Human Reproduction, Vol. 15, No. 7, 1573-1577,
July 2000
© 2000 European Society of Human Reproduction and Embryology
Post-operative consequences of glove powder used pre-operatively in the vagina in the rabbit model
1 Karolinska Institute, Department of Obstetrics and Gynaecology at Stockholm Söder Hospital, S-118 83 Stockholm, Sweden and 2 Department of Anatomy, Guy's, King's and St Thomas's School of Biomedical Sciences, London, UK
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Abstract |
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This study was undertaken to determine if a retrograde migration of glove powder (BiosorbTM) from the vagina into the abdominal cavity in combination with a subsequent intra-abdominal trauma could affect the development of adhesions. A rabbit model was used with one control and one test group. A total of 50 mg BiosorbTM was deposited intravaginally in the test cases before ovulation was induced. Three days later a laparotomy with a small standardized surgical trauma was carried out on the left Fallopian tube and the ipsilateral peritoneum. Ten days later the extent of intra-abdominal adhesions was evaluated. The presence of starch particles in cell smears and biopsies was also investigated. Significant differences in the formation of adhesions were found between the control and the test cases (P < 0.001). In the test group there were dense adhesions and in four cases the Fallopian tube was completely attached to the peritoneal wall. In the control cases only loose minor adhesions were found. This study indicates that the number of starch particles migrating from the vagina to the abdominal cavity is sufficient to enhance significantly the formation of post-operative adhesions. We therefore suggest that powder-free medical or surgical gloves should be used in obstetrics and gynaecology.
Key words: gloves/post-operative adhesions/starch particles/vaginal surgery and examination
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Introduction |
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TopAbstractIntroductionMaterials and methodsResultsDiscussionReferences |
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Tubal and pelvic adhesions are a major cause of female infertility in humans (Lalos, 1988
; Healy et al., 1994). After an adhesiolysis and reconstruction of Fallopian tubes there is still a low intrauterine pregnancy rate (Laatikainen et al., 1988; Oelsner et al., 1994). Post-operative adhesions occur after most surgical procedures (Ellis, 1997; Ellis et al., 1999). Of all re-admissions, 5.7% have been classified as being directly related to adhesions, 3.8% managed operatively. It is the leading cause of intestinal obstruction in more than 40% of all cases and 60–70% of cases which involve the small bowel. The development of adhesions is initiated by many factors: peritoneal injury by mechanical trauma, fibrin depositions caused by bleeding, leakage of fibrinogen during the inflammatory process after trauma (Holmdahl et al., 1997), tissue ischaemia (Ellis, 1962, 1971; Thompson and Whawell, 1995), chemical agents (Markman et al., 1986), infections (O'Leary and Coakley, 1992; Menzies, 1993) and foreign materials, e.g. glove powder (Roberts, 1947; Jagelman and Ellis, 1973; Myllärniemi, 1997, Duron et al., 1997).
Intraperitoneally, starch from powdered gloves can cause an inflammatory reaction (Edelstam et al., 1992). In combination with surgical trauma it may induce the formation of adhesions (Ellis, 1990; O'Leary and Coakley, 1992) and granulomata. Adhesion formation includes the release of inflammatory mediators from activated macrophages and interference with the fibrinolytic pathway (Chegini and Renz, 1999). The formation of granulomata initiated by glove powder may be mediated and maintained in part by macrophage-derived cytokines and reactive oxygen intermediates (Renz et al., 1993).
For most gynaecological examinations and during vaginal surgery, starch-powdered gloves are used (Sjösten et al., 1999). Our previous investigation in the rabbit model has indicated a retrograde migration of glove powder from the vagina into the intra-abdominal cavity (Edelstam et al., 1997) with most particles found after 3 days. These results have raised the question as to whether a combination of starch particles (BiosorbTM) deposited in the vagina plus subsequent intra-abdominal gynaecological surgical trauma can increase any post-operative adhesion formation. We also wanted to investigate further whether the third day after vaginal BiosorbTM deposition is the day when most particles have migrated into the abdominal cavity.
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Materials and methods |
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Animals and anaesthesia
Female New Zealand white rabbits (n = 40), weight 2.1–3.7 kg, were used. All rabbits had free access to food and water during the experiments. One test rabbit died during induction of anaesthesia. The rabbits were all in pre-oestrus phase and housed one to a cage under standardized conditions with only female rabbits in the room. They were anaesthetized i.m. with a mixture (0.2 ml/kg rabbit) of fluanisonum 10 mg/ml and fentanyl citrate 0.315 mg/ml (Hypnorm®; Janssen-Cilag Ltd, High Wycombe, Bucks, UK) and i.v. with a mixture (0.4 ml/kg rabbit) of pentobarbitalum natricum 60 mg/ml, benzyl alcohol 20 mg/ml and propyleneglycol 600 mg/ml (Pentobarbitalnatrium®; Apoteksbolaget, Umeå, Sweden) respectively.
All animals were killed after measuring adhesion formation at the second-look laparotomy.
