Ann Thorac Surg 2005;80:1078-1080
© 2005 The Society of Thoracic Surgeons
Original article: General thoracic
Unnoticed Glove Perforation During Thoracoscopic and Open Thoracic Surgery
Yuko Kojima, MD
a
,
*
,
Masahiko Ohashi, MD
b
a Department of Anesthesiology, Suwa Red Cross Hospital, Nagano, Japan
b Department of Thoracic Surgery, Suwa Red Cross Hospital, Nagano, Japan
Accepted for publication March 16, 2005.
* Address reprint requests to Dr Kojima, Department of Anesthesiology, Suwa Red Cross Hospital, 5-11-50 Kogan-dori, Suwa-city, Nagano, 392-8510 Japan (Email: fayuko33{at}hotmail.com).
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Abstract
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BACKGROUND: Surgeons tend to underestimate the risk of transferring infection during thoracoscopic operations, although data on glove perforation in thoracoscopic operations have not been reported.
METHODS: Unnoticed perforations of the gloves worn by the same primary surgeon during thoracoscopic procedures and open thoracotomy were studied. Gloves with gross damage and those changed due to assumed damage were excluded. Gloves were tested by filling with water and squeezing to inflate each finger, which could detect a perforation by a 30-gauge needle.
RESULTS: Perforation was found in 25% after thoracoscopic operation, although this was significantly lower than 70% after open thoracotomy. Twelve percent of the gloves worn during thoracoscopic operation were perforated. The perforation rate was higher for gloves worn for more than 2 hours during thoracoscopic operation.
CONCLUSIONS: Glove perforation occurred without being noticed in 25% of thoracoscopic procedures, and in 12% of the gloves used during the procedure. Glove change within 2 hours is recommended.
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Introduction
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Unnoticed glove perforation during surgical procedures represents a potential risk of infection for the surgeon by prolonged skin exposure to blood or other body fluids. Although glove damage was noted less often in endoscopic procedures than in conventional procedures during orthopedic and otolaryngologic operations [1, 2], data about glove perforations in thoracoscopic procedures have not been reported. This study investigated the frequency of unnoticed glove perforations in thoracoscopic procedures and open thoracotomy.
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Material and Methods
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Unnoticed perforations of gloves in 47 thoracic procedures (24 thoracoscopic operations and 23 open thoracotomy) were studied. Thoracoscopic procedure was defined as one using three ports without incision. Thoracoscopic procedures that were converted to thoracotomies were excluded from this study. All gloves were Conform MK-II sterile latex gloves (Ansell Healthcare Inc, CA) and were worn by the same surgeon as the primary operator. After each procedure, gloves were collected and tested for perforation according to a method similar to that described by Brough and colleagues [3]. Gloves that had been contaminated and changed intraoperatively were included in the study, whereas gloves that had conspicuous tears or that were changed because of assumed damage were excluded. Each glove was inflated with 500 mL of water, twisted at the cuff end, and then squeezed to inflate each finger (Fig 1). As a control, 23 unused gloves were tested for perforations.
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Fig 1. Method of glove testing by filling with water and squeezing to inflate each finger. A hole is shown by a fine jet of water spraying from the index finger of the glove (arrow).
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Before the study, this method of identifying occult perforation was validated by puncturing 5 gloves with a 30-gauge needle (diameter of 0.3 mm) to ensure that leakage could be detected. The hydrosufflation method without squeezing each digit [4–6] could detect a digital hole by a 25-gauge needle (diameter of 0.5 mm) or larger.
Records were kept of the type of procedure, length of time worn, worn on right or left hand, and perforations for each glove. This prospective study was conducted from July 1997 through March 1999 at Suwa Red Cross Hospital.
The length of time worn was analyzed for each glove by the Student’s t test, with results expressed as mean ± standard deviation. The perforation rate was evaluated using both the number of procedures during which perforations occurred (procedure perforation rate) and the number of gloves with perforations (glove perforation rate). Comparisons between categories were made using a contingency table with the 
2 analysis. Differences were considered significant at p less than 0.01. All analyses were performed using the Stat-View for Macintosh software package (Version 5.0; SAS Institute Inc, Cary, NC).
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Results
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Thoracoscopic operation was performed on 24 patients (19 male, 5 female: age range from 14 to 82 years old) who underwent 13 bleb eliminations for pneumothorax and 11 tumor resections for pulmonary or pleural tumors. Open thoracotomy was performed on 23 patients (16 male, 7 female: age range from 26 to 80 years old) who underwent two bleb eliminations for pneumothorax, 16 lobectomy or wedge resections for pulmonary tumors, and 5 resections of mediastinal masses. There was no difference between the two procedures in the duration each glove was worn (thoracoscopic operation vs open thoracotomy; 135 ± 91 minutes vs 144 ± 83 minutes, p = 0.61).
Both the procedure perforation rate and glove perforation rate were significantly lower in thoracoscopic operations than in open thoracotomy (Table 1). In thoracoscopic operations, the perforation rate was significantly higher in gloves worn for more than two hours (Table 2). There was no difference between the perforation rate of gloves worn on the right or left hand in either thoracoscopic procedure or open thoracotomy (p = 0.41, and p = 0.29). There were no holes in any of the 23 unused gloves.
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Comment
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Our results showed that, although significantly less often than in open thoracotomy, unnoticed glove damage occurred in 25% of thoracoscopic procedures, and in 12% of all gloves used during a procedure. In thoracoscopic operations, the perforation rate was significantly higher when gloves were worn for more than 2 hours, consistent with previous reports in other surgical procedures [6, 7]. However, there was no difference in open thoracotomy for the time gloves were worn, probably because many gloves were changed due to obvious damage and thus excluded from this study.
In open thoracotomy, the surgeon is directly placing his hand deep into the body cavity encircled by the ribs or sternum. This is considered the reason that the reported perforation rate in thoracotomy is the highest among surgical specialties [8], and surgeons are willing to wear double gloves or change gloves frequently, even though most surgeons tend to underestimate their risk of infection from bloodborne pathogens during surgical procedures [9]. However, surgeons rarely wear double gloves or change gloves during thoracoscopic operations. Thoracoscopic procedures involve much less handling of sharp instruments, and both of the operator’s hands are in full view rather than positioned within a body cavity while the instruments are being used [10]. Moreover, surgeons have less frequent contact with blood and tissue. For all of the above reasons, most surgeons further underestimate the risk of infection during thoracoscopic procedures. In our study, postoperative infection (leukocytosis with fever on the fourth and fifth postoperative day) was suspected in one of 24 patients who underwent thoracoscopic operation, while 4 of 23 patients with open thoracotomy had postoperative wound infection or pneumonia. It cannot be denied that a major source of wound infection in patients comes from the operators’ hand because streptococcus aureus is the most common organism of infection after thoracoscopic procedures [11]. We tested only gloves worn by the same primary surgeon in order to eliminate factors related to the glove wearer’s skills or working position that might affect the glove perforation rate [4, 5].
Our study showed that in thoracoscopic procedures, unnoticed glove perforations of the primary operator occurred during 25% of procedures, and in 12% of all gloves worn during thoracoscopic operation. Glove change within 2 hours is recommended to protect not only the surgeon but also the patient.
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Acknowledgments
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The authors thank Dr Chieko Nishimura at the Shinshu University School of Medicine for her assistance in the preparation of the manuscript.
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References
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Abstract
Introduction
