1 Karolinska Institutet, Department of Obstetrics & Gynaecology at Stockholm Söder Hospital, s-118 83 Stockholm, Sweden and 2 Department of Anatomy, Guys, Kings and St Thomas School of Biomedical Sciences, London Bridge, London SEI 9RT, UK 3 To whom corespondence should be addressed. e-mail: anette.sjosten{at}sos.sll.se
![]() |
Abstract |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Key words: female/gloves/retrograde migration/starch particles/vaginal examination
![]() |
Introduction |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Powder-free gloves have been available for 20 years, but starch-powdered gloves are still available and in use (Sjösten et al., 1999).
It is well documented that starch-powdered gloves are not appropriate for abdominal surgery (Ellis, 1990; Holmdahl et al., 1994
), and intraperitoneally, starch particles can initiate inflammatory reaction and the formation of adhesions (Edelstam et al., 1992
; diZerega, 1994
), although the mechanism by which starch increases the propensity of tissues to form adhesions is not known. Reduced peritoneal fibrinolysis and activation of leukocytes by particulate starch granules have been suggested as possible mechanisms. Activated leukocytes, particularly macrophages, produce supernormal amounts of oxygen-free radicals, prostaglandin E2, thromboxane B2 and various cytokines (Osman and Jensen, 1999
). Starch particles also increase the eicosanoid production which may contribute to the inflammatory or immune reactions and development of adhesions (Chegini and Rong, 1999
). If already injured mesotelial surface of the peritoneum is exposed to starch, more dense adhesions are created compared to the effect of peritoneal trauma or starch separately. Application of glove powder on minimally or severely traumatized peritoneum facilitates tumour cell adhesion and growth alone (van den Tol et al., 2001
). Histological re-evaluation after tubal reconstructive surgery due to peritubal or peri-ovarian adhesions has shown residual starch from powdered gloves (Yaffe et al., 1980
).
A causal connection has been shown between operative tissue damage, intra-abdominal ischaemia, infections, reactions to foreign materials such as sutures, particles of gauze, glove dusting powder and post-operative adhesions (Myllärniemi, 1967; Holmdahl et al., 1996
). One of the proven causes of post-operative intestinal adhesions is microscopic foreign bodies which are present in up to 93% of adhesions (Duron et al., 1997
). After open abdominal or pelvic surgery, a third of the patients are readmitted at least twice during the subsequent 10 years for a disorder directly or possibly related to adhesions (Ellis et al., 1999
).
Our previous investigation in a rabbit model indicated a retrograde migration of glove powder from the vagina into the intra-abdominal cavity (Edelstam et al., 1997). The amount that reaches the peritoneum is sufficient to significantly increase formation of post-operative adhesions after a standardized trauma (Sjösten et el., 2000
).
Therefore, this subsequent study in humans was done to investigate whether starch particles from powdered gloves also in humans might gain access to the abdominal cavity through the vagina after a gynaecological examination with powdered gloves.
![]() |
Materials and methods |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
Surgical procedure
An abdominal subtotal or total hysterectomy was undertaken with the operating team and the nurse who set up the instrument tray wearing powder-free gloves. Immediately the abdominal cavity was opened, peritoneal fluid was collected and cell smears were then taken from the peritoneal fluid. From the fimbriae of the Fallopian tubes, additional cell smears were taken per-operatively and when the uterus had been removed, i.e. post-operatively from the uterine cavity and the cervical canal. For making the smears sterile, forceps or peans were used. Smears from the fimbriae of the Fallopian tubes were omitted if they were not removed during the hysterectomy.
