Randomized controlled trial of glove perforation in single- and double-gloving in episiotomy repair after vaginal delivery

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.

Surgical glove perforation during laparoscopic colorectal procedures

Background

It has been reported that in conventional open surgery, approximately 10% of surgical gloves are perforated during surgery without being noticed. To protect both the patient and medical staff from harm, double gloving or changing gloves routinely at certain intervals during surgery is recommended. However, whether these protective measures are also necessary for laparoscopic colorectal surgery is unknown because the actual perforation rate during laparoscopic procedures is unclear.

Methods

Seventy-seven laparoscopic colorectal surgeries were evaluated, and a total of 616 surgical gloves used in the surgeries were collected for analysis. The presence of glove perforation was tested by the standard water-leak test method (EN455-1).

Results

Seven perforations were detected (1.1%). The duration of the laparoscopic procedure was not a statistically significant risk factor for glove perforation (p = 0.41). Postoperative surgical site infections (SSIs) were observed in 12 cases (15.6%), but there was no significant correlation between the presence of glove perforation and SSI (p = 0.92). According to the bacterial cultivation results, the majority of causative agents of SSI were enterobacteria, which belong to the major gut flora.

Conclusion

Although the perforation rate was considerably lower than that in open surgery, surgical glove perforation occurred during laparoscopic procedures. Double gloving in laparoscopic colorectal surgery is recommended not to prevent SSI but to protect medical workers from harmful infections after direct contact with the patient.

Effectiveness of double-gloving method on prevention of surgical glove perforations and blood contamination: A systematic review and meta-analysis

AIMS

To determine the effectiveness of the double-gloving method on preventing surgical glove perforation and blood contamination compared with single gloving.

DESIGN

Systematic review.

DATA SOURCES

Seven electronic databases were searched including: Embase, CINAHL, OVID, Medline, Pubmed, Web of Science, and Foreign Medical Literature Retrieval Service in March 2020.

REVIEW METHOD

Our systematic review and meta-analysis was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting guideline. Risk of bias of Cochrane Handbook (Version 5.1.0) was applied to evaluate the study quality. Revman 5.3 was used to calculate the effect size of odds ratio (OR) with 95% confidence interval (CI). Meta-analysis with forest plot and funnel plot was performed to compare the rate of surgical glove perforation and to determine the published bias, respectively. This review has been registered with ID: CRD42020189694 on the web site of PROSPERO.

RESULTS

Seven randomized controlled trials regarding the efficacy of double gloving on reducing surgical glove perforation were identified and a total of 7090 gloves were tested. After analyzing the pooled data, we identified that the rate of surgical glove perforation in the double-gloving group was lower than that of single gloving with statistical significance (OR = 0.75, 95% CI: 0.64-0.89, p < .05). It was statistically significant that surgical glove perforation was lower in the double-inner gloves as well as matched outer-inner perforated gloves compared with that of single glove (OR = 0.05, 95% CI: 0.03-0.07, p < .05).

CONCLUSION

Findings of this systematic review demonstrate that double gloving could reduce the rate of surgical-glove perforation. Meanwhile, the risk of being contaminated by a blood-borne pathogen during surgery could be reduced by wearing double gloves. We strongly suggest that surgical team members when operating should wear double gloves to protect themselves and reduce the risk of occupational blood exposure.

IMPACT

The necessity of double gloving for preventing blood contamination was demonstrated. The rate of surgical glove perforation is statistically significant in double-gloving group compared to single gloving. Double gloving could reduce the risk of being contaminated during surgery by blood-borne pathogen. Evidence is provided for surgical team and decision makers that double gloving could reduce occupational exposure.

