ARTICLE IN PRESS

American Journal of Infection Control ■■ (2017) ■■-■■

Contents lists available at ScienceDirect

American Journal of Infection Control American Journal of

Infection Control

j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g

Major Article

Evaluation of surgical glove integrity and factors associated with

glove defect
Mohamed Ayoub Tlili MHS a,*, Amina Belgacem MHS a, Haifa Sridi ORT b,
Maha Akouri ORT b, Wiem Aouicha MHS a, Sonia Soussi MHS c, Faten Dabbebi d,
Mohamed Ben Dhiab a
a
Health Sciences Research, Higher School of Health Sciences and Techniques of Sousse, University of Sousse, Tunisia
b
Higher School of Health Sciences and Techniques of Sousse, University of Sousse, Tunisia
c
Health Sciences Research, Higher School of Health Sciences and Techniques of Tunis, University of Tunis El Manar, Tunisia
d Department of Occupational Medicine, University Hospital Center of Sahloul, Tunisia

Key Words: Background: Surgical glove perforation may expose both patients and staff members to severe compli-
Perforation cations. This study aimed to determine surgical glove perforation rate and the factors associated with
Infection glove defect.
Patient safety
Material and methods: This descriptive cross-sectional study was conducted between January and March
2017 at a Tunisian university hospital center in 3 different surgical departments: urology, maxillofacial,
and general and digestive. The gloves were collected and tested to detect perforations using the water-
leak test as described in European Norm NF EN 455-1. For percentage comparisons, the χ2 test was used
with a significance threshold of 5%.
Results: A total of 284 gloves were collected. Of these, 47 were found to be perforated, a rate of 16.5%.
All perforations were unnoticed by the surgical team members. The majority of perforated gloves (61.7%)
were collected after urology procedures (P = .00005), 77% of perforated gloves were detected when the
duration of the procedure exceeded 90 minutes (P = .001), and 96% were from brand A, which were the
thicker gloves (P = .015).
Conclusions: This study highlighted an important problem neglected by surgical teams. The findings re-
affirm the importance of double-gloving and changing gloves in surgeries of more than 90 minutes’ duration.
© 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier
Inc. All rights reserved.

Operating rooms are high-risk environments and among the most
critical hospital units1 where professionals are exposed directly to
blood, body fluids, secretions, and excretions.2 Gloves are consid-
ered a barrier that can prevent transmission of microorganisms from
practitioners to patients and from patients to surgical team members
and are of equal importance as surgical hand antisepsis.3,4 However,
tears and microperforations may occur, exposing both patients and
surgical team members to several complications.3,5,6 Studies have
reported that glove perforation rate can be up to 50% depending
on the type of surgery.7
This accident exposes surgical team members to many dis-
eases such as HIV, hepatitis C virus, and hepatitis B virus.4 Indeed,
* Address correspondence to Mohamed Ayoub Tlili, MHS, Higher School of Health
Sciences and Techniques of Sousse, Tazakestan St, Sahloul II, 4054, Tunisia.
E-mail address: medtlili@hotmail.fr (M.A. Tlili).
Conflicts of interest: None to report.
in cases of glove perforation, germs find a passage to wearers’
hands. 3,5 In 2010, Harnoß et al 8 reported that 15% of gloves
tested were perforated and concluded that the perforation in the
glove layer allows bacteria to pass from the surgical site to the sur-
geon’s hands.
Glove perforation increases also the risk of surgical site infection.4
In their study, Jid et al9 found a higher rate of surgical site infec-
tion during procedures in which gloves were defective.
Because of its importance, many studies worldwide have been
interested in studying the problem of glove perforation and its risks
for decades.3,4,10-14
Nevertheless, most operating room professionals tend to un-
derestimate the risk caused by glove perforation and the importance
of double-gloving in minimizing the rate of contamination.5 Indeed,
operating room team members, especially surgeons, prefer not to
wear double gloves because they ascribe to this a diminishment of
sensitivity. They choose to work comfortably although they are not
protected enough.15

