Why is glove change necessary before placing mesh in hernia repair?

Why Glove Change Before Placing Mesh in Hernia Repair

Changing gloves before placing mesh during hernia repair is a critical infection prevention strategy designed to minimize bacterial contamination of the prosthetic material, thereby reducing the risk of devastating mesh infections that often require complete mesh removal.

The Core Problem: Mesh as a Foreign Body

• Prosthetic mesh implantation creates a decreased threshold for infection compared to native tissue repairs, as foreign materials provide a surface for bacterial adherence and biofilm formation 1
• Mesh infections, though occurring in only 1-8% of cases, represent a catastrophic complication that frequently necessitates complete surgical removal of the mesh to eradicate infection 1, 2
• Staphylococcus species, particularly S. aureus, along with Enterococcus species and Gram-negative bacteria are the most commonly isolated organisms in mesh infections 1

Glove Contamination During Surgery

• Surgical glove integrity deteriorates significantly over time, with microperforation rates increasing from 15.4% at ≤90 minutes to 23.7% when worn longer than 150 minutes 1
• Latex gloves undergo measurable hydration after just 30 minutes of surgical use, resulting in a 24% decrease in rupture load and compromised mechanical resistance 1
• Glove perforation rates are particularly high in open abdominal surgery, making routine glove changes at 90-minute intervals or before critical steps (like mesh placement) a recommended practice 1

The Bacterial Burden Principle

• Bacterial burden is the most significant risk factor for surgical wound healing complications and postoperative infection 1
• While bacteria inherently colonize all surgical wounds, the presence of foreign materials like mesh significantly lowers the threshold at which bacterial contamination leads to clinical infection 1
• During hernia repair with bowel manipulation or resection, gloves become contaminated with enteric flora, creating a polymicrobial aerobic and anaerobic bacterial load 1

Surgical Field Classification and Mesh Safety

• In clean surgical fields (CDC Class I), mesh infection rates remain low, but any contamination dramatically increases risk 1
• Clean-contaminated fields (CDC Class II) with bowel manipulation show surgical site infection rates of 7.1%, rising to 19% in contaminated fields (CDC Class III) when polypropylene mesh is used 1
• The odds of postoperative complications increase 3.56-fold in clean-contaminated cases and 5.05-fold in contaminated cases when mesh is used 3

Practical Implementation

• Change gloves immediately before handling and placing the mesh, even if current gloves appear intact 1
• Consider double-gloving with an indicator system to detect outer glove perforations more easily, though this does not reduce perforation rates 1
• Change gloves whenever they become excessively contaminated with surgical fluids, blood, or after bowel manipulation 1
• If surgery duration exceeds 90 minutes before mesh placement, mandatory glove change is recommended for all team members directly handling the mesh 1

Common Pitfalls to Avoid

• Do not assume intact gloves are uncontaminated—microperforations are often undetectable and bacterial contamination occurs even without visible breaches 1
• Avoid placing mesh in contaminated or dirty fields (CDC Classes III-IV) altogether when possible; primary repair or biological mesh are preferred alternatives 1
• Do not underestimate the risk of mesh infection in emergency settings where bacterial translocation from strangulated bowel increases contamination risk 1
• Remember that mesh infections can present weeks to years after surgery, making prevention at the time of implantation critical 2

Supporting Evidence for Infection Prevention

• Emergency operations carry a 2.46-fold increased risk of mesh infection compared to elective cases 1
• Smoking (RR 1.36), ASA score ≥3 (RR 1.40), and longer operative duration all significantly increase mesh infection risk 1
• When mesh infection occurs, 72.7% of cases require mesh explantation, representing a major failure of the initial repair 1