Comparison of surgical gloves: perforation, satisfaction and manual dexterity

The purpose of this study was to assess the effectiveness of two different surgical gloves (powdered latex and powder and latex free) for glove perforation frequency, problems and satisfaction with glove usage and manual dexterity levels during surgical operations that include scrub nurses. Scrub nurses wore antiallergenic gloves (powder and latex free) gloves during three operations, double latex and powdered gloves during three operations and single latex and powdered gloves during three operations. The gloves were checked for punctures after each surgery with a water-inflation test. In our study, 19% of single gloves and 18.1 % of double gloves and 4.8% of powder and latex free worn by scrub nurses were punctured during surgery. None of the inner gloves in double gloves were punctured. Although wearing double gloves restricts manual dexterity, results in discomfort problems such as perspiration and fetor and results in a low satisfaction rate among scrub nurses, double gloves are protective against injuries and punctures.

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.

Perforation rates in double latex gloves and protective effects of outer work gloves in a postmortem examination room: A STROBE-compliant study

Medical staff face the risk of exposure to blood-borne infectious agents during postmortem examinations. This study investigated the effectiveness of non-slip work gloves worn over 2 layers of surgical latex gloves (outer and inner gloves) as a means of reducing hand and finger injuries. Complete sets of outer and inner gloves worn during postmortem examinations were collected from participating forensic staff. Latex gloves were categorized into 2 groups based on the users' actions during the examination: the wearing group if the wearer wore their work gloves continuously without interruption, and the taking-off group if the wearer removed them at least once. Perforation rates, locations, and shapes were compared between these groups. Outer-glove perforation occurred significantly more often in the taking-off group (n = 102 pairs) than in the wearing group (n = 91 pairs) (30.4% vs 3.8%, P < .001). Inner-glove perforation occurred at rates of 2.0% and 0.5% (P = .38), respectively. The wearers did not incur hand or finger injuries. Perforation rates were similar between the dominant and non-dominant hands (P = .18). Regarding location, gloves were punctured most frequently at the thumb, followed by the index finger. Most examiners (85.6%) did not notice the perforation when the damage occurred. Therefore, we could not confirm that a specific operation within a set of plural operations affected the rate of perforation. Additionally, we could not prove a relationship between glove perforation and each operation performed with/without work gloves. The perforation appearances varied greatly in shape and size, suggesting multiple causes of perforation. The continuous (i.e., uninterrupted) wear of work gloves during postmortem examinations reduced the incidence of perforations in both latex glove layers and thus reduced the risk of hand and finger injury.

Incidence of sharps injuries in surgical units, a meta-analysis and meta-regression

BACKGROUND

Sharps injuries occur often among surgical staff, but they vary considerably.

METHODS

We searched PubMed and Embase for studies assessing the incidence of sharps injuries. We combined the incidence rates of similar studies in a random effects meta-analysis and explored heterogeneity with meta-regression.

RESULTS

We located 45 studies of which 11 were randomized control trials, 15 were follow-up studies, and 19 were cross-sectional studies. We categorized injuries as self-reported, glove perforations, or administrative injuries. We calculated the population at risk as person-years and as person-operations (po). Meta-analysis of the incidence rate based on the best outcome measure resulted in 13.2 injuries per 100 time-units (95% confidence interval [CI], 4.7-37.1; I² = 100%). Per 100 person-years, the injury rate was 88.2 (95% CI, 61.3-126.9; 21 studies) for self-reported injuries, 40.0 for perforations (95% CI, 19.2-83.5; 15 studies), and 5.8 for administrative injuries (95% CI, 2.7-12.2; 5 studies). Per 100 po, the respective figures were 2.1 (95% CI, 0.8-5.0; 4 studies), 11.1 (95% CI, 6.6-18.9, 15 studies), and 0.1 (95% CI, 0.05-0.21). I² values were all above 90%. Meta-regression indicated lower incidence rates in studies that used perforations per po.

CONCLUSIONS

A surgeon will have a sharps injury in about 1 in 10 operations . Reporting of sharps injuries in surgical staff should be standardized per 100 po and be assessed in prospective follow-up studies.