Cell smears
The cell smears were quantitatively standardized on 1 cm2 of one-half of a glass slide with the other blank side serving as control for contamination with air-borne starch particles. All the slides were stained with MayGrünewald Giemsa by a biochemical assistant wearing powder-free gloves in a laboratory where only powder-free gloves were used. The slides were coded and analysed by two independent investigators with a Zeiss 4/76 microscope using polarized light at magnification x250. The starch particles were counted in a standardized procedure for all slides. The numbers on the blank side (i.e. contamination) were subtracted from that in the smears so that the number of starch particles on each slide represent the net number without contaminating particles. Since there are differences in the size of starch particles they where divided into two sizes: (i) smaller than a leukocyte and (ii) larger than a leukocyte. Leukocytes for comparison in size were always present in the smears. The study was approved by the local ethics committee.
Statistics
Non-parametric MannWhitney U-tests and Fishers exact test were used and values are given as SEM for the group. Differences were considered significant at the P < 0.001, P < 0.01 and P < 0.05 levels. All statistical tests were computerized and carried out with statistics programs (StatisticaTM; Statsoft, USA).
![]() |
Results |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
|
|
|
|
![]() |
Discussion |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
The possibility of retrograde migration of starch particles in the female genital tract into the intraperitoneal cavity has been suspected for several decades (Saxen et al., 1963). The present study in humans has attempted to investigate whether previous results from animal researchthat starch particles can migrate from the vagina into the abdominal cavity (Edelstam et al., 1997
)reflects the case in humans. This study indicates such a retrograde migration of starch particles after gynaecological examination with powdered gloves. There were statistically significant differences between study and control groups in cervix, uterus and Fallopian tubes on the first day after vaginal examination with powdered gloves compared to powder-free examination. The low number of starch particles in the cell smear of the peritoneal fluid may reflect differences in the total amount of fluid and that it might have been better to collect all the fluid and after centrifugation prepare cell smears. However, with the present approach a significant difference between pre-operative examination with powdered and powder-free was demonstrated. The lower number of particles on the fourth day might indicate that absorption of starch particles had started, or that the particles had adhered to the peritoneum. In previous animal studies, most particles were found on the third day after deposition in the vagina (Edelstam et al., 1997
). The numbers found in the controls indicate that the presence of starch particles in the peritoneal cavity is in accordance with reported persistance for up to 18 months (Ellis, 1971
). Our present patients have been examined in that time before the referral for hysterectomy.
A considerable number of gynaecologists wears starch-powdered gloves (Sjösten et al., 1999), despite evidence of starch-induced complications. The starch particles can migrate not only from the vagina into the cervical canal and the uterine cavity but also through the Fallopian tubes into the peritoneal fluid. Women exposed to intra-abdominal surgical trauma 14 days after a gynaecological examination with powdered gloves may be at increased risk of intra-abdominal adhesions. But even without a surgical procedure there is a risk of intra-abdominal or peri-tubal adhesions due to the examination with powdered gloves (Osser et al., 1989
). Ongoing subclinical PID can cause infective tissue damage. An extensive study by Myllärniemi (1967
) showed that talc, starch powder and lint in the abdominal cavity tended to accumulate in the traumatized areas of the peritoneum so that the foreign material contaminating the peritoneal tissues could act together with other traumatizing conditions, possibly preventing the resorption of fibrinous adhesions. This corresponds to our previous finding in the rabbit model that starch particles deposited in the vagina can migrate in a retrograde direction from the vagina into the abdominal cavity and, combined with an intra-abdominal trauma, generate dense adhesions (Sjösten et al., 2000
). Since there are indications towards retrograde migration of powder, it must not be used regardless of cyclic variations or sexual activity.
In conclusion, our results show that starch particles can migrate from the vagina into the cervical canal, the uterine cavity and through the Fallopian tubes up to 4 days after a gynaecological examination with powdered gloves. Glove powder contributes to adverse intra-abdominal reactions, which include adhesion formation and adhesion-related complications such as chronic pelvic pain and bowel obstruction. Tubal and pelvic adhesions are a major cause of female infertility. Since evidence suggests that a retrograde migration could be a general mechanism, our recommendation is that we should be critical of harmful substances, e.g. glove powder, that could migrate from the vagina to abdominal cavity.
