Factors contributing to airborne particle dispersal in the operating room

Abstract

Background
Surgical-site infections due to intraoperative contamination are chiefly ascribable to airborne particles carrying microorganisms. The purpose of this study is to identify the actions that increase the number of airborne particles in the operating room.

Methods
Two surgeons and two surgical nurses performed three patterns of physical movements to mimic intraoperative actions, such as preparing the instrument table, gowning and donning/doffing gloves, and preparing for total knee arthroplasty. The generation and behavior of airborne particles were filmed using a fine particle visualization system, and the number of airborne particles in 2.83 m³ of air was counted using a laser particle counter. Each action was repeated five times, and the particle measurements were evaluated through one-way analysis of variance multiple comparison tests followed by Tukey–Kramer and Bonferroni–Dunn multiple comparison tests for post hoc analysis. Statistical significance was defined as a P value ≤ .01.

Results
A large number of airborne particles were observed while unfolding the surgical gown, removing gloves, and putting the arms through the sleeves of the gown. Although numerous airborne particles were observed while applying the stockinet and putting on large drapes for preparation of total knee arthroplasty, fewer particles (0.3–2.0 μm in size) were detected at the level of the operating table under laminar airflow compared to actions performed in a non-ventilated preoperative room (P < .01).

Conclusions
The results of this study suggest that surgical staff should avoid unnecessary actions that produce a large number of airborne particles near a sterile area and that laminar airflow has the potential to reduce the incidence of bacterial contamination.

Full text

R E S E A R C H A R T I C L E Open Access
Factors contributing to airborne particle
dispersal in the operating room
Chieko Noguchi
1
, Hironobu Koseki
2*
, Hidehiko Horiuchi
1
, Akihiko Yonekura
1
, Masato Tomita
1
, Takashi Higuchi
2
,
Shinya Sunagawa
2
and Makoto Osaki
1
Abstract
Background: Surgical-site infections due to intraoperative contamination are chiefly ascribable to airborne particles
carrying microorganisms. The purpose of this study is to identify the actions that increase the number of airborne
particles in the operating room.
Methods: Two surgeons and two surgical nurses performed three patterns of physical movements to mimic
intraoperative actions, such as preparing the instrument table, gowning and donning/doffing gloves, and preparing
for total knee arthroplasty. The generation and behavior of airborne particles were filmed using a fine particle
visualization system, and the number of airborne particles in 2.83 m
3
of air was counted using a laser particle
counter. Each action was repeated five times, and the particle measurements were evaluated through one-way
analysis of variance multiple comparison tests followed by Tukey–Kramer and Bonferroni–Dunn multiple
comparison tests for post hoc analysis. Statistical significance was defined as a Pvalue ≤.01.
Results: A large number of airborne particles were observed while unfolding the surgical gown, removing gloves,
and putting the arms through the sleeves of the gown. Although numerous airborne particles were observed while
applying the stockinet and putting on large drapes for preparation of total knee arthroplasty, fewer particles (0.3–2.
0μm in size) were detected at the level of the operating table under laminar airflow compared to actions
performed in a non-ventilated preoperative room (P< .01).
Conclusions: The results of this study suggest that surgical staff should avoid unnecessary actions that produce a
large number of airborne particles near a sterile area and that laminar airflow has the potential to reduce the
incidence of bacterial contamination.
