Annals of the Royal College of Surgeons of England (1975) 1o01
57
ASPECTS OF TREATMENT*
A
method
from
of removing
surgeons'
starch
powder
gloves
S J S Kent FRCS K G Burnand FRCS D Owen MRCPath St Thonas's Hospital, London
Summary A method of washing the outside of surgeons? gloves with cetrimide is described. Experiments on animals showed that the method resulted in a considerable reduction in the amount of intraperitoneal contamination by starch powder.
Introduction Reports of postoperative intraperitoneal starch granulomata1" have recently aroused interest in methods of preventing peritoneal contamination by glove powder'->. Jagelman and Ellis", accepting the continued use of starch in the manufacture of gloves, demonstrated that the washing of gloves with water was unsuccessful in removing starch powder. This paper reports experiments showing that the detergent cetrimide is effective in removing starch powder from surgeons' gloves. Materials and methods A) Glove experiments Six successive pairs of Regent disposable surgeons' gloves were put on and the hands immersed in a bowl
*Felloxvs
of water for I min and scrubbed with a gauze swab. The gloves were then removed and Lugol's iodine applied to the ouiter suirface, any colour change being observed. Six pairs of the same type of glove were then successivelv put on and the hands immersed in a bowl containing a 00 weight/ volume solution of cetrimide for I min andl scrubbed with a gauze swab. The gloves were then rinsed in water and tested with Lugol's iodine. Twenty-four B) Animal experiments guiineapigs were randomly divided into 4 groups and anaesthetized with intramuscular Hypnorm (fentanyl citrate and fluanisone) and ether. The abdominal cavity was opened through a midline incision by a surgeon who did not wear gloves. A second surGroup i (6 guinea pigs) geon wearing a pair of unwashed Regent disposable gloves handled the omentum thoroughly for one minute. The first surgeon then excised the omentum and placed it in formol saline fixative. The animals were then killed by intravenous injection of air. The same techGroup 2 (6 guineapigs)
and Members initerested in submitting papers for coinsideration in this series should first write to the Editor
publication
wNith
a
View
to
A method of
removing
nique was used except that the second surgeon washed and scrubbed his gloves in water for one minute before handling the omentum. Group 3 (6 guineapigs) The same technique was used except that the second surgeon washed and scrubbed his gloves in cetrimide (i % w/v solution) for one minute and rinsed them in water before handling the omentum.
starch powder from surgeons' gloves
2I3
One slide from each omentum was examined and a count made of the number of starch granules present. The results were expressed according to the number of granules per slide as follows: < IO, + ; 10-50, + +; 5I-100, + + + IOI-500, + + + +; > 500, + + + +±. Greater accuracy was not justified as it was not possible to ensure that exactly the same amount of omentum was examined from each guineapig. The slides were examined by one of us (D 0) who was unaware from which group
Group 4 (6 control guineapigs) The same technique as for the preceding groups was used, but the second surgeon did not wear gloves at any time during the procedure. any specimen originated. Different sets of instruments were used for each group to avoid contamination with Results starch between the different groups of A) Glove experiments All the 6 pairs of animals. gloves washed in water showed blue disHistological examination Approximately colouration on testing with iodine, indicating equal quantities of omentum were taken the continued presence of starch. None of from each guineapig and fixed for 48 h in the 6 pairs of gloves washed in cetrimide formol saline. The processing, embedding, showed any discolouration on testing with and sectioning of the specimens were per- iodine, suggesting that starch had been formed separately from routine laboratory eliminated from the outer surface of the specimens and no gloves were used at any gloves. stage in an attempt to reduce contamination with starch powder in the laboratory. Sec- B) Animal experiments The starch grantions were stained by the periodic-acid-Schiff ule counts in the 4 groups are shown in technique and examined in polarized light. the table. Under these conditions starch granules are mnagenta-coloured, with a characteristic Discussion 'Maltese cross' birefringence. The glove manufacturers are at present un-
Results of histological examination of biopsy specimens of guineapig omentum in Experiment B Group i Group 3 Group 2 Group 4 (unwashed gloves) GuineaGranule pig no.
