Abstract
Oral and maxillofacial surgery, which involves several sharp instruments and fixation materials, is consistently at a high risk for cross-contamination due to perforated gloves, but it is unclear how often such perforations occur. This study aimed to address this issue. The frequency of the perforation of surgical gloves ( n = 1436) in 150 oral and maxillofacial surgeries including orthognathic surgery ( n = 45) was assessed by the hydroinsufflation technique. Orthognathic surgery had the highest perforation rate in at least 1 glove in 1 operation (91.1%), followed by cleft lip and palate surgery (55.0%), excision of oral soft tumour (54.5%) and dental implantation (50.0%). The perforation rate in scrub nurses was 63.4%, followed by 44.4% in surgeons and first assistants, and 16.3% in second assistants. The odds ratio for the perforation rate in orthognathic surgery versus other surgeries was 16.0 (95% confidence interval: 5.3–48.0). The protection rate offered by double gloving in orthognathic surgery was 95.2%. These results suggest that, regardless of the surgical duration and blood loss in all fields of surgery, orthognathic surgery must be categorized in the highest risk group for glove perforation, following gynaecological and open lung surgery, due to the involvement of sharp objects.
Wearing gloves is considered mandatory for protecting both patient and surgeon from the risk of cross-infection during surgical procedures. Intact surgical gloves are a barrier to the threat of viruses, bacteria and other pathogens, but once perforated, they lose their ability to act as a safeguard. Although universal precautions are applied in any surgical intervention, most surgeons do not notice perforations of surgical gloves during surgery. 56–100% of glove perforations go unnoticed by plastic surgeons, although the overall risk of glove perforation has been reported to be 0–93.1%. In general, orthopaedic, cardiothoracic, gynaecological, and plastic surgeries are considered to have a high risk of glove perforation. In Europe and the USA, double gloving appears to be the standard practice in orthopaedic and maxillofacial surgery. Avery et al. found that the incidence of glove perforation during the surgical treatment of maxillofacial fractures was 32.1% (341/1061 gloves). Popejoy et al. noted that the procedures involved in oral surgery have no blood contact events. Despite several reports of glove perforations in maxillofacial surgery, it is unclear how often glove perforations occur, particularly in orthognathic surgery, which requires the use of several sharp instruments, such as bone-cutting devices and fixation wires.
The aim of this study was to elucidate the incidence of latex glove perforation among surgical staff performing oral and maxillofacial surgery in the operating room and identify the procedures associated with these perforations, focusing on orthognathic surgery.
Materials and methods
From April 2009 to January 2010, surgical gloves used by operating surgeons, first and second assistants, and scrub nurses were examined for perforation at the end of surgeries. During that period, 150 oral and maxillofacial procedures were completed. All surgical staff were right-handed, and a double-gloving protocol was installed for all orthognathic surgeries, which involved the wearing of larger sized gloves on the inside and smaller sized ones on the outside. A single-gloving protocol was then installed for other operations. The latex gloves (Esteem ® Micro, CareFusion, San Diego, USA) used in the oral and maxillofacial procedures were examined by the water pressure test after each operation by a single observer (H.S.) who was uncommitted to the surgical procedures. The water pressure test, which is similar to Hollaus’ method, in which a glove is filled with 1000 ml of water, was applied by the surgeon of each team immediately after the completion of the operations. This pressure was held for about 2 min, whether or not the glove was observed to be leaking. For calculating the perforation rates in the double-gloving technique, both inner and outer glove perforation in all matching gloves were taken into account. If there were any glove changes intraoperatively due to recognized glove damage or any other reasons, these were also accounted for. In order to assure the quality of the gloves, the authors tested a sample randomly as a control. They performed the water pressure test for 50 pairs of gloves prior to use, and no perforated gloves were detected. The anatomical location of the perforation site was charted according to left or right hand, fingers, palm, or dorsum of the hand. In addition, the following information was documented: type of surgery; blood loss; duration of operation; whether or not the perforation was noticed when it occurred; what operation was being performed; and what type of instrument punctured the glove.
The authors compared the glove perforation rate in each staff member (surgeon, first and second assistants, and scrub nurse) with respect to the operations, duration of surgery, blood loss and use of instruments. They evaluated the relationship between surgical experiences by the professions and the frequency of glove perforations. A period of 4 years of surgical experience was used as the cut-off point for the scrub nurses and the surgical assistants who became senior junior doctors after this period. The cut-off point for the surgeons was about 14 years or more of surgical experience, the pint when they were ready to become certified oral and maxillofacial surgeons. The data were analysed using the χ 2 test and Student’s t test, respectively. The authors estimated the odds ratio with a 95% confidence interval (95% CI) for glove perforation. All data were statistically analysed by the JMP v8 software programme (SAS Institute Inc., Cary, NC, USA). The differences were considered significant at P < 0.05.