Keywords: Surgery, Airborne particle, Surgical-site infection, Intraoperative action
Background
The Centers for Disease Control and Prevention’s Na-
tional Nosocomial Infection Surveillance (NNIS) system
reported 15,523 surgical-site infections (SSIs) following
593,344 operations between 1986 and 1996, and 77% of
the deaths following complications from surgery were
reported to be related to SSI [1]. Especially in the field
of orthopedics, SSI after prosthetic arthroplasty is a
devastating complication because treating the infection
requires several procedures at considerable expense. The
incidence of SSI in the United States after primary total
hip arthroplasty (THA) is 0.88% and on the rise, whereas
the infection rate for revision THA is more than double
that for primary procedures [2]. Though SSIs are multi-
factorial in origin and include both patient- and
procedure-specific factors, airborne infection is thought
to be one of the major sources of exogenous contamin-
ating bacteria [3–5]. During surgical procedures,
bacteria-laden airborne particles, including textile fibers,
dust particles, skin fragments, and respiratory aerosols,
may settle on surgical instruments or directly enter the
surgical site, resulting in SSI [6–9]. Hansen et al. noted
that bacterial counts were lower in environments with
fewer airborne particles, and that the number of parti-
cles larger than 5 μm was closely correlated with bacter-
ial concentration [10]. Campbell et al. reported that a
* Correspondence: koseki@nagasaki-u.ac.jp
2
Department of Locomotive Rehabilitation Science, Unit of Rehabilitation
sciences, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1
Sakamoto, Nagasaki 852-8520, Japan
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Noguchi et al. BMC Surgery (2017) 17:78
DOI 10.1186/s12893-017-0275-1
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

decreased turnover of operating staff resulted in lower
rates of SSI [11]. Other studies have demonstrated that
80%–90% of pathogenic bacteria detected from surgical
wounds were related to airborne particles in the operat-
ing room [12] and that airborne skin scales can act as
vectors for pathogenic microorganisms to infect the
surgical wound [13]. The Healthcare Infection Control
Practices Advisory Committee guidelines for the preven-
tion of SSI published in 1999 recommended to “consider
performing orthopedic implant operations in operating
rooms supplied with ultraclean air”and classified this
recommendation as category II (suggested for imple-
mentation and supported by suggestive clinical or epi-
demiological studies or theoretical rationale) [1]. Thus,
surgical-site contamination by airborne microorganisms
plays a central role in the exogenous pathogenesis of
SSIs, and controlling and minimizing airborne particles
in the operating room deserves close attention to protect
patients against exogenous infection caused by airborne
bacteria.
Non-woven fabric, widely used for surgical drapes,
gowns, and hoods, is thought to be one of the major
origins of airborne particles in the operating room.
There is a high level of activity involving fabrics during
preoperative preparation of a patient, resulting in the
dispersal of a large number of airborne particles [14].
Textile fibers from non-woven fabric may migrate to or
come in contact with unsterile areas, such as the walls,
floor, and human skin. Therefore, a greater number of
particles produced from non-woven fabric increases the
chances of airborne particles being contaminated with
bacteria. Although any action in the operating room can
produce particles, the degree to which these actions
generate particles remains unclear, and the dispersal
conditions of airborne particles during preoperative pro-
cedures has not yet been visualized. To prevent SSIs,
operating staff including surgeons must understand the
situations that are at high risk for producing airborne
particles in the operating room.
The aim of this study is to investigate and quantify the
dispersion and distribution of airborne particles due to
actions in the operating room.
Methods
Experimental design
All surgical drapes and garments used in this study were
made from generally used spunlaced non-woven fabric
that consisted of 45% wood pulp and 55% polyester pulp.
Spunlacing is a technique used to give a web of fibers
sufficient cohesion by mechanical bonding, while the
paper-making technique allows the production of a web
where the fibers are consolidated by hydroentanglement.
The water jet pressure was up to 100 bar. After removal
of water by suction, the non-woven fabric was air dried
(180 °C). The surface density of the non-woven fabric
was 80 g/m
2
. The authors performed the following three
patterns of physical movements in the present study to
mimic some of the intraoperative actions that take place
during major orthopedic surgery.
Preparing instrument table
Step 1: an assistant holds and opens a sterilized package.
Step 2: the operating room nurse removes the folded
surgical drape (DEF-58-T®, hopes Co. Ltd., Hokkaido,
Japan) from the package and unfolds it in front of his or
her chest. Step 3: the nurse slowly spreads the drape on
an instrument Table (1 m high, 80 cm wide, and 50 cm
deep).