Study design
After anaesthesia, ovulation was induced by mechanical cervical stimulation by a glass rod for 1 min. The test animals were in addition given 50 mg BiosorbTM (Johnson and Johnson, Surgikos Ltd, Livingstone, Scotland) intravaginally before ovulation. During all the experiments only powder-free gloves (BiogelTM, Regent® Broxbourne, UK) were used.
The rabbits were divided into two groups to test two models.
Model A
(i) Control animals (n = 6) and (ii) test animals (n = 6), where cell smears were collected 3 days post-ovulation.
Three days after ovulation a skin incision was made in the linea alba and 100 ml cold phosphate buffered saline (PBS; Dulbecco, Biological Industries, Kibbutz Beit Haemek, Israel) was injected. The peritoneal cavity was rinsed for 1 min and the lavage fluids were aspirated with Teflon catheters (diameter 1.7 mm; Optinova, Godby, Finland) into polypropylene syringes and mixed with Heparin® (Kabi Pharmacia and Upjohn AB, Stockholm, Sweden) to a concentration of 10–15 IU/ml lavage fluid. The lavage fluids were kept chilled and then centrifuged in test tubes of Teflon. After the peritoneal lavage, cell smears were taken from the cervical canal, the uterine cavity, the Fallopian tubes and cell pellets after centrifugation of the peritoneal lavage fluid. The animals were then killed.
Cell smears
The cell smears were made on one half of a glass slide. All glass slides were stained with May–Grunewald–Giemsa and the laboratory assistant used powder-free gloves. The slides were analysed in a Zeiss 4/76 microscope using polarized light at magnification x100 and x250. The number of starch particles was counted under standardized conditions and the particles on the blank side of the slide were subtracted (i.e. contamination) from the number of particles found in the smears. Three different sizes of particle were counted: (i) smaller than a leukocyte; (ii) larger than a leukocyte; (iii) clusters of starch particles.
Model B
(i) Control animals (n = 14) and (ii) test animals (n = 13), where a standardized surgical trauma was made 3 days post-ovulation followed by a second-look laparotomy 10 days later to evaluate post-operative adhesions.
All surgical procedures and scoring of adhesions were made by the same researcher. All rabbits were randomized and given a code number and this could not be associated with whether it was a control or a test animal.
Adhesion induction
The abdomen was shaved and a 10 cm midline skin incision was made and lifted with two surgical forceps attached to the linea alba. The muscular layer of the abdominal wall was exposed. The parietal peritoneum was opened by sharp incision in the linea alba in order to avoid bleeding. A standard surgical trauma to the left Fallopian tube was made by crushing four times with a needle holder. Abrasion was carried out with a small synthetic brush, 5x10 mm, at the corresponding left peritoneal wall within an approximately 20x40 mm area close to the left Fallopian tube. There was no macroscopic bleeding on the trauma site. The peritoneal and abdominal incisions were closed with a continuous 4/0 suture (Vicryl®; Johnson and Johnson, Sollentuna, Sweden) in separate layers. Post-operatively the animals were caged under the same conditions as before the operation. There was no excessive post-operative bleeding or wound infections.
Quantification of adhesions
At the 10th post-operative day, a second-look laparotomy was carried out (Holmdahl et al., 1994). Under full anaesthesia the abdominal cavity was opened wide and all intraperitoneal adhesions were registered. The length of adhesions and the attachment between the Fallopian tubes and the peritoneal wall were measured in mm. The type of adhesion was also evaluated in terms of filmy or dense, and easy or difficult to free by dissection.
Biopsies
Biopsies were collected from the Fallopian tubes and the fimbriae, the peritoneum, the post-operative adhesions as well as from cross-sections of the uterus and cervix. The biopsies were preserved in 4% formaldehyde solution and then embedded in paraffin for sectioning (5 µm) and routine staining with haematoxylin-eosin. The slides were analysed in a Zeiss 4/76 microscope using polarized light at magnification x100 and x250. The number of starch particles was counted in the same way as described above for the cell smears.
Statistics
Data are stated as ±SEM. Differences were considered significant at the P < 0.001, P < 0.01 and P < 0.05 levels. Statistical analyses of differences in adhesion formation between groups were made with the Mann–Whitney U test for independent samples. All statistical tests were computerized and carried out with statistics programs (StatisticaTM; Statsoft, Tulsa, OK, USA).
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Results |
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All rabbits survived the experiment and laparotomies without any infections.
Method A
Cell smears
Starch particles were found on all slides in the test cases but no significant differences were observed between test and control animals in the cervix, uterus and Fallopian tubes. The number of particles found on the slides represented the net number when the air contamination particles had been subtracted. Increased numbers of both small and larger starch particles were found on the preparation side from peritoneal fluid cell pellets in the test group. The increased number of small particles in the cell pellets from the peritoneal fluid (P < 0.06) was not statistically significant in contrast to the number of large particles (P < 0.02) using Mann–Whitney U test. In the control cases, four slides from different animals had single starch particles on the preparation side which may have represented air-contamination.
Model B
Adhesion formation
The adhesion formation was measured as the length of adhesions and the attachment between the Fallopian tube and the peritoneal wall, both in mm. The type of adhesions was also evaluated.