Incidence of Glove Perforation During Hand Surgical Procedures

PURPOSE

To determine the rate of glove perforation during hand surgery.

METHODS

We prospectively examined the rate of glove perforations among 10 fellowship-trained hand surgeons at our institution during a 6 week period. Gloves were tested for perforation using a water-fill technique at the conclusion of each surgical procedure. Surgeons recorded the presence of any glove perforations.

RESULTS

Eleven perforations were identified in 10 gloves among 600 surgical procedures during the study period. The perforation rate per case was 1.5% (95% confidence interval, 0.78% to 2.8%). Forty percent of perforations (n = 4) occurred during fracture surgery. Other holes occurred during isolated carpal tunnel release (n = 3) or combined carpal tunnel and trigger finger release (n = 3). The perforation was noticed intraoperatively in only 2 gloves. The difference in perforation rate between single- and double-gloved procedures was not significant. There were no perforations in the inner glove of surgeons who double gloved. A total of 73% of holes (8 of 11) occurred on surgeons' index finger; 75% of these were on the dominant hand. The dominant thumb, non-dominant ring and nondominant little fingers each had a single perforation.

CONCLUSIONS

The rate of glove perforation during hand surgery is low. Holes can occur even during soft tissue procedures of short duration. The dominant index finger appears to be at greatest risk for perforation. When they do occur, most often holes are not noticed by the operating surgeon. The baseline glove perforation rate is unknown.

CLINICAL RELEVANCE

A high level of vigilance is required to maintain sterile technique.

Adherence to surgical hand rubbing directives in a hospital district of Southwest Finland

BACKGROUND

The primary objective was to measure the compliance with alcohol-based surgical hand rubbing (SHR) among operation room personnel. The secondary objective was to evaluate the effect of feedback sessions on compliance.

METHODS

This was a prospective observational before-after intervention study. Between October 2010 and June 2012 the hygiene nurses observed SHR among operation room personnel in the hospital district of Southwest Finland. After feedback sessions a second observation round was conducted in the main operation room of Turku University Hospital. The first observation round comprised 477 observations: 259 (54%) were doctors, 190 (40%) nurses and 28 (5%) other personnel. In the second observation round a total of 210 observations were made.

RESULTS

During the first round in 42% of observations the 3 min SHR time recommended by WHO was used. Median times for SHR were 1 min 50 s (range 0 min to 5 min 44 s) for doctors and 3 min 25 s (range 1 min 1 s to 8 min 15 s) for nurses, respectively (p < 0.0001). In 40% of observations hands were not properly dried after a wash before applying SHR and in 45% hands were not allowed to dry properly after SHR before donning surgical gloves. After feedback, time for SHR did not significantly improve but technique did.

CONCLUSIONS

SHR was performed incorrectly in most observations even after feedback. The results stress the importance of more effective education, helping techniques and positive role models for operation room personnel to promote SHR.

Effects of glovebox gloves on grip and key pinch strength and contact forces for simulated manual operations with three commonly used hand tools

This study examined the effects of glovebox gloves for 11 females on maximum grip and key pinch strength and on contact forces generated from simulated tasks of a roller, a pair of tweezers and a crescent wrench. The independent variables were gloves fabricated of butyl, CSM/hypalon and neoprene materials; two glove thicknesses; and layers of gloves worn including single, double and triple gloving. CSM/hypalon and butyl gloves produced greater grip strength than the neoprene gloves. CSM/hypalon gloves also lowered contact forces for roller and wrench tasks. Single gloving and thin gloves improved hand strength performances. However, triple layers lowered contact forces for all tasks. Based on the evaluating results, selection and design recommendations of gloves for three hand tools were provided to minimise the effects on hand strength and optimise protection of the palmar hand in glovebox environments.

PRACTITIONER SUMMARY

To improve safety and health in the glovebox environments where gloves usage is a necessity, this study provides recommendations for selection and design of glovebox gloves for three hand tools including a roller, a pair of tweezers and a crescent wrench based on the results discovered in the experiments.