Gowning and donning/doffing gloves
Step 1: an assistant holds and opens a sterilized package.
Step 2: the surgeon removes the folded surgical gown
(JG-100®, hopes Co. Ltd.) made from spunlaced non-
woven fabric from the package and unfolds it in front of
his or her chest. Step 3: a circulating nurse helps the
surgeon put on the surgical gown according to the trad-
itional closed gowning technique. Step 4: the surgeon
puts on and takes off latex powdered surgical gloves
(Tradition®, Medline International Japan, Tokyo, Japan).
Procedures 1 and 2 were performed in a non-ventilated
preoperative room.
Preparation for total knee arthroplasty (TKA)
Step 1: one of the co-authors acting as a patient is laid
on the operating table and positioned correctly under
laminar airflow (LAF) in a bio-clean room (ISO class 7
criterion; Fed. Standard class 10,000) with a high-
efficacy particulate air (HEPA) filter. The settings for
LAF were: wind velocity, 0.44 m/s; room temperature,
21.9 °C; and humidity, 32.4%. Step 2: after all surgeons
were gowned with Sterishield Togas and T4 helmets
(Stryker Instruments, Kalamazoo, MI, USA), one sur-
geon lifted the patient’s left leg. Another surgeon applied
a stockinet and wrapped the leg with an elastic bandage.
Step 3: one surgeon fit three hydrophobic drapes (RH-
33®, hopes Co. Ltd.) around the patient’s thigh, and then
the surgeons passed the patient’s leg through a large,
holed drape (RH-710EFC90®, hopes Co. Ltd.). Step 4: a
surgeon cut and removed the piece of stockinet from
around the surgical site and covered the patient’s leg
with an iodine-impregnated plastic film.
The generation and behavior of airborne particles were
filmed using a fine particle visualization system (Shin-
Nihon Air Technologies Co. Ltd., Tokyo, Japan) with a
green laser apparatus. After making a uniform laser
sheet, light reflected from airborne particles was filmed
using a highly sensitive camera with an interference
filter. The number of airborne particles in 2.83 m
3
of air
Noguchi et al. BMC Surgery (2017) 17:78 Page 2 of 6
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

was counted using a laser particle counter (KC-52®, RION,
Tokyo, Japan), and the mean value was taken as the mea-
sured value. Sampling was performed at 1.1 m above floor
level, simulating the height of the operating table. The
sampling tube (6 mm internal diameter) was attached to
the air intake port of the particle counter, and the meas-
urement interval was set to 1 min (2.83 m
3
). Particles were
separated into four categories based on their size (0.3–
0.5 μm, 0.5–1.0 μm, 1.0–2.0 μm, and 2.0–5.0 μm).
Statistical analysis
Each established intraoperative action was repeated five
times, and the particle measurements were compiled for
statistical analysis, which included one-way analysis of vari-
ance multiple comparison tests followed by Tukey–Kramer
and Bonferroni–Dunn multiple comparison tests for post
hoc analysis, using SPSS version 22.0 (SPSS, Chicago, IL,
USA). Values are expressed as means ± standard deviations.
Statistical significance was defined as a Pvalue ≤.01.
Results
Preparing instrument table
The fine particle visualization system showed that many
particles were dispersed in the antero-inferior direction
while the operating room nurse unfolded a surgical
drape. The mean number of airborne particles for every
action is shown in Table 1. Most of the particles
detected were 0.3–0.5 μm in size.
Gowning and donning/doffing gloves
Similar to when unfolding the drape, many particles
were dispersed in the antero-inferior direction while the
surgeon unfolded a surgical gown (Fig. 1). Notably,
particles burst from the cuffs or collar of the gown the
moment the arms were put through the sleeves and the
tail of the gown was stretched (Fig. 2). Moreover, a lot of
small airborne particles, which were thought to be
powder, sweat, and skin fragments, were observed when
the surgeon removed the surgical gloves (Fig. 3). The
mean number of airborne particles during gowning and
donning/doffing surgical gloves was similar to that
during preparation of the instrument table.