Results
Among the 150 examined surgical cases, 45 were orthognathic surgeries, 22 dental implantations, 20 plastic surgeries for cleft lip and palate, and 63 other surgeries ( Table 1 ). No emergency operations were included. The rate of perforation in at least 1 glove in 1 operation was 91.1% in orthognathic surgeries, followed by the plastic surgical procedures of cleft lip and palate (55.0%), excision of oral soft tumour (54.5%) and dental implantation (50.0%). Among the surgical team, surgeons and first assistants were involved in all cases of perforations, followed by second assistants in 106 cases and scrub nurses in 134 cases. Of the 150 operations, 44 were performed by double-gloved surgeons and first assistants, and 106 were performed by single-gloved surgeons. Despite the protocol of double gloving in orthognathic surgeries, 1 of the 45 surgeries was carried out with the single-gloving technique, as the surgeon was uncomfortable with double gloving. Of the 134 operations involving scrub nurses, 39 were performed with double gloving and 95 were performed with single gloving. In total, 1436 gloves were examined after the operations. Of all gloves under actual surgical conditions ( n = 1436), 334 inner gloves, 1080 outer or single gloves and 22 outer gloves exchanged during surgery were tested ( Table 2 ). The individual glove perforation rate was 10.4% (150/1436 gloves). The percentages of glove perforation in surgeons, first assistants, second assistants and scrub nurses were 9.1% (36/395 gloves), 10.2% (40/394 gloves), 4.4% (13/296 gloves) and 17.4% (61/351 gloves), respectively. Of the 334 inner gloves, 16 (4.8%) were perforated and of the 1080 outer or single gloves, 116 (10.7%) were perforated. 18 of the 22 exchanged outer gloves (81.8%) were perforated. Matching perforations between inner and outer gloves were found in 16 cases (100%). Thus, the protection rate offered by double gloving in orthognathic surgery was 95.2% (318/334 cases).
| Operation | Number | Surgical duration | Blood loss | Surgical gloves | |
|---|---|---|---|---|---|
| Mean, SD, min | Mean, SD, ml | Perforations * /No. of surgeries | % | ||
| Orthognathic surgery | 45 | 143.7, 58.3 | 138.0, 143.4 | 41/45 | 91.1 |
| Bissos ** | 30 | 111.6, 30.2 | 82.0, 79.5 | 27/30 | 90.0 |
| LeFort I + BISSOs | 9 | 217.8, 42.2 | 258.2, 138.1 | 9/9 | 100.0 |
| Others *** | 6 | 193.2, 52.2 | 237.5,239.1 | 5/6 | 83.3 |
| Cleft lip and palate | 20 | 92.5, 26.7 | 14.1, 12.4 | 11/20 | 55.0 |
| Tumour of oral soft tissue | 11 | 42.2, 26.2 | 9.0, 9.4 | 6/11 | 54.5 |
| Dental implantation | 22 | 76.0, 49.5 | 21.1, 31.5 | 11/22 | 50.0 |
| Dental extraction | 12 | 59.9, 37.4 | 16.3, 20.4 | 4/12 | 33.3 |
| Others | 14 | 87.0, 38.5 | 19.4, 20.1 | 4/14 | 28.6 |
| Jaw cyst | 12 | 63.0, 23.7 | 23.0, 32.0 | 2/12 | 16.7 |
| Total | 150 | 95.3, 55.7 | 56.9, 99.3 | 82/150 | 54.7 |
* Number of perforations at least in 1 glove in 1 operation.
** BISSOs; BISSO alone ( n = 27), BISSO + Genioplasty ( n = 1), BISSO + Genioplasty ( n = 1), BISSO + Mandiblar midline osteotomy ( n = 1).
*** Others; Genioplasty ( n = 2), Maxillary alveolar osteotomy ( n = 3), Mandibular body osteotomy ( n = 1).
| Gloves | Total | Surgeon | First assistant | Second assistant | Scrub nurse | ||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| No. of gloves | Perforation | % | No. of operations | No. of gloves | No. of perforations | % | No. of operations | No. of gloves | No. of perforations | % | No. of operations | No. of gloves | No. of perforations | % | No. of operations | No. of gloves | No. of perforations | % | |
| Outer or single glove | 1080 | 116 | 10.7 | 150 | 300 | 25 | 8.3 | 150 | 300 | 31 | 10.3 | 106 | 212 | 8 | 3.8 | 134 | 268 | 52 | 19.4 |
| Inner glove | 334 | 16 | 4.8 | 44 | 88 | 7 | 8.0 | 44 | 88 | 4 | 4.5 | 40 | 80 | 1 | 1.3 | 39 | 78 | 4 | 5.1 |
| Exchanged glove * | 22 | 18 | 81.8 | 7 | 7 | 4 | 66.7 | 6 | 6 | 5 | 83.3 | 4 | 4 | 4 | 100.0 | 5 | 5 | 5 | 100.0 |
| Total | 1436 | 150 | 10.4 | 150 | 395 | 36 | 9.1 | 150 | 394 | 40 | 10.2 | 106 | 296 | 13 | 4.4 | 134 | 351 | 61 | 17.4 |
* Exchanged glove: There are any glove changes intra-operatively due to recognized glove damage or any other reasons.
