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Wetting Surgical Gloves for Knot Tying

Wetting surgical gloves before tying — typically with sterile saline — is a long-standing operative pearl intended to reduce friction between suture and glove, improve throw run-down, and limit the suture's tendency to cut the glove. The practice is most relevant with monofilament (polypropylene, polydioxanone, nylon) and high-tensile-strength UHMWPE braids (FiberWire, Orthocord, Herculine), which both slide poorly across a dry glove and aggressively abrade it.[1][5][6]

For the broader suture-handling context — material choice, throw counts, and knot-type security — see Sutures.

Rationale​

A dry glove against a slippery monofilament creates two problems:

  1. The suture "grabs" and indents the glove — the high local pressure at the fingertip is concentrated through a thin filament, perforating the glove and, in published series, allowing bacterial pass-through.[5]
  2. Throws do not run down smoothly — the surgeon either over-tensions (cutting into tissue or breaking the suture at the knot) or under-tensions (air knot), producing inconsistent knot mechanics.

A thin saline film between glove and suture creates predictable, low-friction sliding so that throws set with reproducible tension and the glove is loaded across a larger contact area rather than at a stress-concentrating point.

Evidence — Wet vs Dry on Knot Mechanics​

StudyDesignFinding
Pietschmann 2011[1]Five suture materials; dry vs saline-soakedWet conditions reduced knot slippage (14 slippages wet vs. 30 dry, p < 0.05)
Savage 2023[2]Polyblend arthroscopic suturesStatistically significant three-way interaction between suture material, knot type, and environment — no single knot type is optimal across all conditions
Coleridge 2017[3]Surgeon's, square, Aberdeen knots in polyglactin 910 and PDSFluid exposure (balanced electrolyte, serum, fat) either had no effect or significantly improved knot holding capacity
Muffly 2012[4]Saline-soaked vs petroleum-exposed sutureSaline-soaked sutures had higher knot failure loads than petroleum-exposed ones

The aggregate signal: moisture is at worst neutral and often beneficial for knot mechanics. The intuition that "wet sutures slip more" is not supported by the bench data.

Glove Integrity and Perforation Risk​

Knot tying is a major (and often under-appreciated) cause of intraoperative glove damage:

  • Enz 2023[5] — glove damage from knot tying occurred in 25–37% of THA, TKA, and rotator-cuff cases; the pulling hand was most commonly affected; index-, middle-, and ring-finger fingertips were the dominant perforation sites. Bacterial pass-through through damaged gloves was confirmed.
  • Martinez 2013[6] — overall 3.4% glove perforation rate with arthroscopic knot tying using high-tensile-strength sutures. All perforations occurred in thicker powdered gloves; none in thinner powder-free gloves.
  • Battersby 2016[7] — double gloving reduces knot quality by ~24% overall (up to 50% with 4-0 sutures) — a real trade-off between barrier safety and knot precision.
  • Enz 2026 global consensus[8] — 10-recommendation framework emphasizing proper fit, double gloving, and routine glove change every ~90 minutes to maintain barrier integrity; the WSES 2020 position paper makes the same point in the SSI context.[9]

Practical Pearls​

VariableRecommendation
When to wetBefore tying monofilament or UHMWPE braids; less helpful with naturally high-friction braids (Vicryl, Ethibond, silk)
What to wet withSterile saline from the field — irrigation cup or wet sponge. Avoid blood, fat, and povidone-iodine residue, which behave more like dry/petroleum than saline.[4]
Glove choiceThinner powder-free gloves perforate less during knot tying than thicker powdered gloves[6]
Double glovingMaintains the barrier but reduces knot quality ~24%; consider changing the outer glove for the closure if knot precision is critical[7]
Glove change cadenceRoutine change every ~90 minutes per global consensus[8]
Throw count (monofilament)≥ 4–5 throws for surgeon's / square knots; 6 throws with blocking half-hitches in laparoscopic settings[10][11][12]
Surgeon's knot twists3–5 initial twists; benefit plateaus beyond 5