Gloves, extra gloves or special types of gloves for preventing percutaneous exposure injuries in healthcare personnel

BACKGROUND

Healthcare workers are at risk of acquiring viral diseases such as hepatitis B, hepatitis C and HIV through exposure to contaminated blood and body fluids at work. Most often infection occurs when a healthcare worker inadvertently punctures the skin of their hand with a sharp implement that has been used in the treatment of an infected patient, thus bringing the patient's blood into contact with their own. Such occurrences are commonly known as percutaneous exposure incidents.

OBJECTIVES

To determine the benefits and harms of extra gloves for preventing percutaneous exposure incidents among healthcare workers versus no intervention or alternative interventions.

SEARCH METHODS

We searched CENTRAL, MEDLINE, EMBASE, NHSEED, Science Citation Index Expanded, CINAHL, NIOSHTIC, CISDOC, PsycINFO and LILACS until 26 June 2013.

SELECTION CRITERIA

Randomised controlled trials (RCTs) with healthcare workers as the majority of participants, extra gloves or special types of gloves as the intervention, and exposure to blood or bodily fluids as the outcome.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed study eligibility and risk of bias, and extracted data. We performed meta-analyses for seven different comparisons.

MAIN RESULTS

We found 34 RCTs that included 6890 person-operations as participating units and reported on 46 intervention-control group comparisons. We grouped interventions as follows: increased layers of standard gloves, gloves manufactured with special protective materials or thicker gloves, and gloves with puncture indicator systems. Indicator gloves show a coloured spot when they are perforated. Participants were surgeons in all studies and they used at least one pair of standard gloves as the control intervention. Twenty-seven studies also included other surgical staff (e.g. nurses). All but one study used perforations in gloves as an indication of exposure. The median control group rate was 18.5 perforations per 100 person-operations. Seven studies reported blood stains on the skin and two studies reported self reported needlestick injuries. Six studies reported dexterity as visual analogue scale scores for the comparison double versus single gloves, 13 studies reported outer glove perforations. We judged the included studies to have a moderate to high risk of bias.We found moderate-quality evidence that double gloves compared to single gloves reduce the risk of glove perforation (rate ratio (RR) 0.29, 95% confidence interval (CI) 0.23 to 0.37) and the risk of blood stains on the skin (RR 0.35, 95% CI 0.17 to 0.70). Two studies with a high risk of bias also reported the effect of double compared to single gloves on needlestick injuries (RR 0.58, 95% CI 0.21 to 1.62).We found low-quality evidence in one small study that the use of three gloves compared to two gloves reduces the risk of perforation further (RR 0.03, 95% CI 0.00 to 0.52). There was similar low-quality evidence that the use of one fabric glove over one normal glove reduces perforations compared to two normal gloves (RR 0.24, 95% CI 0.06 to 0.93). There was moderate-quality evidence that this effect was similar for the use of one special material glove between two normal material gloves. Thicker gloves did not perform better than thinner gloves.There was moderate to low-quality evidence in two studies that an indicator system does not reduce the total number of perforations during an operation even though it reduces the number of perforations per glove used.There was moderate-quality evidence that double gloves have a similar number of outer glove perforations as single gloves, indicating that there is no loss of dexterity with double gloves (RR 1.10, 95% CI 0.93 to 1.31).

AUTHORS' CONCLUSIONS

There is moderate-quality evidence that double gloving compared to single gloving during surgery reduces perforations and blood stains on the skin, indicating a decrease in percutaneous exposure incidents. There is low-quality evidence that triple gloving and the use of special gloves can further reduce the risk of glove perforations compared to double gloving with normal material gloves. The preventive effect of double gloves on percutaneous exposure incidents in surgery does not need further research. Further studies are needed to evaluate the effectiveness and cost-effectiveness of special material gloves and triple gloves, and of gloves in other occupational groups.