Preparation for TKA
Before any actions, airborne particles in the bio-clean
room drifted downward slowly under LAF. The actions
of applying a rolled stockinet (Fig. 4), and cutting the
elastic bandage generated a lot of airborne particles.
Additionally, when placing the large drape with a hole in
the center over the leg, many particles were generated
under the drape as it rubbed the stockinet. However,
most of the particles drifted downward slowly due to the
LAF. As a result, the counts in the bio-clean room for
particles (0.3–1.0 μm in size) were significantly lower
compared to those when preparing the instrument table
or when gowning and donning/doffing gloves (P< .01).
The counts for particles (1.1–2.0 μm in size) were also sig-
nificantly lower than those when gowning and donning/
doffing gloves (P<.01).
Discussion
The microorganism most often responsible for SSIs is
Staphylococcus aureus, which can adhere to particles.
Airborne transmission has been implicated in nosoco-
mial outbreaks of methicillin-resistant Staphylococcus
aureus (MRSA) [15]. Because MRSA range from 0.8 to
1.0 μm in diameter, it is anticipated that not only larger
sized airborne particles but also aggregates of smaller
sized airborne particles held together by static electricity
can be laden with pathogenic bacteria. Surgical drapes
and garments are thought to be two of the major origins
of airborne textile fiber particles. This is one reason why
the material of surgical drapes and garments has been
switched from cotton to non-woven fabric [16]. Cotton
can generate many textile fiber particles, and woven
cotton has interlacing gaps ranging from 7 to 50 μmin
diameter that can easily pass bacteria-laden airborne
particles or skin fragments from medical staff. Even non-
woven fabrics, however, may generate many textile fiber
particles depending on the action of the wearer in the
operating room. Therefore, prediction and reduction of
particle dispersion and distribution from non-woven
fabrics are key to lowering the risk of contamination by
airborne microorganisms.
In our study, a high number of dispersed airborne
particles were observed when unfolding the drape and
surgical gown. Since the drape and surgical gown were
initially sterile, the particles from them are considered to
be free of bacteria. However, airborne particles can act
as vectors for transmission of bacteria after coming in
contact with unsterile areas (e.g. skin, walls, or floor) [4].
Particles settled on an unsterile floor can be easily
Table 1 Mean number and standard deviation of airborne particles (particles/2.83 m
3
)
Particle size category (μm) 0.3–0.5 0.6–1.0 1.1–2.0 2.1–5.0
Preparing instrument table 16,826 (509.1) 1423 (33.9) 187 (7.8) 128 (14.8)
Gowning and donning/doffing gloves 18,075 (4202.7) 1589 (344.7) 232 (49.6) 173 (31.4)
Preparation for TKA 1207 (125.9)
§*
202 (15.6)
§*
66 (2.8)
*
109 (0.7)
§
:P< .01 compared to the actions of preparing the instrument table
*
:P< .01 compared to the actions of gowning and donning/doffing gloves
Noguchi et al. BMC Surgery (2017) 17:78 Page 3 of 6
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

dispersed by air eddies generated from opening doors
and foot traffic. A recent study noted a trend towards
lower SSI rates in hospitals with decreased operating
room staff turnover [11]. Thus, it is preferable that the
actions such as unfolding a drape and surgical gown
should be carried out away from the operating and
instrument Tables.