0196-6553/© 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajic.2017.07.016
 ARTICLE IN PRESS
2 M.A. Tlili et al. / American Journal of Infection Control ■■ (2017) ■■-■■
More importantly, practitioners often fail to perceive perforations3
and many tears are not noticed until the end of the surgery when
gloves are removed.14,16 This highly increases the risks to which sur-
gical teams are exposed.11
Furthermore, studies have shown that several factors can be as-
sociated with glove perforation, including type and duration of
surgery, instrumentation, function and experience of the wearer, and
glove quality.14,17,18
Thus, the current study aimed to determine the rate of glove per-
foration in 3 different surgical departments and the factors associated
with glove defect.
MATERIAL AND METHODS
Study design, duration, and setting
This study was descriptive and cross-sectional. It lasted for a
period of 3 months (January-March 2017) and was conducted in 3
different surgical units in Tunisian University Hospital Center of
Sahloul (Sousse).
Study population
Participants
The study included surgical teams, which are composed of sur-
geons, residents, operating room technicians, and scrub nurses. The
selection of participants for our study was based on a conve-
nience sampling method and the sample size was 49.
Gloves
The study material comprised all gloves used (n = 284) by afore-
mentioned surgical teams during the different surgical procedures.
In the course of this study, 2 brands (brand A and brand B) from 2
different manufacturers were used and all were made from natural
rubber latex. The 2 brands are different in thickness: brand A gloves
are thicker than brand B gloves (0.22 mm vs 0.18 mm). The gloves
used were also different in whether the gloves were powdered or
not.
Data collection
Gloves were collected after their removal by the wearer, sepa-
rated, labeled, and identified in plastic bags according to the type
of the surgery, the duration of the glove’s use, function of the wearer
and his or her dominant hand for activity, and the characteristics
of the gloves (ie, fabricant and powder existence). It was also noted
whether a given pair of gloves was the initially worn pair or a re-
placement pair and whether the glove perforation was noticed during
the surgical procedure or not.
Also, after each procedure, each participant on the surgical team
was asked to fill out a brief demographic characteristics question-
naire that requests information regarding age, gender, surgical
specialty, function, years of experience, and dominant hand for
activity.
Study instrument
The collected gloves were tested immediately at the practical
training room of the Higher School of Health Sciences and Tech-
niques of Sousse using the approved and standardized water-leak
test method according to European Norm NF EN 455-1.19
This test runs as follows: a polyvinyl chloride tube the dimen-
sions of which fit the glove and such that the tube is capable of
holding any of the 1,000 mL water that may exceed the natural fill
volume of the glove is inserted vertically into the glove and fixed
with a ring positioned at 40 mm from the end to avoid glove
damage.
One liter of water (±50 mL) is poured into the glove from the open
side of the pipe, allowing the water to pass freely into the glove.
Some water may remain in the filling tube depending on the glove
being tested.
The glove is allowed to hang and is immediately inspected during
a period of 2-3 minutes for visual water leakage as either a jet or
droplets.
A data collection sheet was filled out by the researchers that
allows recording of information about the type and the duration
of the intervention, the glove characteristics (eg, manufacturer and
powder existence), the wearer’s function, the location, the number
of perforations, and whether or not the perforation was perceived
by the participant.
Ethical considerations
Data collection started after obtaining approval from the chiefs
from the 3 concerned departments. The water-leak test does not
require permission, although the participants were fully informed
about the research being conducted. The study’s aim and methods
were explained to participants, as were their rights of anonymity,
confidentiality, and the right to refuse participation. They gave verbal
consent to participate and filled out the questionnaire.
Data analysis
Results were produced using the Statistical Package for Social
Sciences version 20.0 (IBM-SPSS Statistics, Armonk, NY) for Windows.
For percentage comparisons, the χ2 test was used with a signifi-
cance threshold of 5%.
RESULTS
Altogether, 284 gloves were collected from the different fields
and 49 participants from the concerned operating rooms agreed to
participate in this study, for a participation rate of 73.1%.
Demographic data and characterization of surgeries
Of all participants, 40.8% (n = 20) were members of the urology
surgical team, the participants were predominately men (61.2%;
n = 30) and were surgical residents in 38.8% of cases (Table 1). The
right hand was the dominant one in 89.8% of cases (n = 44).
As for gloves used in the different procedures, they were from
2 brands (brand A and brand B) from 2 different manufacturers and
were made of natural rubber latex. Brand A gloves, which were
thicker than brand B gloves represented 83.8% (n = 238) of all gloves
used. Powdered gloves represented 87.3% (n = 248) of gloves, whereas
12.7% (n = 36) of gloves used were powder-free.
The distribution of glove use according to surgical specialty, to
wearer’s function, and to surgery duration is represented in Table 2.
Water-leak test
Our findings were that the overall perforation rate was 16.5% (47
perforated gloves) with 52 perforations. The most-perforated finger
was the index finger, with 18 perforations (34.6%), followed by the
thumb with 12 perforations (23.1%), and the ring finger with 8 per-
foration (15.4%). One perforation occurred in the little finger (1.9%).
As for perforation location with regard to hand dominance, our
results showed that the index finger of the nondominant hand was
the most common perforation location (21.1%) followed by the
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Table 1 Table 3
Characteristics of participants Factors associated with glove perforation

