Safer Use of Surgical Hoods and Togas in Joint Arthroplasty
Why This Matters
Surgical hoods and togas are now standard in many operating rooms performing hip, knee, and shoulder arthroplasty. For many surgeons, they provide an added layer of protection – shielding both the patient and surgical team from blood, fluids, bone debris, and airborne particles.
At the same time, newer research and clinical experience have raised important questions about how modern positive-pressure hoods and togas are used, and whether certain practices may unintentionally increase contamination risk if not handled carefully.
This article is not about eliminating hoods or togas from the operating room. Instead, it focuses on practical steps surgeons and OR staff can take to use these products more safely and intentionally during total joint arthroplasty, based on real-world experience and existing data
A Brief Context: How Modern Togas Differ
Earlier systems, such as the original Charnley toga, relied on negative pressure – pulling air away from the surgeon and venting it outside the operating room. While less comfortable, this design limited the release of internal air into the sterile field.
Most modern systems, by contrast, use positive pressure with an internal fan. These are significantly more comfortable and easier to wear, but they also increase air circulation inside the gown and around the surgical field. That added airflow makes proper technique and handling even more important.
Practical Recommendations for Safer Hood and Toga Use
The following recommendations are intended to reduce contamination risk while continuing to allow surgeons and staff to benefit from modern hood and toga systems.
1. Test the Helmet and Fan Before Entering the OR
Turn the fan on briefly to confirm functionality, then turn it off or disconnect the battery before entering the operating room. This confirms the system works without introducing unnecessary airflow.
2. Keep the Fan Off During Donning
Do not turn the fan on until the toga and gloves are fully in place. This helps prevent unfiltered air from circulating around the head and neck during gowning.
3. Avoid Zippers When Possible
Togas without zippers reduce the chance of accidental contamination by circulating staff during gowning.
4. Watch for Face Shield Contamination
If using a hood or two-piece system, ensure the surgical technician does not touch the face shield after it has contacted the helmet.
5. Manage Waist Ties Carefully
The waist tie should be handled in a controlled manner and pulled down carefully to avoid contact with non-sterile areas.
6. Tie the Waist Loosely
A looser waist tie allows positive pressure air to escape near the feet, reducing pressure at the glove–gown interface and lowering wrist contamination risk.
7. Protect the Wrists During Gloving
During inner glove application, keep fingertips inside the gown sleeve cuff to reduce exposure.
8. Seal the Wrist Interface
Use Ioban or a similar adhesive to secure the inner glove to the gown sleeve, minimizing air leakage at this critical junction.
9. Use the Lowest Comfortable Fan Setting
Higher fan speeds increase internal pressure and airflow. Keeping the fan at the lowest effective setting helps limit particle movement near the sterile field.
10. Avoid Mask Adjustment After Gloving
If mask adjustment is necessary, do it before donning outer gloves. Thin material around the neck and face increases contamination risk.
11. Treat the Crown of the Hood as Non-Sterile
Do not assume the top of the hood is sterile. This area may be thinner or more permeable than other sections.
12. Turn Off the Fan Before Doffing
Before removing the toga, turn off or unplug the fan. Whenever possible, do this outside the operating room or away from the sterile field to reduce airborne particle spread.
Closing Thoughts
Positive-pressure hoods and togas remain widely used in joint arthroplasty for good reason. However, how they are used matters just as much as whether they are used.
By applying consistent, thoughtful technique and awareness during donning, use, and removal, surgeons and OR staff can reduce unnecessary contamination risk while maintaining the protective benefits these systems provide
If you have suggestions or additional insights on safer hood and toga use, feedback from practicing clinicians is always valuable.