Risk of glove perforation with arthroscopic knot tying using different surgical gloves and high-tensile strength sutures

PURPOSE

To examine the risk of glove tears associated with arthroscopic knot tying using 4 commonly used high-tensile strength sutures and 2 different types of gloves.

METHODS

We analyzed 2 different surgical latex glove types (0.24-mm-thick powder-free and 0.32-mm-thick powdered) for perforation after arthroscopic knot tying with 4 different high-tensile strength sutures: Hi-Fi (ConMed Linvatec, Largo, FL), Ultrabraid (Smith & Nephew, Memphis, TN), FiberWire (Arthrex, Naples, FL), and Orthocord (DePuy Mitek, Raynham, MA). All knots were tied by a double-gloved single surgeon. Twelve trials of 4 knots each were performed for every glove-suture combination. All gloves were analyzed for perforation by a blinded evaluator using visual inspection, hydro-insufflation, and electroconductivity.

RESULTS

The overall incidence of glove perforation was 3.4% and was detectable only by the electroconductivity method; the other 2 methods did not detect any perforations. There was a statistically significantly higher rate (P < .001) of perforations in the 0.32-mm powdered gloves (6.8%) compared with the 0.24-mm powder-free gloves (0%). Perforation of the inner glove occurred 5.7 times more frequently than perforation of the outer glove. However, simultaneous perforation of both the inner and outer gloves did not occur in any set. The Hi-Fi suture was involved in 6 perforations compared with 4 for FiberWire, 3 for Ultrabraid, and 0 for Orthocord.

CONCLUSIONS

Double gloving provides an adequate surgical barrier between the surgeon and the patient during arthroscopic knot tying with high-tensile strength sutures as indicated by the low incidence of glove perforations in our study in an in vitro biomechanical evaluation. There were no instances of simultaneous perforation of both the inner and outer gloves. All perforations occurred only in the thicker (0.32-mm) powdered gloves.

CLINICAL RELEVANCE

Glove tears and finger lacerations have been reported with the use of high-tensile strength sutures during arthroscopic shoulder surgery, thereby raising a concern for safety and disease transmission. This study addresses these concerns by evaluating the risk of glove tears during arthroscopic knot tying.

Role of blunt suture needle in episiotomy repair at uncomplicated vaginal deliveries in reducing glove perforation rate: a randomized controlled trial

AIM

The aim of this study was to evaluate the role of blunt suture needles for episiotomy repair at uncomplicated vaginal deliveries in reducing glove perforation rate.

METHODS

This was a prospective randomized controlled trial wherein 300 nulliparous women with uncomplicated vaginal deliveries were randomized to episiotomy repair with either blunt or sharp suture needles. Patient demographics and clinical variables were collected. Postoperatively, the surgeons were surveyed regarding ease of using the needle, and glove perforation was determined by three tests: air insufflation, water filling and water load.

RESULTS

A total of 41 perforations occurred in the 39 episiotomy repairs with glove perforations (13%). There was a significantly higher number of glove perforations using the sharp suture needles (28/150; 18.7%) than with the blunt suture needles (11/150; 7.3%) (P = 0.005). Glove perforation of the non-dominant hand occurred in 90% of the cases. Using a blunt suture needle took significantly more time (P < 0.001) to complete the repair than using a sharp needle. Surgeons reported that blunt needles were more difficult to use than sharp needles (P < 0.001).

CONCLUSION

Blunt suture needles for episiotomy repair were shown to have a significantly lower instance of glove perforation but required more time and are perceived to be more difficult to complete the repair as compared to sharp needles.

