Gloves, Colon Surgery, and…Parachutes

Editor’s Comment: I’d like to welcome back Dr. Goldfarb for another guest post, this time to discuss the importance of glove changes in relation to preventing wound contamination.

When I was training in General Surgery, from 1967-1972, the every other night on call rotation was not the most rigorous part of the ordeal of training. The harder part was the daily routine working under strict surgeons who themselves were not even allowed to get married during their training. The Chief of Surgery was a meticulous surgeon who demanded total silence during surgery and total focus on the part of all participants. Other than opening and closing the abdomen, he performed all of the surgery on his private patients. The residents were responsible for the clinic and/or non-private patients. But the “eyes and spies” of the Chief of Surgery were everywhere, and if a resident skipped steps during an operation, it was expected that an OR nurse would report that misdemeanor to the Chief.  And you might be told to “Go home,” if you omitted any of these critical steps, if you omitted any steps.

One of the steps that became tattooed on my mind was the frequent glove changes during surgery, a critical step in preventing bacterial contamination of the surgical wound.  The glove changes during open bowel surgery would occur automatically every one to two hours. We changed gloves even if they had not become shriveled at the fingertips or covered with blood or stool, or otherwise have any obvious holes. The nurse or often the senior surgeon would simply say, “Let’s change gloves.” Then, after the bowel surgery, we washed out the wound, usually with a bulb syringe of saline. Before closing, we ALWAYS changed gloves. If you began to close a wound after an intestinal operation and did not change gloves, you wouldn’t just “Go home,” but rather might “Burn in hell!” as a result of this transgression. Verbal abuse aside, you were very sternly reminded that you might be responsible for seeding a wound infection in the patient. And if you caused a deep wound infection, you guaranteed a long course of healing, with prolonged hospital stay and eventual incisional hernia.

There have been so many myths perpetrated throughout surgical history. Are frequent glove changes during colon surgery one of those myths? As a “type A” compulsive surgeon, I did not want to tempt fate and so I changed my gloves often and ALWAYS before closing a wound. An article, “Bacterial Migration Through Punctured Surgical Gloves Under Real Surgical Conditions,” Huber N et al., BMC Infectious Diseases, 2010;10:192, stressed that “unnoticed perforations of surgical gloves are not uncommon and that their frequency increases with duration of wear. Suggested preventative measures to lower the risk of glove perforation include a change of gloves at least every 90 minutes, the use of double gloving, or the strengthening of common glove puncture sites.”

So maybe it was not a myth regarding the undetected glove punctures and contamination of wounds. But, beyond unnoticed perforations, I was also concerned with the direct contamination of the wound by gloves that had created a bowel anastomosis, just a little earlier in the operation.  How can a surgeon use the same gloves that touched stool to close a wound? In either case, touching a wound with a hole in the glove finger or touching a wound with stool from a bowel anastomosis could both cause wound infection.  Modern measures to decrease wound infection for colon surgery, ranging from type of bowel preparation to type of wound preparation may all help decrease the high rate of wound infection. But perhaps simply not touching a wound with a hole in the glove or not touching a wound with stool on the glove are also significant, and too often ignored. You do not need a randomized double blind study to test the validity of a parachute.