D. Berger-Richardson1, A. Govindarajan1, R. S. Xu1, R. A. Gladdy1, A. McCart1, C. J. Swallow1 1University of Toronto,Department Of Surgery,Toronto, Ontario, Canada
Introduction:
The changing of gloves and instruments following the extirpative phase of cancer surgery is done with the intent of reducing the risk of local and wound recurrences. Although malignant cells have been identified in washings from gloves and instruments used during resection of upper aero-digestive squamous cell and basal cell cancers, no evidence definitively demonstrates that cells retained on gloves and instruments can cause tumor seeding and recurrence. To determine the potential impact of further investigation of this question, we surveyed the practice and beliefs of a broad spectrum of surgeons who operate on cancer.
Methods:
A pilot-tested survey was mailed to all general surgeons listed in the public registry provided by the College of Physicians and Surgeons of Ontario, Canada using a modified Dillman approach. Respondents were retained for analysis if they met inclusion criteria: staff surgeons in active practice who perform oncologic resections.
Results:
438 of 945 surveys were returned, 351 of which met inclusion criteria, yielding an American Association of Public Opinion Research adjusted response rate of 46%. Based on their years in practice (60% at least 10 years), gender (24% female), subspecialty training (66% with clinical fellowship training of some type), and proportion of operative practice consisting of cancer surgery (52% self-reporting less than one third), the respondents were representative of the spectrum of general surgeons of the province of Ontario. 52% of respondents reported that they change gloves during cancer resections with the intent of decreasing the risk of tumor seeding, and 40% said they change instruments for this purpose. The most common circumstances cited for changing gloves were: before reconstruction, and when direct tumor handling was suspected (e.g. perforated tumor). Instruments were most commonly changed when the procedure involved discontiguous surgical fields (e.g. tumor bed and graft harvest site). 73% of respondents said they routinely take measures to protect the wound during laparoscopic cancer resection (wound protector, specimen retrieval bag), compared to 31% during open resection (wound barriers, irrigation) (p<0.01). Type of subspecialty fellowship training and years in practice predicted some of these behaviors. The majority of respondents opined that gloves and instruments are likely to harbor malignant cells, while the minority thought it likely that these retained cells contribute to tumor recurrence.
Conclusion:
There is no consensus on how gloves and instruments should be handled in cancer operations. Future studies should determine whether surgical gloves and instruments actually harbor malignant cells that are capable of seeding wounds, since the protective strategies currently employed by some surgeons and institutions carry significant financial and environmental burdens.