count
(gloves washed with water) GuineaGranule pig. no count
(gloves washed with cetrimide) GuineaGranule pig no. count ++ 9 + 13 ++ 17
I
+++ + +
2
++ + +
4 6
++ + +
5
J+ + +
10
+++
12
+++
20
+
'5
++ ++ + +
23 24
+
II
14
I9
+++
++++ + +++ ++
i6
+ ++ +
(controls) Guineapig no. 3 7
8
Granule count + + +
I8 21
+
22
+
+
214
S J S Kent, K G Burnand, and D Owen
willing to stop using starch as a glove lubricant8. As there is good evidence that starch contamination can produce granulomata`5 its removal by some means is desirable. A method has been described for removing starch powder by scrubbing gloves with a swab soaked in cetrimide8, but this was rejected because even after subsequent rinsing with water it was found that starch remained on the outside of the gloves. In the method described here the gloves are scrubbed while immersed in a bowl of cetrimide solution and then rinsed in water. It is probable that rinsing washes away the starch powder that the cetrimide has dislodged from the pores of the gloves. The simple iodine testing in the glove experiments showed that this technique is apparently effective in the removal of starch powder. The animal experiments were designed to parallel the clinical situation and to provide a more sensitive test for the presence of starch, as individual granules could be counted by microscopic examination. A count of between o and i o granules per slide was found in all the control specimens, presumably as a result of contamination in the laboratory by starch powder from the gloves used in handling routine histological specimens, despite precautions taken to prevent this occurrence. If this background count is considered the results show satisfactory elimination of starch by washing with cetrimide in 3 animals in Group 3 and a considerable reduction in the remaining 3. Comparison with Group 2 shows that cetrimide is much more effective in removing starch powder from gloves than washing in water and reduces contamination to a minimal level. It has been suggested that a hyper-
sensitivity reaction is responsible for the development of starch granulomata9'1. If this hvpothesis is accepted anything short of complete exclusion of starch from an operating field may fail to prevent the formation of starch granulomata in hypersensitive individuals. However, the considerable reduction in starch powder contamination achieved by washing surgeons' gloves with cetrimide is likely to limit the severity, extent, and duration of any subsequent reaction. We thank Mr B T Jackson for his help in the
l)reparation of this article.
References McAdams, G B (1956) Surgery, 39, 329. 2 McNaught, E H D (I964) British Journal of Surgery, 51, 845. 3 Neely, J, and Davies, J D (I97i) British Medic al Journal, 3, 625. I
4 Colin, J, and Wastell, C (I97i) British Medical
Journal, 4, 47.
5 Aarons, J, and Fitzgerald, N
(I947) Surgery,
Gynecology and Obstetrics, I38, 385. 6 Jagelman, D G, and Ellis, H Journal of Surgery, 6o, iii.
(I973) British
7 Nash, D F E
(I9 7i) British Medical Journal, 3, I83. 8 Nash, D F E (i973) British Medical Journal, I, 485. 9 Bates, B (1965) Annals of Internal Medicine,
62, 335. Io
Sobel, H J, Schiffman, R J, Schwarz, R, and Albert, W S (97I) Archives of Pathology, 9I,
559.
iI Holgate, S T, Wheeler, J H, and Bliss, B P
(1973) Annals of the Royal College of Surgeons of England, S2. I82.
57
ASPECTS OF TREATMENT*
A
method
from
of removing
surgeons'
starch
powder
gloves
S J S Kent FRCS K G Burnand FRCS D Owen MRCPath St Thonas's Hospital, London
Summary A method of washing the outside of surgeons? gloves with cetrimide is described. Experiments on animals showed that the method resulted in a considerable reduction in the amount of intraperitoneal contamination by starch powder.
Introduction Reports of postoperative intraperitoneal starch granulomata1" have recently aroused interest in methods of preventing peritoneal contamination by glove powder'->. Jagelman and Ellis", accepting the continued use of starch in the manufacture of gloves, demonstrated that the washing of gloves with water was unsuccessful in removing starch powder. This paper reports experiments showing that the detergent cetrimide is effective in removing starch powder from surgeons' gloves. Materials and methods A) Glove experiments Six successive pairs of Regent disposable surgeons' gloves were put on and the hands immersed in a bowl
*Felloxvs
of water for I min and scrubbed with a gauze swab. The gloves were then removed and Lugol's iodine applied to the ouiter suirface, any colour change being observed. Six pairs of the same type of glove were then successivelv put on and the hands immersed in a bowl containing a 00 weight/ volume solution of cetrimide for I min andl scrubbed with a gauze swab. The gloves were then rinsed in water and tested with Lugol's iodine. Twenty-four B) Animal experiments guiineapigs were randomly divided into 4 groups and anaesthetized with intramuscular Hypnorm (fentanyl citrate and fluanisone) and ether. The abdominal cavity was opened through a midline incision by a surgeon who did not wear gloves. A second surGroup i (6 guinea pigs) geon wearing a pair of unwashed Regent disposable gloves handled the omentum thoroughly for one minute. The first surgeon then excised the omentum and placed it in formol saline fixative. The animals were then killed by intravenous injection of air. The same techGroup 2 (6 guineapigs)
and Members initerested in submitting papers for coinsideration in this series should first write to the Editor
publication
wNith
a
View
to
A method of
removing
nique was used except that the second surgeon washed and scrubbed his gloves in water for one minute before handling the omentum. Group 3 (6 guineapigs) The same technique was used except that the second surgeon washed and scrubbed his gloves in cetrimide (i % w/v solution) for one minute and rinsed them in water before handling the omentum.