In the control group, one animal had no adhesion at all, one had three filmy adhesions and 12 animals had one filmy adhesion between the Fallopian tube and the peritoneal wall (Table I). A slight traction detached the Fallopian tube from the peritoneal wall. All these adhesions were easy to divide bluntly and measured 3–20 mm in length, median 8 mm. The fimbriae were unaffected.
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The vast majority of animals in the starch group had dense adhesions where sharp dissection was necessary for separating the tissue (Table I
). In four animals the Fallopian tube was attached for the whole length to the peritoneal wall and in the same four animals the fimbriae were closed and surrounded by adhesions (Figure 1A and B). There were also adhesions between the Fallopian tube and the vesico uterine fossa in two animals. The adhesions varied in length between 8–60 mm, median 40 mm. The right control side was unaffected in all animals. The difference in adhesion formation between the control and the starch group was significant (P < 0.001) (Figure 2).
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Biopsies
There were small numbers of both small and large starch particles found in all but three biopsies in the test cases. The number of particles on the slides represented the net number when the air contamination particles had been subtracted (Table II
). In the test cases, increased numbers of large starch particles were found in biopsies from the Fallopian tube (P < 0.01), from the fimbriae (P < 0.04) and the uterus (P < 0.05). An increased number of small particles was found in biopsies from the peritoneum (P < 0.02) and the Fallopian tube (P < 0.04). In the test as well as control cases only occasional particles were found in the cervical biopsies and too few for any statistical calculation. At the other locations of the control cases, single starch particles were found on the preparation slide in three cases and none in the remaining 11.
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Discussion |
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TopAbstractIntroductionMaterials and methodsResultsDiscussionReferences |
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In this model, glove powder has been deposited in the vagina of rabbits prior to ovulation in order to investigate any retrograde migration of starch particles into the intra-abdominal cavity and register the amount of adhesions in the peritoneal cavity after a subsequent surgical trauma. The study design simulated a normal gynaecological examination with powdered gloves. The maximum amount of powder present on an examination glove can be as high as 700 mg, i.e. ~12 mg/kg for a 60 kg woman. In this rabbit model 50 mg BiosorbTM intravaginally was used for a 2–4 kg rabbit, i.e. 15 mg/kg in our experiment. All animals were in the pre-oestrus phase and ovulation was induced at the time of vaginal starch deposition. The previous investigation indicated that there was a retrograde migration of starch particles from the vagina but with large individual variations and most particles were found on the third day (Edelstam et al., 1997
). In this investigation we have confirmed a significant retrograde migration of starch particles on the third day after vaginal deposition. The results from the first animal model (A) demonstrate significant differences in large starch particles in the peritoneal fluid, but non-statistical difference at the other locations. This corresponds with our previous study where the highest number of particles was found in cell smears from the Fallopian tube on the third day after vaginal deposition (Edelstam et al., 1997). In this study with focus only on the third day, the results show significantly more starch particles in the cell smears from model A, as well as in the biopsy sections from model B in the test cases compared to controls. In the second model (B) where a standardized surgical trauma was added on the third day and a second-look laparotomy was carried out 10 days later for evaluation of the adhesion formation, a significant difference in the formation of adhesions between the control and the test group (P < 0.001) was found. The adhesions in the test animals were mainly dense and in four animals the fimbriae were closed and surrounded by adhesions, whereas the right control slides were unaffected. The filmy and limited adhesions in the control group were only between the Fallopian tubes and the peritoneal wall. Thus the number of starch particles reaching the abdominal cavity was associated with a significant increase in intra-abdominal post-operative adhesions.
This corresponds to other investigations which indicate that glove powder can induce an inflammatory response with a subsequently sterile peritonitis, granuloma and adhesion formation (Paine and Smith, 1957; Ellis, 1990). Glove powder particles also carry an inflammation-inducing potential similar to bacterial or fungal compounds (Renz and Gemson, 1997).
Intra-abdominal adhesions, particularly tubal and pelvic adhesions, are an important cause of female infertility. At present, little is known on how to identify women at risk of developing post-operative adhesions. There is also insufficient knowledge about host factors in the susceptibility of patients to form adhesions and the large individual variations in adhesion development among humans. The present experiments indicate that there is a retrograde migration of glove powder from the vagina into the intra-abdominal cavity and that this can participate in the formation of dense post-operative adhesions in rabbits. Glove powder contamination of the vaginal mucosa is therefore not recommended. Fibrinolysis and wound healing are also negatively influenced by glove powder, which in addition can act as a vector for bacterial pathogens (Newsom and Shaw, 1997).
In conclusion, this study in the rabbit model has shown a retrograde migration of glove powder from the vagina and subsequent post-operative adverse tissue reactions. Our speculation is therefore that powder-free medical or surgical gloves should be used not only for gynaecological surgery but also for vaginal examinations.
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Acknowledgments |
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We thank Mr Brian Thomas for editorial advice. The study was sponsored by Karolinska Institute, Stockholm, Sweden and Regent Medical, London, UK.
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Notes |
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1 To whom correspondence should be addressed.E-mail: Anette.Sjosten{at}sos.ki.se
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References |
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Submitted on December 15, 1999; accepted on April 4, 2000.
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