience
1-5
41
47.1
6-10
26
29.9
>10
20
23
Dominant hand
Right
82
94.3
Left
5
5.7
The gloves usage characteristics is summarized in Table 2.
The overall perforation rate was 22.5% (n=72). Eighty different
perforations were noted. The most perforated finger was the index
finger (34%). Perforation was located in the thumb in 25% of cases,
in the ring finger in 14% and the little finger in 11%. Most of the
perforations occurred in the non-dominant hand (left hand).
Materials and Methods
Study design
This study is descriptive, cross-sectional and multicentric. It was
conducted in 4 different surgical units for 3 months (Tunis,
Tunisia):
*Department of urology ,Charles Nicolle hospital
*Department otorhinolaryngology, Charles Nicolle hospital
*Department of cardiovascular surgery,La Rabta hospital
*Department of general surgery, Mongi Slim hospital.
Population
This study included surgeons, residents, operating room
technicians and scrub nurses. The study included all gloves used
by the participants during the different surgical procedures. We
have tested two different brands of gloves made from natural
rubber latex (A and B). The brand A glove thickness was 0.20mm
and the brand B glove thickness was 0.16mm.
Data collection
Members of the surgical teams included were asked to fill out a
brief questionnaire about age, gender, function, years of
experience and dominant hand. All gloves were collected in a
plastic bag labeled according to the type of the procedures,
duration of the glove’s use, position of member and the dominant
hand for activity. The characteristics of the glove’s brand were
collected for each participant.
The gloves were collected and tested immediately at the
sterilization units using the leak test as described in European
Norm EN 455-1.19. Each Glove was evaluated separately. A 50-
mm-diameter tube made of polyvinyl chloride is inserted vertically
into the glove and fixed with a ring positioned at 40 mm from the
end to avoid glove damage. One liter (+/- 50 ml) of water is
poured into the glove. The glove was immediately inspected for 2-
3 minutes to detect any leakage. The number and location of
perforations as well as participant’s perception were noted.
Data analysis
Data was entered and analyzed using the Statistical Package for
Social Sciences (SPSS) version 19.0. The Chi-square test (X2) was
used for the comparative study. Significance was retained for P
value <0.05. Results were presented in the form of tables and
graphics using Microsoft Excel 2007.
10
Unnoticed surgical gloves intraoperative perforation: A multicentric study of the leading factors.
Citation: Medhioub F, Jaber E, Hamrouni A, Gharbi L. Unnoticed surgical gloves intraoperative perforation: A multicentric study of
the leading factors. Jr. med. res. 2020; 3(3):9-12. Medhioub et al © All rights are reserved.
Submit your manuscript: www.jmedicalresearch.com
The variability in these results may be explained by the
difference in specialties, instrumentation, experiences and
working conditions. One of the main issues encountered is
the lack of perforation perception before the end of the
procedure.
Glove perforation can expose both patients and surgical team
members to considerable risks. It may increase the incidence
of patient’s nosocomial infections specially those caused by
Staphylococcus Aureus. The practitioners maybe exposed to
viral blood-borne diseases such as AIDS and Hepatitis [6].
The perforation remains unnoticed usually until the end of
the procedure. This makes mandatory the identification of
associated factors. These factors are related to the surgical
procedure, the practitioner, and the glove itself. Gloves
perforation is more common in orthopedic surgery than in
soft tissue procedure [7].
The use of power tools, handling sharp bones and working in
deep cavities could contribute more to glove perforation in
orthopedic procedures [8]. It was reported in a study that
the rate rises to 67% during a hip arthroplasty closure and
with the use of cone-shaped needles [9].
In our study, the rate of perforation was significantly higher
in cardio-vascular surgical procedures (40.3%) and in the
senior surgeon’s gloves (41.7%). Other studies had the same
findings [10-13]. This high rate is explained by the fact that
surgeons are the first users of instruments and that the
manipulation of instruments and implants increases the risk
of perforation [14,15].
Our study found that 70.8% of perforations are detected on
the non-dominant hand. These findings are comparable to
those revealed by some other authors [17,18]. The surgeon’s
index finger and thumb seem to be the site of predilection for
glove perforation. [19].
Regarding the duration of the procedure, all authors agreed
that the risk of unnoticed glove perforation is significantly
higher for long and complex procedures. Our study showed a
cut-off point at 90 minutes concurring with the findings of
several other studies [20-22]. We have tested in two
different brands of gloves (A and B) made from natural
rubber latex. Brand A gloves are thicker than brand B gloves.
We found significant higher perforation rate in the thinner
brand. The glove characteristics may interfere with the
perforation rate.
The optimized air and waterproofness as well as the balanced
elasticity could ensure the barrier glove’s role and minimize
perforation risk [23].