A greater number of scattered particles were also seen
when removing gloves, putting the arms through the
sleeves of the surgical gown, and stretching the tail of
the gown. Individuals in the operating room generate
many bacteria-laden skin fragments [17, 18], which may
migrate from sites of uncovered skin (e.g. neck and face)
or through gaps in the material used to make surgical
garments [19]. Dharan and Pittet reported that more
than half of all infections following clean surgery were
caused by the normal skin flora of patients and health-
care workers [20]. Dispersed airborne particles visualized
during removal of surgical gloves and during donning a
surgical gown in this study are thought to contain many
skin fragments and bacteria-laden textile fibers or pow-
ders that may cause SSIs. Regarding SSIs and surgical
gloves, most of the recommendations focus on the risk
of permeability and perforation, and there is no evidence
associated with particle dispersion [21–23]. Our findings
support a clear practical recommendation—removing
gloves and donning a surgical gown should be strictly
avoided near the surgical site or sterile instruments.
Moreover, surgeons should pay close attention to minim-
izing the production of airborne particles while applying or
Fig. 3 Removing surgical gloves. Particles including powder, sweat,
and skin fragments dispersed and floated in the air
Fig. 4 Applying stockinet. One surgeon lifted the left leg of an
author acting as a patient and another surgeon applied a stockinet.
Many particles were produced around the patient’s leg and then
migrated downward slowly under laminar airflow
Fig. 2 Putting arms through the sleeves. A large number of particles
burst from the cuffs of the gown
Fig. 1 Unfolding the surgical gown. The dispersal of reflective
airborne particles (bright dots) could be observed with a fine particle
visualization system
Noguchi et al. BMC Surgery (2017) 17:78 Page 4 of 6
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

cutting an elastic bandage or stockinet and covering a limb
with a holed drape, especially for immunocompromised
patients. Our results demonstrated that both an elastic
bandage and stockinet made of cotton produce many
textile fiber particles when cut, stretched, or even rubbed
close to the surgical site. Interestingly, although many parti-
cles were observed during preparation for TKA, only a
small number of airborne particles were detected at the
level of the operating table. The LAF system, which is com-
monly used in bio-clean rooms [24], creates a homogenous,
low-turbulence airflow directly over the operating area
through a combination of high airflow rates and HEPA
filtration [10]. Laminar airflow with HEPA filters can
remove approximately 99.97% of airborne particles
larger than 0.3 μm, resulting in minimal air bacterial
counts [6, 20]. The fine particle visualization system
used in the present study revealed that airborne particles
in the operating room drifted downward slowly under
LAF. This is why there were fewer particles at the level of
the operating table compared to the number of particles
detected in the non-ventilated preoperative room. Re-
cently, some publications have questioned whether LAF
ventilation confers any benefit and even suggest that post-
operative SSI rates may be higher after surgery under LAF
conditions compared to conventional operating rooms
with turbulent ventilation [25, 26]. The most recent global
guidelines from the World Health Organization on the
prevention of SSI also suggested that LAF ventilation
systems should not be used for patients undergoing total
arthroplasty [27]. However, the strength of the recommen-
dation is “conditional level”, and the quality of the evi-
dence is “low to very low”. Moreover, the onset of SSIs is
influenced by multiple factors, including the virulence of
the bacteria, quality of the patient’s immune defenses, and
prophylactic antibiotic therapy. Therefore, although the
relationship between LAF systems and SSI rates remains
unclear, it can be speculated from our results that LAF
can decrease the chances of bacterial air contamination.
Each action investigated in the present study was in
preparation for TKA, and not representative of the entire
operation. Although surgical-site bacterial counts correl-
ate with airborne bacteria and particle counts [3–5], they
have not been demonstrated to correlate directly with the
rate of SSIs [4]. The actual relationship among the amount
of particles, the incidence of bacterial contamination, and
the rate of SSIs was not addressed in this study. The
present results, obtained using well-defined environmental
conditions, cannot necessarily be translated directly to
different settings, i.e. different sized operating rooms or a
different number of personnel within the operating room.
However, our study simulating some of the intraoperative
actions gives surgical staff a clearer picture of the disper-
sion and distribution of particles that could contaminate
the surgical site. Surgical staff should consider carefully
measures to minimize the production of airborne particles
and decrease particle counts during intraoperative proce-
dures to lower the risk of contamination by airborne
microorganisms.