Characteristic Frequency % Perforated Nonperforated

Total 49 100 Associated factor gloves gloves P value
Gender Total 47 (100) 237 (100)
Men 30 61.2 Duration of surgery, min .001*
Women 19 38.8 < 90 11 (23.4) 117 (49.4)
Age, y ≥ 90 36 (76.6) 120 (50.6)
25-30 17 34.7 Participant’s function 0.110
31-40 21 42.9 Surgeon 23 (48.9) 81 (34.2)
> 40 11 22.4 Surgical resident 18 (38.3) 102 (43)
Surgical specialty Scrub nurse or surgical 6 (12.8) 54 (22.8)
Urology 20 40.8 technologist
Maxillofacial 11 22.4 Surgical speciality .00005*
General and digestive 18 36.7 Urology 29 (61.7) 67 (28.3)
Function General 10 (21.3) 82 (34.6)
Surgeon 16 32.7 Maxillofacial 8 (17) 88 (37.1)
Surgical resident 19 38.8 Hand dominance 0.632
Surgical technologist or scrub nurse 14 28.6 Dominant hand 22 (46.8) 120 (50.6)
Experience, y Nondominant hand 25 (53.2) 117 (49.4)
1-10 33 67.4 Thickness .015*
11-20 12 24.5 Brand A 45 (95.7) 193 (81.4)
> 20 4 8.2 Brand B 2 (4.3) 44 (18.6)
Dominant hand for activity Powder 0.327
Right hand 44 89.8 Powdered 39 (83) 209 (88.2)
Left hand 5 10.2 Powder-free 8 (17) 28 (11.8)

Values are presented as n (%).

*P < .05.
Table 2
Glove use according to surgical specialty, wearer’s function, and surgery duration