![]() |
Acknowledgements |
---|
![]() |
References |
---|
![]() ![]() ![]() ![]() ![]() ![]() ![]() |
---|
di Zerega GS (1994) Contemporary adhesion prevention. Fertil Steril 61,219235.[Medline]
Duron JJ, Ellian N and Olivier O (1997) Post-operative peritoneal adhesions and foreign bodies. Eur J Surg 579(Suppl),1516.
Edelstam GAB, Lundkvist E., Laurent TC et al (1992) The concentration and turnover of intraperitoneal hyaluronan during inflammation. Inflammation 16,459469.[Medline]
Edelstam GAB, Sjösten ACE and Ellis H (1997) Retrograde migration of starch in the genital tract of rabbits. Inflammation 21,489499.[CrossRef][Medline]
Ellis H (1971) The cause and prevention of postoperative intraperitoneal adhesions. Surg Gynecol Obstet 133, 497511.[Medline]
Ellis H (1990) The hazards of surgical glove dusting powder. Surg Gynecol Obstet 171,521527.[Medline]
Ellis H, Moran JB, Thompson NJ et al (1999) Adhesion-related hospital readmissions after abdominal and pelvic surgery: a retrospective cohort study. Lancet 9163,14761480.[CrossRef]
Giercksky KE, Qvist H, Nesland TM et al (1994) Multiple glove powder granulomas masquerading as peritoneal carcinomatosis. J Am Coll Surg 179,299304.[Medline]
Heller DS, Westhoff C, Katz N et al (1996) The relationship between perineal cosmetic talc usage and ovarian talc particle burden. Am J Obstet Gynecol 174,15071510.[Medline]
Holmdahl L, Al-Jabreen M and Risberg B (1994) Experimental models for qantitative studies on adhesion formation in rats and rabbits. Eur Surg Res 26,248256.[Medline]
Holmdahl L, Al-Jabreen M and Risberg B (1994) The impact of starch-powdered gloves on the formation of adhesions in rats. Eur J Surg 160,257261.[Medline]
Myllärniemi H (1967) Foreign material in adhesion formation after abdominal surgery. Acta Chir Scand 377,148.
Osman MO and Jensen SL (1999) Surgical gloves: current problems. World J Surg 23,630637.[Medline]
Osser S, Persson K and Liedholm P (1989) Tubal infertility and silent chlamydial salpingitis. Hum Reprod 4,280284.[Abstract]
Paine CG and Smith P (1957) Starch granulomata. J Clin Pathol 10,5155.[Medline]
Renz H and Gemsa D (1997) Effects of powder on infection risks and associated mechanisms. Eur J Surg 579(Suppl),3538.
Saxen L, Kissinen A. and Saxen E (1963) Peritoneal foreign-body reaction caused by condom emulsion. Lancet 2,12951296.
Sjösten ACE, Blomgren H and Edelstam GAB (1999) Precautions taken to prevent adhesionsa questionnaire study among Swedish obstetricians and gynaecologists. Eur J Surg 165,736741.[CrossRef][Medline]
Sjösten ACE, Ellis H and Edelstam GAB (2000) Post-operative consequences of glove powder used pre-operatively in the vagina in the rabbit model. Hum Reprod 15,15731577.
van den Tol M.P., Haverlag R, Jeekel J et al (2001) Glove powder promotes adhesion formation and facilitates tumour cell adhesion and growth. Br J Surg 88,12581263.[CrossRef][Medline]
Yaffe H, Beyth Y and Levij IS (1980) Foreign body granulomas in peritubal and periovarian adhesions: a possible cause for unsuccessful reconstructive surgery in infertility. Fertil Steril 33,277279.[Medline]
Ylikorkala O (2001) Tubal ligation reduces the risk of ovarian cancer. Acta Obstet Gynecol Scand 80,875877.[CrossRef][Medline]
Submitted on December 11, 2002; resubmitted on November 21, 2003; accepted on November 26, 2003.
|