Conclusions
Fine particle visualization and automatic particle counting
revealed that a large number of airborne particles were
produced during unfolding the surgical gown, removal of
gloves and placing arms through the sleeves of the gowns.
Medical staff in the operating room should avoid those
actions near sterile areas. Fewer particles were detected at
the level of the operating table under laminar airflow,
which suggests that laminar airflow has the potential to
reduce the incidence of bacterial contamination.
Abbreviations
HEPA: High-efficacy particulate air; LAF: Laminar airflow; MRSA: Methicillin-
resistant Staphylococcus aureus; NNIS: National Nosocomial Infection
Surveillance; SSIs: Surgical-site infections; THA: Total hip arthroplasty;
TKA: Total knee arthroplasty
Acknowledgements
The authors gratefully acknowledge Central Uni Co. Ltd. (Tokyo, Japan) for
kindly permitting use of the bio-clean operating room. The authors did not
receive and will not receive any benefits or funding from any commercial
party related directly or indirectly to the subject of this article.
Funding
This work was partially supported by JSPS KAKENHI Grant Number
232024000.
Availability of data and materials
The authors do not wish to share their data for the following reason:
-The dataset is part of ongoing study protocols.
Authors’contributions
All authors made substantial contributions to this article. CN and HK
conceived and designed the study. CN, HK, HH, TH, and SS participated in
the experiments and gathered the data. CN, HK, AY, MT, and MO analyzed
and interpreted the data. CN wrote the initial drafts of the manuscript, and
HK and MO performed the statistical analysis and ensured the accuracy of
the data. All authors have read and approved the final version of the
manuscript and affirm that the work has not been submitted or published
elsewhere in whole or in part.
Ethics approval and consent to participate
All study participants were informed both verbally and in writing of the
objectives of the study and were asked to sign a consent form when
they agreed to participate in the study. The study was granted an
exemption from requiring ethics approval by the ethics committee of
Nagasaki University Graduate School of Biomedical Sciences because this
study did not involve human subjects, human materials, nor did it use
data from actual patients.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Noguchi et al. BMC Surgery (2017) 17:78 Page 5 of 6
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Author details
1
Department of Orthopedic Surgery, Nagasaki University Graduate School of
Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
2
Department of Locomotive Rehabilitation Science, Unit of Rehabilitation
sciences, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1
Sakamoto, Nagasaki 852-8520, Japan.
Received: 15 May 2017 Accepted: 28 June 2017
References
1. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for
prevention of surgical site infection. Am J Infect Control. 1999;27:97–134.
2. Kurtz SM, Lau E, Schmier J, Ong KL, Zhao K, Par vizi J. Infection burden
for hip and knee arthroplasty in the United States. J Arthroplast. 2008;
23:984–91.
3. Beggs CB. The airborne transmission of infection in hospital buildings: fact
or fiction? Indoor Built Environ. 2003;12:9–18.
4. Chauveaux D. Preventing surgical-site infections: measures other than
antibiotics. Orthop Traumatol Surg Res. 2015;101:S77–83.
5. Lidwell OM, Lowbury EJ, Whyte W, Blowers R, Stanley SJ, Lowe D. Airborne
contamination of wounds in joint replacement operations: the relationship
to sepsis rates. J Hosp Infect. 1983;4:111–31.
6. McHugh S, Hill A, Humphreys H. Laminar airflow and the prevention of
surgical site infection. More harm than good? Surgeon. 2015;13:52–8.
7. Sadrizadeh S, Tammelin A, Ekolind P, Holmberg S. Influence of staff number
and internal constellation on surgical site infection in an operating room.
Particuology. 2014;13:42–51.
8. Pasquarella C, Pitzurra O, Herren T, Poletti L, Savino A. Lack of influence of
body exhaust gowns on aerobic bacterial surface counts in a mixed-
ventilation operating theatre. A study of 62 hip arthroplasties. J Hospital
Infect. 2003;54:2–9.
