Humans have used gloves since the Ice Age for their own protection; initially against the cold, but subsequently, mostly for protection against injury. Remarkably, glove-wearing in surgery occurred remarkably late in surgical history, and initially not for antisepsis. For barber surgeons, speed mattered, and there was no understanding of contamination: such that wiping hands on grubby aprons was encouraged. By 1700, increasingly complex procedures were being performed (eg amputations), and the amount of blood on the surgeon’s coat became a measure of their experience. Any finger cots used were for the protection of the surgeon and to avoid direct contact with foul putrid tissue. The advent of anaesthesia from 1846 (ether) enabled more complex operations, but longer procedures increased the risk of sepsis. Joseph Lister started using carbolic acid sprays and emphasized cleaning instruments (and wounds), but even he saw no need to advocate gloves. The inconsistent use of surgical gloves was to protect the skin from the corrosive and irritating effects of antiseptics, and not to protect against the transmission of infection. The gloves used then were heavy rubber or linen. The big advance was in 1890, and for a bizarre reason. William Stewart Halsted at Johns Hopkins engaged the Goodyear Rubber Company to make custom thin rubber gloves for his favourite nurse Caroline Hampton because she suffered severe dermatitis from contact with mercuric chloride. The improvement to the condition of her skin was so remarkable, and clearly so well received, that they then married. But there was another unanticipated consequence: his colleagues noticed dramatically lower infection rates, and it was this observation that heralded the gradual adoption of gloves for surgery. What was initially motivated to protect staff skin was to have an even more profound advantage in protecting patients from sepsis. Over the next 30 years there were multiple observational studies showing reduction in infection rates; incrementally, gloves became more widely used until they became the standard in clean surgery - but not universally. It was refinements in rubber manufacturing, better sterilization methods and an increasing understanding of microbiology that facilitated the routine use of gloves. In the 1960s single-use latex gloves were introduced, whereas previously gloves were re-used and sterilized between cases. By 1980 double-gloving was beginning to be introduced for some orthopaedic procedures and trauma. At about the same time, with the scourge of HIV and Hepatitis B and C, there was a paradigm shift to mutual protection (surgeon and patient). And as problems with latex were becoming more apparent, alternatives were developed: nitrile and neoprene. In the last few years, a new inflection point has been emerging: the massive environmental cost of surgical gloves. The focus now is how their adverse significant environmental effects and financial costs to health institutions can be reduced without compromising patient or surgeon. Billions of sterile gloves are produced annually; and they are the highest-volume single-use items in hospitals. Their substantial and measurable adverse environmental costs relate to the raw materials, production, sterilization, transport/distribution and disposal. Double-gloving, indicator systems and frequent glove changes magnify the problem. This presentation analyses the apparent lack of benefit of double-gloving in routine surgery against the environmental damage caused, the cost to the health system and the ethical ramifications. Double-gloving as a routine for surgical procedures was introduced over 25 years ago in the belief it might reduce surgical site infection and risk to theatre staff from blood-borne infection. No study has shown this to be true (the two RCT studies looking at surgical site infection (SSI) failed to show any benefit), although about 100 studies have confirmed that gloves acquire multiple micro-perforations during surgery. The factors that increase glove perforation rates (e.g. duration of surgery, jagged bone) have been well documented. In the absence of any direct evidence of value by double-gloving, glove perforation rates have been used as a proxy for justifying the practice. In 2019, the Covid epidemic embedded the practice in many Western countries, again without any evidence of patient or surgeon benefit. There are strong grounds for challenging routine double-gloving on the basis that the adverse consequences far outweigh any actual benefits. These include the costs to the health system, environmental damage from production and disposal (such as CO2 footprint, toxic emissions of volatile organic compounds, ozone depletion and release of heavy metals and microplastics), and ethical concerns. This paper outlines the potential benefits and the range of adverse consequences of routine double-gloving during surgical procedures; and provides guidelines for the proper use of double-gloving based on the best evidence currently available.

The development of endovascular aortic repair represents one of the most significant paradigm shifts in vascular surgery. While Juan Parodi’s first implantation in Buenos Aires in 1991 is rightly recognised as a pivotal milestone [1], the city of Perth, Western Australia (WA), played a key role in transforming endovascular repair from a concept to a viable therapy. In the 1990s, Professors Michael Lawrence-Brown and David Hartley, together with colleagues including Drs John Anderson and Barry Baker, collaborated with engineer David Gunning to design, test, and refine some of the earliest prototype stent-grafts for abdominal aortic aneurysms [2]. The Perth team leveraged interdisciplinary cooperation and a culture of innovation to overcome considerable technical and logistical barriers. Their first human implantations demonstrated the feasibility of aneurysm exclusion, validating and extending Parodi’s work. This presentation will trace the technical evolution of early stent-graft systems, and highlight the unique environment in Perth that cultivated these advances. By situating Perth’s contributions within the broader global narrative, this presentation will underscore how local WA innovation had profound worldwide impact, laying out the foundation for what is now a standard, life-saving therapy. References 1. Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg. 1991;5(6):491-9. 2. Lawrence-Brown MM, Hartley DE, Anderson J, Gunning D, McAullay G, Sieunarine K, et al. The Perth experience with endoluminal bifurcated grafting of abdominal aortic aneurysms. J Endovasc Surg. 1996;3(2):123-35.

Haemorrhage has historically been the leading cause of early mortality following trauma. Contemporary methods of vascular control are often framed as post-medieval innovations, with earlier practice frequently characterised as relying predominantly on cautery and compression. However, the literature of Byzantine physician-surgeons demonstrates a more developed operative approach to haemostasis that refined earlier traditions and informed later surgical practice. Analysis of translated passages from Paul of Aegina’s Epitome of Medicine (7th century CE), alongside the writings of Aëtius of Amida, shows clinical differentiation between brighter, pulsatile arterial bleeding and slower, darker venous haemorrhage. Both authors describe mechanical control using hooks to isolate bleeding vessels, facilitating targeted haemorrhage control. Paul provides step-by-step operative descriptions for the exposure of major vessels and application of ligatures proximal to the site of injury. He advocates ligation at the vessel root prior to division as the safest approach, refining earlier recommendations by the Roman physician Galen, who described ligation or transection as separate, non-sequential strategies. Unlike earlier references to vessel control, these Byzantine texts situate haemostasis within the context of traumatic injury. They emphasise vessel identification and proximal control. These principles informed later surgical texts, including Kitab al-Tasrif written by 10th century Andalusian surgeon Albucasis. The writings of Byzantine physician-surgeons demonstrate an empirical understanding of haemorrhage and operative strategy that aligns with modern principles of proximal vascular control. Their work represents a critical and often under-recognised link between ancient surgical knowledge and modern trauma practice, highlighting the enduring importance of targeted haemostasis in the management of traumatic bleeding.