The perforation rate in at least 1 glove in 1 operation in orthognathic surgeries was higher than that in other surgeries (91.1% vs. 39.0%, odds ratio 16.0, 95% CI: 5.3–48.0, P < 0.0001) ( Table 3 ). In orthognathic surgeries, scrub nurses had the highest perforation rate (63.4%) in at least 1 glove in 1 operation, followed by surgeons/first assistants (44.4%) and second assistants (16.3%). The involvement of orthodontic brackets and wire in surgical cases had a higher total perforation rate in at least 1 glove in 1 operation compared with cases where they were not used (88.6% vs. 40.6%, odds ratio 11.4, 95% CI: 4.2–31.3, P < 0.0001) ( Table 4 ). Using mechanical cutting tools and minimal needles showed no statistical significance in terms of the glove perforation rate, although there was a significant difference while using mechanical cutting tools ( P = 0.02) in surgeons. There were no significant differences in the perforation rate for either the duration of surgery or blood loss.
| Variables | Total | Surgeon | First assistant | Second assistant | Scrub nurse | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Perforations * /No. of operations | Perfora tion rate (%) | Odds ratio | 95%CI | P -value | Perforations * /No. of operations | Perforation rate (%) | P -value | Perforations * /No. of operations | Perforation rate (%) | P -value | Perforations * /No. of operations | Perforation rate (%) | P -value | Perforations * /No surgeries | Perforation rate (%) | P -value | |
| Orthognathic surgery | 41/45 | 91.1 | 16.0 | 5.3–48.0 | <0.0001 | 20/45 | 44.4 | <0.0001 | 20/45 | 44.4 | <0.0001 | 7/43 | 16.3 | 0.046 | 26/41 | 63.4 | 0.0001 |
| Other surgery | 41/105 | 39.0 | 1.0 | 8/105 | 7.6 | 11/105 | 10.5 | 3/63 | 4.8 | 26/93 | 28.0 | ||||||
| Total | 80/150 | 53.3 | 28/150 | 18.7 | 31/150 | 20.7 | 10/106 | 9.4 | 52/134 | 38.8 | |||||||
* Number of perforations at least in 1 glove in 1 operation.
| Variables | Total ( n = 150) | Surgeon ( n = 150) | First assistant ( n = 150) | Second assistant ( n = 106) | Scurb nurse ( n = 134) | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Perforations * /No. of operations | % | Odds ratio | 95% CI | P -value | Perforations * /No. of operations | % | P -value | Perforations * /No. of operations | % | P -value | Perforations * /No. of operations | % | P -value | Perforations * /No. of operations | % | P -value | ||
| Orthodontic tooth bracket and wire | (+) | 39/44 | 88.6 | 11.4 | 4.2–31.3 | <0.0001 | 18/44 | 40.9 | <0.0001 | 19/44 | 43.2 | <0.0001 | 7/42 | 16.7 | 0.04 | 25/40 | 62.5 | <0.001 |
| (−) | 43/106 | 40.6 | 1.0 | 10/106 | 9.4 | 12/106 | 11.3 | 3/64 | 4.7 | 27/94 | 28.7 | |||||||
| Mechanical cutting tool | (+) | 63/108 | 58.3 | 1.7 | 0.8–3.7 | 0.14 | 25/108 | 23.1 | 0.02 | 22/108 | 20.4 | 0.89 | 8/73 | 11.0 | 0.42 | 43/101 | 42.6 | 0.11 |
| (−) | 19/42 | 45.2 | 1.0 | 3/42 | 7.1 | 9/42 | 21.4 | 2/33 | 6.1 | 9/33 | 27.3 | |||||||
| Minimal needle | (+) | 6/12 | 50.0 | 0.8 | 0.2–2.7 | 0.73 | 1/12 | 8.3 | 0.34 | 5/12 | 41.7 | 0.06 | 0/11 | 0.0 | 0.26 | 1/7 | 14.3 | 0.17 |
| (−) | 76/138 | 55.1 | 1.0 | 27/138 | 19.6 | 26/138 | 18.8 | 10/95 | 10.5 | 51/127 | 40.2 | |||||||
* Number of perforations at least in 1 glove in 1 operation.
The perforation pattern of the gloves is shown in Fig. 1 . Regardless of surgical personnel, many more perforations were noted in left gloves than in right gloves (70% vs. 30%). The forefinger of the left non-dominant hand was the most commonly involved site (68.2%: 60 of 91). First assistants who had 4 years or more of surgical experience had the highest risk of glove perforation ( P = 0.008) ( Table 5 ). Scrub nurses who had less than 4 years of experience were more likely to have glove perforation than those with 4 years or more of experience ( P = 0.008).