9. Diab-Elschahawi M, Berger J, Blacky A, Kimberger O, Oguz R, Kuelpmann R,
et al. Impact of different-sized laminar air flow versus no laminar air flow on
bacterial counts in the operating room during orthopedic surgery. Am
J Infect Control. 2011;39:e25–9.
10. Hansen D, Krabs C, Benner D, Brauksiepe A, Popp W. Laminar air flow
provides high air quality in the operating field even during real operating
conditions, but personal protection seems to be necessary in operations
with tissue combustion. Int J Hyg Environ Health. 2005;208:455–60.
11. Campbell DA Jr, Henderson WG, Englesbe MJ, Hall BL, O'Reilly M, Bratzler D,
et al. Surgical site infection prevention: the importance of operative
duration and blood transfusion –results of the first American College of
Surgeons–National Surgical Quality Improvement Program Best Practices
Initiative. J Am Coll Surg. 2008;207:810–20.
12. Howorth FH. Prevention of airborne infection during surgery. Lancet.
1985;1:386–8.
13. Brown J, Doloresco Iii F, Mylotte JM. "never ev ents": not every
hospital-acquired infection is preventable. Clin Infect Dis. 2009;49:743–6.
14. Knobben BAS, van Horn JR, van der Mei HC, Busscher HJ. Evaluation of
measures to decrease intra-operative bacterial contamination in
orthopaedic implant surgery. J Hosp Infect. 2006;62:174–80.
15. Mortimer EA, Wolinsky E, Gonzaga AJ, Rammelkamp CH. Role of airborne
transmission in staphylococcal infections. Br Med J. 1966;1:319–22.
16. Blomgren G, Hoborn J, Nyström B. Reduction of contamination at total
hip replacement by special working clothes. J Bone Joint Surg Br. 1990;
72:985–7.
17. Dineen P, Drusin L. Epidemics of postoperative wound infections associated
with hair carriers. Lancet. 1973;302:1157–9.
18. Moylan JA, Fitzpatrick KT, Davenport KE. Reducing wound infections:
improved gown and drape barrier performance. Arch Surg. 1987;122:152–7.
19. Andersson AE, Bergh I, Karlsson J, Eriksson BI, Nilsson K. Traffic flow in the
operating room: an explorative and descriptive study on air quality during
orthopedic trauma implant surgery. Am J Infect Control. 2012;40:750–5.
20. Dharan S, Pittet D. Environmental controls in operating theatres. J Hosp
Infect. 2002;51:79–84.
21. Alijanipour P, Karam J, Llinas A, Vince KG, Zalavras C, Austin M, et al.
Operative environment. J Arthroplast. 2014;29:49–64.
22. Hubble MJ, Weale AE, Perez JV, Bowker KE, MacGowan AP, Bannister GC.
Clothing in laminar-flow operating theatres. J Hosp Infect. 1996;32:1–7.
23. Beldame J, Lagrave B, Lievain L, Lefebvre B, Frebourg N, Dujardin F. Surgical
glove bacterial contamination and perforation during total hip arthroplasty
implantation: when gloves should be changed. Orthop Traumatol Surg Res.
2012;98:432–40.
24. Iudicello S, Fadda A. A road map to a comprehensive regulation on
ventilation technology for operating rooms. Infect Control Hosp Epidemiol.
2013;34:858–60.
25. Brandt C, Hott U, Sohr D, Daschner F, Gastmeier P, Rüden H. Operating
room ventilation with laminar airflow shows no protective effect on the
surgical site infection rate in orthopedic and abdominal surgery. Ann Surg.
2008;248:695–700.
26. Salassa TE, Swiontkowski MF. Surgical attire and the operating room: role in
infection prevention. J Bone Joint Surg Am. 2014;96:1485–92.
