Gloves and surgery… (Day -243)

Bristol Vet School Glove Perforation Study

Something that many take for granted is once you put the sterile operating gloves on, unless you do something stupid you remain sterile. This is even more important when it comes to pet guardians who when entrusting their animals to us take it for granted that a vet will do everything possible to ensure a good outcome.

A good outcome here is there being no Surgical Site Infection because the surgeon has worn gloves, and taken all steps to reduce the risk.

However a recent study published in July this year has shown that perforations (holes) occurred in gloves during 43% of orthopaedic surgeries (you can read the study here). This followed an earlier study looking a glove perforations in general surgery which identified perforation in 26.2% of surgical procedures. The latest study confirms that perforations are more likely in orthopaedic surgeries.

This is concerning as in a human study the risk of surgical site infection doubles when there is glove perforation. When dealing with orthopaedic surgery especially the effect of an infection can be devastating especially when there is an implant or metalwork involved. Anything that can be done here to lower the risk of infection is therefore extremely important.

Unfortunately though as surgeons the ability to detect a glove perforation can be extremely difficult. The studies I read here have detection of a perforation at between 7-31% – in human surgery it is only 37%.

So as with most problems there is a solution, and in this case it is wearing a pair of sterile indicator gloves under the surgical gloves. These indicator gloves are made exactly the same as the surgical gloves with just the addition of a dye. Therefore when the outer glove is perforated and liquid contacts the inner glove a colored spot will appear on the glove at the site of perforation to alert the surgeon that it has occurred.

With the use of indicator under gloves the detection rate of glove perforation by surgeons increased to 90%.

Whilst from this it would be logical to say that every single surgeon should use indicator undergloves there are the practical concerns of veterinary medicine to consider. Currently there is no study on the ability to perform surgery to the same level and dexterity in veterinary surgery so whilst double gloving may decrease the risk of infection in 26.2% of all cases (43% in orthopaedics), in the other cases it may increase the risk of surgical mistakes when a glove slips for example.

Then there is the economical impact – indicator undergloves will increase the cost of the surgery. And already pet guardians commonly complain about the cost of veterinary medicine. So adding £10 to the cost of every surgery in case gloves break so that the surgeon can recognise they have broken may not for many owners be acceptable.

However when doing orthopaedic surgery like a joint replacement where a surgical site infection may result in removal of the implant and in some cases amputation then £10 becomes very little indeed.

I would love to hear your thoughts and comments as it is definitely one that needs consideration…

Small Animal Soft Tissue Surgery Book Review

Small Animal Soft Tissue Surgery Book Review

As a vet student learning surgery is one of the biggest challenges that lies ahead, and is something that is exciting, yet bears a weight of great responsibility. Most of the surgery textbooks that I have seen are either very specific, or are absolutely massive so I was slightly surprised at the size (and weight) of this book. Flicking through quickly it is possible to see that for the size it has a lot of good solid information without the “fluff” that some books add starting with principles and techniques of aseptic technique, instrument use, and suturing. The book then moves on to discuss the different organ systems, and soft tissue surgical procedures that are used with these.

What I especially love is that the basics are covered in a high level of detail, with the different approaches to the same task considered and contrasted. For example looking at haemostasis the options of direct pressure, crushing haemostasis, ligation, vessel clips, vasoconstriction, diathermy (monopolar and bipolar), topical haemostatic agents are all considered before finishing with a discussion of the complications of bleeding disorders. The two chapters on suturing cover the different materials, and then the different patterns that are used with step by step photographs of each pattern. Pain management, post-operative nutrition, wound management and reconstruction with amputation is covered with an entire chapter on oncological surgery and skin tumours.

When looking at abdominal surgery it starts with a chapter on the principles of abdominal surgery looking at the different approaches, prevention of adhesions, exploring the abdomen and limiting complications. The rest of the section covers the procedures for separate organ systems within the abdomen with each chapter covering the principles behind the system, before going into the clinical indications, diagnostic imaging and different techniques for each procedure. Off note here is the chapter on gastrointestinal surgery which covers the different approaches for diagnosis, special principles and techniques including suture patterns and performing a leak test. The chapter then looks at gastric obstruction and GDV covering from initial stabilisation through to selecting a site for gastropexy. One of my favourite (and as a student most useful) chapters is the one of peritonitis management and the acute management which covers the stabilisation, oxygen & fluid therapy, right through investigation, imaging, diagnosis and treatment.

I’ve already had the pleasure of seeing some small animal surgical clinics here, and this book with its concise indications for, differentials and description of the procedure has been a golden resource for me to quickly get up to speed on the procedures being performed. This is especially useful as I am studying in Slovakia and my understanding of the language still needs improving so prevents me getting completely lost.

One of the first things that got me was that the images are not in colour and are instead printed in high contrast black and white. To be honest I personally like this as I find that they have a higher contrast between tissues which makes them easier to see as colour images rarely match up to what you see in surgery with the difference in lighting and perfusion etc.

For a vet student starting surgery this is a book I would thoroughly recommend, it has the answers to all the “stupid questions”, as well as covering the basic skills that once mastered will make you a better surgeon. I for one will be keeping this book on hand throughout the next 3 years of my training!

This is a book I’d recommend to go into any veterinary collection for a quick reference of the different surgical options available for a client, or as a cheat guide to avoiding the common pitfalls of different procedures.