starch powder from surgeons' gloves
2I3
One slide from each omentum was examined and a count made of the number of starch granules present. The results were expressed according to the number of granules per slide as follows: < IO, + ; 10-50, + +; 5I-100, + + + IOI-500, + + + +; > 500, + + + +±. Greater accuracy was not justified as it was not possible to ensure that exactly the same amount of omentum was examined from each guineapig. The slides were examined by one of us (D 0) who was unaware from which group
Group 4 (6 control guineapigs) The same technique as for the preceding groups was used, but the second surgeon did not wear gloves at any time during the procedure. any specimen originated. Different sets of instruments were used for each group to avoid contamination with Results starch between the different groups of A) Glove experiments All the 6 pairs of animals. gloves washed in water showed blue disHistological examination Approximately colouration on testing with iodine, indicating equal quantities of omentum were taken the continued presence of starch. None of from each guineapig and fixed for 48 h in the 6 pairs of gloves washed in cetrimide formol saline. The processing, embedding, showed any discolouration on testing with and sectioning of the specimens were per- iodine, suggesting that starch had been formed separately from routine laboratory eliminated from the outer surface of the specimens and no gloves were used at any gloves. stage in an attempt to reduce contamination with starch powder in the laboratory. Sec- B) Animal experiments The starch grantions were stained by the periodic-acid-Schiff ule counts in the 4 groups are shown in technique and examined in polarized light. the table. Under these conditions starch granules are mnagenta-coloured, with a characteristic Discussion 'Maltese cross' birefringence. The glove manufacturers are at present un-
Results of histological examination of biopsy specimens of guineapig omentum in Experiment B Group i Group 3 Group 2 Group 4 (unwashed gloves) GuineaGranule pig no.
count
(gloves washed with water) GuineaGranule pig. no count
(gloves washed with cetrimide) GuineaGranule pig no. count ++ 9 + 13 ++ 17
I
+++ + +
2
++ + +
4 6
++ + +
5
J+ + +
10
+++
12
+++
20
+
'5
++ ++ + +
23 24
+
II
14
I9
+++
++++ + +++ ++
i6
+ ++ +
(controls) Guineapig no. 3 7
8
Granule count + + +
I8 21
+
22
+
+
214
S J S Kent, K G Burnand, and D Owen
willing to stop using starch as a glove lubricant8. As there is good evidence that starch contamination can produce granulomata`5 its removal by some means is desirable. A method has been described for removing starch powder by scrubbing gloves with a swab soaked in cetrimide8, but this was rejected because even after subsequent rinsing with water it was found that starch remained on the outside of the gloves. In the method described here the gloves are scrubbed while immersed in a bowl of cetrimide solution and then rinsed in water. It is probable that rinsing washes away the starch powder that the cetrimide has dislodged from the pores of the gloves. The simple iodine testing in the glove experiments showed that this technique is apparently effective in the removal of starch powder. The animal experiments were designed to parallel the clinical situation and to provide a more sensitive test for the presence of starch, as individual granules could be counted by microscopic examination. A count of between o and i o granules per slide was found in all the control specimens, presumably as a result of contamination in the laboratory by starch powder from the gloves used in handling routine histological specimens, despite precautions taken to prevent this occurrence. If this background count is considered the results show satisfactory elimination of starch by washing with cetrimide in 3 animals in Group 3 and a considerable reduction in the remaining 3. Comparison with Group 2 shows that cetrimide is much more effective in removing starch powder from gloves than washing in water and reduces contamination to a minimal level. It has been suggested that a hyper-
sensitivity reaction is responsible for the development of starch granulomata9'1. If this hvpothesis is accepted anything short of complete exclusion of starch from an operating field may fail to prevent the formation of starch granulomata in hypersensitive individuals. However, the considerable reduction in starch powder contamination achieved by washing surgeons' gloves with cetrimide is likely to limit the severity, extent, and duration of any subsequent reaction. We thank Mr B T Jackson for his help in the
l)reparation of this article.
References McAdams, G B (1956) Surgery, 39, 329. 2 McNaught, E H D (I964) British Journal of Surgery, 51, 845. 3 Neely, J, and Davies, J D (I97i) British Medic al Journal, 3, 625. I
4 Colin, J, and Wastell, C (I97i) British Medical
Journal, 4, 47.
5 Aarons, J, and Fitzgerald, N
(I947) Surgery,
Gynecology and Obstetrics, I38, 385. 6 Jagelman, D G, and Ellis, H Journal of Surgery, 6o, iii.
(I973) British
7 Nash, D F E
(I9 7i) British Medical Journal, 3, I83. 8 Nash, D F E (i973) British Medical Journal, I, 485. 9 Bates, B (1965) Annals of Internal Medicine,
62, 335. Io
Sobel, H J, Schiffman, R J, Schwarz, R, and Albert, W S (97I) Archives of Pathology, 9I,
559.
iI Holgate, S T, Wheeler, J H, and Bliss, B P
(1973) Annals of the Royal College of Surgeons of England, S2. I82.