27. Allegranzi B, Zayed B, Bischoff P, Kubilay NZ, de Jonge S, de Vries F, et al.
New WHO recommendations on intraoperative and postoperative measures
for surgical site infection prevention: an evidence-based global perspective.
Lancet Infect Dis. 2016;16:e288–303.
• We accept pre-submission inquiries
• Our selector tool helps you to find the most relevant journal
• We provide round the clock customer support
• Convenient online submission
• Thorough peer review
• Inclusion in PubMed and all major indexing services
• Maximum visibility for your research
Submit your manuscript at
www.biomedcentral.com/submit
Submit your next manuscript to BioMed Central
and we will help you at every step:
Noguchi et al. BMC Surgery (2017) 17:78 Page 6 of 6
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

1.
2.
3.
4.
5.
6.
Terms and Conditions
Springer Nature journal content, brought to you courtesy of Springer Nature Customer Service Center GmbH (“Springer Nature”).
Springer Nature supports a reasonable amount of sharing of research papers by authors, subscribers and authorised users (“Users”), for small-
scale personal, non-commercial use provided that all copyright, trade and service marks and other proprietary notices are maintained. By
accessing, sharing, receiving or otherwise using the Springer Nature journal content you agree to these terms of use (“Terms”). For these
purposes, Springer Nature considers academic use (by researchers and students) to be non-commercial.
These Terms are supplementary and will apply in addition to any applicable website terms and conditions, a relevant site licence or a personal
subscription. These Terms will prevail over any conflict or ambiguity with regards to the relevant terms, a site licence or a personal subscription
(to the extent of the conflict or ambiguity only). For Creative Commons-licensed articles, the terms of the Creative Commons license used will
apply.
We collect and use personal data to provide access to the Springer Nature journal content. We may also use these personal data internally within
ResearchGate and Springer Nature and as agreed share it, in an anonymised way, for purposes of tracking, analysis and reporting. We will not
otherwise disclose your personal data outside the ResearchGate or the Springer Nature group of companies unless we have your permission as
detailed in the Privacy Policy.
While Users may use the Springer Nature journal content for small scale, personal non-commercial use, it is important to note that Users may
not:
use such content for the purpose of providing other users with access on a regular or large scale basis or as a means to circumvent access
control;
use such content where to do so would be considered a criminal or statutory offence in any jurisdiction, or gives rise to civil liability, or is
otherwise unlawful;
falsely or misleadingly imply or suggest endorsement, approval , sponsorship, or association unless explicitly agreed to by Springer Nature in
writing;
use bots or other automated methods to access the content or redirect messages
override any security feature or exclusionary protocol; or
share the content in order to create substitute for Springer Nature products or services or a systematic database of Springer Nature journal
content.
In line with the restriction against commercial use, Springer Nature does not permit the creation of a product or service that creates revenue,
royalties, rent or income from our content or its inclusion as part of a paid for service or for other commercial gain. Springer Nature journal
content cannot be used for inter-library loans and librarians may not upload Springer Nature journal content on a large scale into their, or any
other, institutional repository.
These terms of use are reviewed regularly and may be amended at any time. Springer Nature is not obligated to publish any information or
content on this website and may remove it or features or functionality at our sole discretion, at any time with or without notice. Springer Nature
may revoke this licence to you at any time and remove access to any copies of the Springer Nature journal content which have been saved.
To the fullest extent permitted by law, Springer Nature makes no warranties, representations or guarantees to Users, either express or implied
with respect to the Springer nature journal content and all parties disclaim and waive any implied warranties or warranties imposed by law,
including merchantability or fitness for any particular purpose.
Please note that these rights do not automatically extend to content, data or other material published by Springer Nature that may be licensed
from third parties.
If you would like to use or distribute our Springer Nature journal content to a wider audience or on a regular basis or in any other manner not
expressly permitted by these Terms, please contact Springer Nature at
onlineservice@springernature.com