Reducing needle stick injuries in healthcare occupations: an integrative review of the literature

Needlestick injuries frequently occur among healthcare workers, introducing high risk of bloodborne pathogen infection for surgeons, assistants, and nurses. This systematic review aims to explore the impact of both educational training and safeguard interventions to reduce needlestick injuries. Several databases were searched including MEDLINE, PsycINFO, SCOPUS, CINAHL and Sciencedirect. Studies were selected if the intervention contained a study group and a control group and were published between 2000 and 2010. Of the fourteen studies reviewed, nine evaluated a double-gloving method, one evaluated the effectiveness of blunt needle, and one evaluated a bloodborne pathogen educational training program. Ten studies reported an overall reduction in glove perforations for the intervention group. In conclusion, this review suggests that both safeguard interventions and educational training programs are effective in reducing the risk of having needlestick injuries. However, more studies using a combination of both safeguards and educational interventions in surgical and nonsurgical settings are needed.

Concentration of bacteria passing through puncture holes in surgical gloves

BACKGROUND

The reasons for gloving-up for surgery are to protect the surgical field from microorganisms on the surgeon's hands and protect the surgeon from the patient's microorganisms. This study measured the concentration of bacteria passing through glove punctures under surgical conditions.

METHODS

Double-layered surgical gloves were worn during visceral surgeries over a 4-month period. The study included 128 outer gloves and 122 inner gloves from 20 septic laparotomies. To measure bacterial passage though punctures, intraoperative swabs were made, yielding microorganisms that were compared with microorganisms retrieved from the inner glove layer using a modified Gaschen bag method.

RESULTS

Depending on the duration of glove wear, the microperforation rate of the outer layer averaged 15%. Approximately 82% of the perforations went unnoticed by the surgical team. Some 86% of perforations occurred in the nondominant hand, with the index finger being the most frequently punctured location (36%). Bacterial passage from the surgical site through punctures was detected in 4.7% of the investigated gloves.

CONCLUSION

Depending on the duration of wear, surgical gloves develop microperforations not immediately recognized by staff. During surgery, such perforations allow passage of bacteria from the surgical site through the punctures. Possible strategies for preventing passage of bacteria include strengthening of glove areas prone to punctures and strict glove changing every 90 minutes.

The use of blunt needles does not reduce glove perforations during obstetrical laceration repair

OBJECTIVE

The objective of the study was to compare the rate of glove perforation for blunt and sharp needles used during obstetrical laceration repair. A secondary aim was to assess physician satisfaction with blunt needles.

STUDY DESIGN

This was an institutional review board-approved, randomized, prospective trial. Patients with obstetric lacerations were randomized to repair with either blunt or sharp needles. Patient demographics, operator experience, and other clinical variables were collected. Physicians reported any percutaneous injuries and were surveyed regarding satisfaction with the assigned needles. Glove perforation was determined using a validated water test method.

RESULTS

There were 438 patients enrolled in the trial: 221 in the control group and 217 in the study group. There was no statistical difference between groups in patient demographics, clinical variables, severity of laceration, or experience level of the surgeon. There was no difference in the glove perforation rate between blunt and sharp needles (risk ratio, 0.79; 95% confidence interval, 0.2-2.95). There was poor correlation between reported perforations and those detected by water test (R(2) = 0.33). The physicians reported that blunt needles were more difficult to use than sharp needles (P = .0001).

CONCLUSION

There was no difference in the rate of surgical glove perforation for blunt, compared with sharp, needles used during vaginal laceration repair. Physicians also reported increased difficulty performing the repair with blunt needles.

Surgical glove practice: the evidence

Surgical gloves are worn to protect both the patient and the surgical team from transferred infections. Wearing two pairs of gloves, perforation indicator systems, glove liners, knitted gloves and triple gloving are said to offer additional protection. This paper presents the main findings from a Cochrane systematic review of 30 trials examining surgical gloving practice.