When the Pearl Matters Most in Reconstructive Urology​

  • Anastomotic urethroplasty knots with 4-0 or 5-0 PDS — slippery monofilament, tight working space, knot precision is the difference between watertight and leaking.
  • Vesicourethral anastomosis after radical prostatectomy / salvage urethroplasty — the same PDS / Monocryl story under additional tension.
  • High-tensile sutures used for sling fixation, fascia sutures in pubovaginal slings, and prosthesis-tubing tie-downs — these abrade gloves aggressively.
  • Robotic / laparoscopic intracorporeal knots — once tied, hard to revise; wetting at the docking-cart stage and using barbed sutures where appropriate are complementary strategies.

References​

1. Pietschmann MF, Sadoghi P, Häuser E, et al. "Influence of testing conditions on primary stability of arthroscopic knot tying for rotator cuff repair: slippery when wet?" Arthroscopy. 2011;27(12):1628–1636. doi:10.1016/j.arthro.2011.06.031

2. Savage E, Hurren CJ, Rajmohan GD, Thomas W, Page RS. "Arthroscopic knots: suture and knot characterisation of modern polyblend suture materials." Heliyon. 2023;9(9):e19391. doi:10.1016/j.heliyon.2023.e19391

3. Coleridge M, Gillen AM, Farag R, Hanson RR, Munsterman AS. "Effect of fluid media on the mechanical properties of continuous pattern-ending surgeon's, square, and Aberdeen knots in vitro." Vet Surg. 2017;46(2):306–315. doi:10.1111/vsu.12627

4. Muffly TM, Couri B, Edwards A, et al. "Effect of petroleum gauze packing on the mechanical properties of suture materials." J Surg Educ. 2012;69(1):37–40. doi:10.1016/j.jsurg.2011.06.012

5. Enz A, Klinder A, Bisping L, et al. "Knot tying in arthroplasty and arthroscopy causes lesions to surgical gloves: a potential risk of infection." Knee Surg Sports Traumatol Arthrosc. 2023;31(5):1824–1832. doi:10.1007/s00167-022-07136-7

6. Martinez A, Han Y, Sardar ZM, et al. "Risk of glove perforation with arthroscopic knot tying using different surgical gloves and high-tensile strength sutures." Arthroscopy. 2013;29(9):1552–1558. doi:10.1016/j.arthro.2013.05.022

7. Battersby CL, Battersby NJ, Hollyman M, Hunt JA. "Double-gloving impairs the quality of surgical knot tying: a randomised controlled trial." World J Surg. 2016;40(11):2598–2602. doi:10.1007/s00268-016-3577-z

8. Enz A, Boermeester MA, Chatterjee A, et al. "Hands deserve better: global clinical consensus recommendations on surgical gloving practice." J Hosp Infect. 2026;172:115–128. doi:10.1016/j.jhin.2026.03.025

9. De Simone B, Sartelli M, Coccolini F, et al. "Intraoperative surgical site infection control and prevention: a position paper and future addendum to WSES intra-abdominal infections guidelines." World J Emerg Surg. 2020;15(1):10. doi:10.1186/s13017-020-0288-4

10. Romeo A, Fujimoto C, Cipullo I, et al. "Effect of diameter and type of suture on knot and loop security." J Clin Med. 2023;12(19):6418. doi:10.3390/jcm12196418

11. Silver E, Wu R, Grady J, Song L. "Knot security — how is it affected by suture technique, material, size, and number of throws?" J Oral Maxillofac Surg. 2016;74(7):1304–1312. doi:10.1016/j.joms.2016.02.004

12. Romeo A, Fernandes LF, Cervantes GV, et al. "Which knots are recommended in laparoscopic surgery and how to avoid insecure knots." J Minim Invasive Gynecol. 2020;27(6):1395–1404. doi:10.1016/j.jmig.2019.09.782