Variable n % Higher rates were found in other studies. Bekele et al14 found a
Surgical specialty rate of 41.4% in emergency procedures and 30% in elective surger-
Urology 96 33.8 ies. On the other hand, Martinez et al7 found a lower perforation
General and digestive 92 32.4 rate (3.4%). The difference between these results can be ascribed to
Maxillofacial 96 33.8 variation in context. These studies were conducted in different coun-
Total 284 100
Wearer’s function 284 100
tries and in different specialties, and thus their circumstances were
Surgeon 104 36.6 different, too. According to Kaplan et al,20 different conditions and
Surgical resident 120 42.3 peculiarities such as instrumentation, surgical equipment, and tech-
Scrub nurse or surgical technologist 60 21.1 niques have the potential to create glove tears. In our study, we found
Total 284 100
different results in the 3 different departments: urology surgery
Duration, min
< 90 128 45 (61.7%), maxillofacial surgery (17%), and general and digestive surgery
≥ 90 156 55 (21.3%).
Total 284 100 Whether glove perforation rate is low or high, glove failure can
influence both patients and surgical team members and expose them
to serious risks. Bacteria can pass through microperforations from
nondominant hand’s thumb (15.4%). It is important to note that none patient to surgeon and vice versa and transmit viral diseases, in-
of the perforations were noticed by the glove wearers. cluding hepatitis B, hepatitis C, and HIV, which can engender serious
health problems.2
Associated factors with glove perforation These risks to which health care professionals are exposed are
increased by being unaware of the perforation immediately when
Our findings show that glove perforations occur significantly more it occurs and continuing to use the pierced glove until the end of
frequently in procedures that exceeded 90 minutes (76.6%) than in the procedure.8,21-23 Indeed, the risk of contamination increases
procedures taking less time (representing 23.4% of all procedures) with the duration of blood and germs contact to the skin.11 In
(P = .001). our study, all perforations went unnoticed by health care
Results showed also that 61% of perforations occurred during professionals.
urology surgeries, 21% during general and digestive surgery pro- When it comes to perforation location, several studies have re-
cedures, and 17% of perforations occurred during maxillofacial vealed that the index finger is the part of the glove most prone to
surgeries (P = .00005). Table 3 represents the different associa- puncture or tearing.11,24,25 Our results confirmed these observa-
tions explored between glove perforation and several factors. tions, revealing that the index finger was the most common
perforated site (34.6%). The second most common location was the
DISCUSSION thumb (23%).
According to literature, many factors can be associated with glove
During surgery, gloves are exposed to a range of chemical and puncture.3,7,12,21 In our study, type and the duration of the surgical
physical stressors such as twisting; pulling; stretching; and expo- procedure, hand dominance, wearer’s function, and type of the glove
sure to fluids, fat, or chemical substances that influence the integrity and its characteristics were assessed.
of gloves and increase the rate of perforation.17 Our findings revealed that glove perforations happened signifi-
The present study revealed that the rate of glove perforation is cantly more frequently in procedures that exceeded 90 minutes
16.5%. Approximately the same results were found by Makama et al (76.6%) than in those taking less time (23.4% of all procedures)
(15.2%)2 and de Oliveira et al3 who reported a rate of (12%). (P = .001). These results confirm what previous studies have already
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found concerning the association between duration of the surgery
and glove perforation. Indeed, the study by Misteli et al12 showed
that risk of glove perforation increases significantly in procedures
lasting more than 2 hours.
Similarly, Makama et al,2 Laine et al,11 and Egeler et al21 con-
cluded that the longer the duration of the operation, the greater the
possibilities of needle puncture or defect in the glove by sharp in-
struments. It has been postulated that this may be due to less-
than-optimal attention that is often the result of fatigue.2 Also, the
operation is usually more demanding if it is longer, and thus there
are more possibilities for glove perforations.11
Concerning surgical specialty, the study by Makama et al2 con-
firmed that the nature of the surgery can directly influence glove
perforation. They found that the highest rate of perforation was ob-
served in general surgery (17.4%) followed by pediatric surgery
(14.6%).2 Our findings recorded that glove perforation in the 3 dif-
ferent departments were as follows: 61.7% of perforations were found
in the gloves used in urology surgery, 17% in maxillofacial surgery,
and 21.3% of perforations occurred during a general or digestive
surgery. The difference between these results was significant
(P = .00005). These results reinforce the fact that glove defect is highly
associated with surgical discipline. Every specialty has its own pe-
culiarities and specifications, such as instrumentation, surgical
equipment, and techniques, that can influence glove performance
and integrity differently.20
As for glove type and characteristics, the gloves tested were
from 2 different brands both made from natural rubber latex.
Brand A gloves were thicker than brand B gloves. Perforations
were as follows for both brands: 95.7% of perforations were
observed in gloves from brand A and 4.3% occurred in gloves from
brand B. The difference was significant (P = .015). We expected to
find more perforations in the thinner gloves. This shows that
perforation occurrence is not only related to glove thickness, but