Double gloving to reduce surgical cross-infection

BACKGROUND

The invasive nature of surgery, with its increased exposure to blood, means that during surgery there is a high risk of transfer of pathogens. Pathogens can be transferred through contact between surgical patients and the surgical team, resulting in post-operative or blood borne infections in patients or blood borne infections in the surgical team. Both patients and the surgical team need to be protected from this risk. This risk can be reduced by implementing protective barriers such as wearing surgical gloves. Wearing two pairs of surgical gloves, triple gloves, glove liners or cloth outer gloves, as opposed to one pair, is considered to provide an additional barrier and further reduce the risk of contamination.

OBJECTIVES

The primary objective of this review was to determine if additional glove protection reduces the number of surgical site or blood borne infections in patients or the surgical team. The secondary objective was to determine if additional glove protection reduces the number of perforations to the innermost pair of surgical gloves. The innermost gloves (next to skin) compared with the outermost gloves are considered to be the last barrier between the patient and the surgical team.

SEARCH STRATEGY

We searched the Cochrane Wounds Group Specialised Register (January 2006), and the Cochrane Central Register of Controlled Trials (CENTRAL)(The Cochrane Library Issue 4, 2005). We also contacted glove manufacturing companies and professional organisations.

SELECTION CRITERIA

Randomised controlled trials involving: single gloving, double gloving, triple gloving, glove liners, knitted outer gloves, steel weave outer gloves and perforation indicator systems.

DATA COLLECTION AND ANALYSIS

Both authors independently assessed the relevance and quality of each trial. Data was extracted by one author and cross checked for accuracy by the second author.

MAIN RESULTS

Two trials were found which addressed the primary outcome, namely, surgical site infections in patients. Both trials reported no infections. Thirty one randomised controlled trials measuring glove perforations were identified and included in the review. Fourteen trials of double gloving (wearing two pairs of surgical latex gloves) were pooled and showed that there were significantly more perforations to the single glove than the innermost of the double gloves (OR 4.10, 95% CI 3.30 to 5.09). Eight trials of indicator gloves (coloured latex gloves worn underneath latex gloves to more rapidly alert the team to perforations) showed that significantly fewer perforations were detected with single gloves compared with indicator gloves (OR 0.10, 95% CI 0.06 to 0.16) or with standard double glove compared with indicator gloves (OR 0.08, 95% CI 0.04 to 0.17). Two trials of glove liners (a glove knitted with cloth or polymers worn between two pairs of latex gloves)(OR 26.36, 95% CI 7.91 to 87.82), three trials of knitted gloves (knitted glove worn on top of latex surgical gloves)(OR 5.76, 95% CI 3.25 to 10.20) and one trial of triple gloving (three pairs of latex surgical gloves)(OR 69.41, 95% CI 3.89 to 1239.18) all compared with standard double gloves, showed there were significantly more perforations to the innermost glove of a standard double glove in all comparisons.

AUTHORS' CONCLUSIONS

There is no direct evidence that additional glove protection worn by the surgical team reduces surgical site infections in patients, however the review has insufficient power for this outcome. The addition of a second pair of surgical gloves significantly reduces perforations to innermost gloves. Triple gloving, knitted outer gloves and glove liners also significantly reduce perforations to the innermost glove. Perforation indicator systems results in significantly more innermost glove perforations being detected during surgery.

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.

Le gantage chirurgical en France : une évolution lente mais nécessaire

Since the end of the 19th century, surgeons have used gloves to prevent infectious complications to the patient. The AIDS epidemic of the 1980's sparked the use of universal precautions to protect the surgeon from infection and vice-versa. The interface between surgeon and patient is in effect a two-way street. Surgical techniques must be modified and barrier protection optimized to minimize these risks. A single layer glove is a fragile barrier to blood exposure; unrecognized glove perforations may lead to unrecognized and prolonged exposure. Double gloving, though far from being a widespread practice in France, seems to be the best protection from pathogen exposure. Glove powder and latex allergies have their own inherent risks to both surgeon and patient in the form of latex allergies and adhesive peritonitis. New institutional protocols will be necesssary in order to make powder-free non-latex gloves available to French surgeons.