The powder reduces the friction between the hand and the
glove’s wall. However, hand perspiration during long
procedures may increase powder temperature and lead to
microperforations [24]. Some authors recommended
“double” gloving to prevent perforation and to optimize
protection. Concordant studies showed that the inner glove is
exceptionally perforated. The implementation of double
11
Table 2: glove usage characteristics
Variables
n
%
Surgical specialty
Cardio-vascular
78
24.4
General and digestive
79
24.7
Urology
86
26.9
Otorhinolaryngology
77
24.1
Position
Surgeon
94
29.4
Surgical resident
129
40.3
Surgical technologist and scrub nurse
97
30.3
Procedure duration
<90
207
64.7
>90
113
35.3
The perforation rate was 67% (n=48) after procedures that
exceeded 90 minutes (p=0.0001). Senior surgeons had the highest
perforation rate (42%). Forty percent of the perforations occurred
during cardio-vascular procedures. Table 3 summarized the
perforations associated factors
Table 3: Glove perforation associated factors
Associated factor
Perforated glove
Non-perforated
glove
P
Duration
0.0001
<90
24 (33.3%)
183 (73.79%)
>90
48 (66.6%)
65 (26.21%)
Surgical specialty
0,001
Cardio-vascular
29 (40.28%)
49 (91.76%)
General and digestive
19 (26.39%)
60 (24.19%)
Urology
14 (19.44%)
72 (29.03%)
Otorhinolaryngology
10 (13.89%)
67 (27.02%)
Participant’s function
0.49
Surgeon
30 (41.66%)
105 (42.34%)
Surgical resident
24 (33.34%)
64 (25.81%)
Surgical technologist or scrub
nurse
18 (25%)
79 (31.85%)
Hand dominance
0.0001
Dominant hand
21 (29.17%)
139 (56.05%)
Non-dominant hand
51 (70.83%)
109 (43.95%)
Thickness
0.001
Brand A
28 (38.8%)
135 (54.4%)
Brand B
44 (61.2%)
113 (45.6%)
Powder
0.018
Powdered
56 (77.8%)
222 (89.52%)
Powder-free
16 (22.2%)
26 (10.48%)
Total
72
248
Discussion
This study investigated the frequency of unnoticed surgical glove
perforation at 3 different Tunisian university hospitals in 4 different
surgical specialized units. It revealed a perforation rate of 22,5%.
According to the literature, this rate varies from 8 to 61% [4]. The
results reported by Tlili et al were comparable with a rate of 16,5%.
However, a higher perforation rate of 52% was shown by Goldman
et al [3,5].
Unnoticed surgical gloves intraoperative perforation: A multicentric study of the leading factors.
Citation: Medhioub F, Jaber E, Hamrouni A, Gharbi L. Unnoticed surgical gloves intraoperative perforation: A multicentric study of
the leading factors. Jr. med. res. 2020; 3(3):9-12. Medhioub et al © All rights are reserved.
Submit your manuscript: www.jmedicalresearch.com
[19] Tao LX, Basnet DK. Study of Glove Perforation during Hip Replacement Arthroplasty: Its
Frequency, Location, and Timing. Int Sch Res Not. 2014; 2014:1-5.
[20] Birnbach DJ, Thiesen TC, McKenty NT, Rosen LF, Arheart KL, Fitzpatrick M, et al. Targeted use
of Alcohol-based hand rub on gloves during task dense periods: One step closer to pathogen
containment by anesthesia providers in the operating room. Anesth Analg. 2019 ;129 :1557-60.
[21] Wichmann T, Moriarty TF, Keller I, Pfister S, Deggim-Messmer V, Gautier E, Kalberer F, Koch
PP, Wahl P. Prevalence and quantification of contamination of knitted cotton outer gloves during hip
and knee arthroplasty surgery. Arch Orthop Trauma Surg. 2019 ;139 :451-59.
[22] Enz A, Klinder A, Mittelmeier H, Kundt G, Mittelmeier W, Zaatreh S. Damages with High
Consequences: Analysis of Perforations in Surgical Latex Operation Gloves from Orthopedic
Surgeries. Eur J Microbiol Immunol (Bp). 2018; 8:159-62.
[23] Bardorf MH, Jäger B, Boeckmans E, Kramer A, Assadian O. Influence of material properties on
gloves’ bacterial barrier efficacy in the presence of microperforation. Am J Infect Control. 2016
Dec;44(12):1645-9.
[24] Martinez A, Han Y, Sardar ZM, Beckman L, Steffen T, Miller BS, et al. Risk of glove perforation
with arthroscopic knot tying using different surgical gloves and high–tensile strength sutures.
Arthrosc J Arthrosc Relat Surg. 2013; 29:1552-8.
[25] Bekele A, Makonnen N, Tesfaye L, Taye M. Incidence and patterns of surgical glove
perforations: experience from Addis Ababa, Ethiopia. BMC Surg. 2017; 17:26.
[26] Elce YA, Laverty S, Almeida da Silveira E, Piat P, Trencart P, Ruzickova P, et al. Frequency of
Undetected Glove Perforation and Associated Risk Factors in Equine Surgery. Vet Surg. 2016;
45:1066-70.
[27] Kumar D, Shantanu K, Kumar M, Kumar A, Sharma V. A Cross-sectional Analysis of Glove
Perforation in Primary and Revision Total Hip Arthroplasty. Malays Orthop J. 2016; 10:31-35
[28] Mingoli A, Brachini G, Sgarzini G, Binda B, Zambon M. Needlestick Injuries, Glove Perforation
and Round-Tipped Blunt Needles. World J Surg. 2017; 41:2413.
gloving concept is sometimes difficult. It may reduce the precision
of the movements according to some surgeons and may increase
the cost of procedure consumables [25-28].
Our study identified a considerable issue in the daily surgical
practice. The rate of the unnoticed surgical team gloves perforation
is high and may interfere with the procedure’s outcomes. The four
subspecialized surgical units involved are performing a high number
of cases. To improve the quality and the safety of the procedures
done, the implementation of some operating theater guidelines
looks mandatory. The glove should be changed regularly in long
procedures. More precaution should be taken for risky tasks. Our
study is limited by the small population and this might be interfering
with the statistics. The leading factors demonstrated might not be
independent and must be proven in a larger series.
Conflict of interest: None
12
Conclusion
For some sophisticated surgical centers, the recommendation of
systematic double gloving and frequent changing of gloves are
reasonable. This could reduce the perforation rate and prevent
its risks. We also suggest training sessions for the surgical team
members in order to increase their awareness about the gravity of
glove perforation and how to avoid the factors and circumstances
that lead to higher perforation rate.
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