also can be imputed to many other characteristics such as elastic-
ity and elongation. In their study, Bardorf et al26 demonstrated
that more elasticity and maximized elongation can block the
passage of bacteria through tiny holes. They also reported that a
glove can close microperforations on its own and that a glove’s
thickness can improve its ability to do so.26
Our study has several limitations. The fact that an evaluation of
glove integrity using the same water-leak test was not performed
with the gloves before use can cause confusion as to the origin of
the defect. The two brands involved in the study were quite differ-
ent in appearance and we cannot be sure that no glove was already
defective or if manufacturers or researchers were responsible for
the observed effect. Also, the water-leak test is unable to detect per-
forations of <0.5 mm; some perforations might have gone undetected.
CONCLUSIONS
This study highlighted an important problem to which members
of surgical teams do not give much importance, despite the risks
that it can generate and its potentially severe consequences. In light
of this study, we recommend systematic double-gloving and fre-
quent changing of gloves to reduce the perforation rate and its risks.
We also suggest training and informing sessions for surgical team
members to draw attention to the gravity of glove perforation, the
importance of double-gloving, and to highlight the factors and cir-
cumstances that lead to higher perforation rates. Research is
recommended to highlight the efficacy of these measures.
Acknowledgments
The authors thank the surgical teams for their cooperation and
the supportive working conditions they offered.
References
1. Mallouli M, Tlili MA, Aouicha W, Ben Rejeb M, Zedini C, Salwa A, et al. Assessing
patient safety culture in Tunisian operating rooms: a multicenter study. Int J
Qual Health Care 2017;29:176-82.
2. Makama JG, Okeme IM, Makama EJ, Ameh EA. Glove perforation rate in surgery:
a randomized, controlled study to evaluate the efficacy of double gloving. Surg
Infect (Larchmt) 2016;17:436-42.
3. de Oliveira AC, Gama CS. Evaluation of surgical glove integrity during surgery
in a Brazilian teaching hospital. Am J Infect Control 2014;42:1093-6.
4. Goldman AH, Haug E, Owen JR, Wayne JS, Golladay GJ. High risk of surgical glove
perforation from surgical rotatory instruments. Clin Orthop Relat Res
2016;474:2513-7.
5. Guo YP, Wong PM, Li Y, Or PPL. Is double-gloving really protective? A comparison
between the glove perforation rate among perioperative nurses with single and
double gloves during surgery. Am J Surg 2012;204:210-5.
6. Beldame J, Lagrave B, Leivain I, Lefebvre B, Frebourg N, Dujardin F. Surgical glove
bacterial contamination and perforation during total hip arthroplasty
implantation: when gloves should be changed. Orthop Traumatol Surg Res
2012;98:432-40.
7. 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.
8. Harnoß J-C, Partecke L-I, Heidecke C-D, Hübner N-O, Kramer A, Assadian O.
Concentration of bacteria passing through puncture holes in surgical gloves. Am
J Infect Control 2010;38:154-8.
9. Jid LQ, Ping MW, Chung WY, Leung WY. Visible glove perforation in total
knee arthroplasty: risk and consequences. J Orthop Surg 2017;25:2309
49901769561.
10. Dxodds RDA, Guy PJ, Peacock AM, Duffy SR, Barker SGE, Thomas MH. Surgical
glove perforation. Br J Surg 1988;75:966-8.
11. Laine T, Aarnio P. How often does glove perforation occur in surgery? Comparison
between single gloves and a double-gloving system. Am J Surg 2001;181:564-6.
12. Misteli H, Weber WP, Reck S, Rosenthal R, Zwahlen M, Fueglistaler P, et al.
Surgical glove perforation and the risk of surgical site infection. Arch Surg
2009;144:553-8.
13. Palmer JD, Rickett JWS. The mechanisms and risks of surgical glove perforation.
J Hosp Infect 1992;22:279-86.
14. 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.
doi:10.1186/s12893-017-0228-8.
15. Han CD, Kim J, Moon SH, Lee BH, Kwon HM, Park KK. A randomized prospective
study of glove perforation in orthopaedic surgery: is a thick glove more effective?
J Arthroplasty 2013;28:1878-81.
16. Choi LY, Torres R, Syed S, Boyle S, Ata A, Beyer TD, et al. Sharps and needlestick
injuries among medical students, surgical residents, faculty, and operating room
staff at a single academic institution. J Surg Educ. 2017;74:131-6.
17. Korniewicz D, El-Masri M. Exploring the benefits of double gloving during
surgery. AORN J 2012;95:328-36.
18. Yinusa W, Li YH, Chow W, Ho WY, Leong JCY. Glove punctures in orthopaedic
surgery. Int Orthop 2004;28:36-9.
19. European Committee for Standardization. EN 455-1: medical gloves for single
use. Brussels: European Committee for Standardization; 2000.
20. Kaplan KM, Gruson KI, Gorczynksi CT, Strauss EJ, Kummer FJ, Rokito AS. Glove
tears during arthroscopic shoulder surgery using solid-core suture. Arthrosc J
Arthrosc Relat Surg. 2007;23:51-6.
21. Egeler K, Stephenson N, Stanke N. Glove perforation rate with orthopedic gloving
versus double gloving technique in tibial plateau leveling osteotomy:
a randomized trial. Can Vet J 2016;57:1156.
22. Carter AH, Casper DS, Parvizi J, Austin MS. A prospective analysis of glove
perforation in primary and revision total hip and total knee arthroplasty.
J Arthroplasty 2012;27:1271-5.
23. Caillot JL. Le gantage chirurgical en France: une évolution lente mais nécessaire.
J Chir (Paris) 2005;142:226-30.
24. Kuroyanagi N, Nagao T, Sakuma H, Miyachi H, Ochiai S, Kimura Y, et al. Risk of
surgical glove perforation in oral and maxillofacial surgery. Int J Oral Maxillofac
Surg 2012;41:1014-9.
25. Arowolo OA, Agbakwuru EA, Obonna GC, Onyia CU, Akinkuolie AA, Olaogun JG.
Safety of the surgeon: ‘Double-gloving’ during surgical procedures. South Afr J
HIV Med. 2014;15:144-7.
26. 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;44:1645-9.