**3.1 Sleeves and cuffs**

In general, there are two different kinds of sleeves in the gowns sold in the market at present: Raglan sleeves and set-in sleeves. A raglan sleeve, which can be identified by the diagonal seam line from the neckline to the armpit, is the most common type of sleeve used in surgical gowns [21]. Another type of sleeve construction found in many garments is commonly referred to as a set-in sleeve. The set-in sleeve is more difficult to construct and offers less freedom of movement

**Figure 2.** *Various surgical gowns.*

for the wearer. The set-in sleeve is tight and results in high garment pressure in the armpit.

Since surgical gowns are worn over the scrubs, it is extremely important that they provide freedom of movement. The necessary comfort and freedom of movement are achieved by raglan sleeves as they create a large area in the armpit and provide more fit for the shoulder and arm [21–23]. In addition, raglan sleeves make donning and doffing easier compared to set-in sleeves because the deep armholes of raglan sleeves make it easier to reach into the sleeves when donning [21].

The sleeve edges were trimmed with a wrist cuff. Generally, three different types of cuffs are used, elastic cuffs around the wrist (disposable), knit cuffs made of cotton or cotton-polyester blend (disposable and reusable), and thumb loops (disposable and reusable) [3]. **Figure 3** contains different cuff designs.

According to the ANSI/AAMI PB70 classification, cuffs are not considered a critical area, so the material used on the cuff does not necessarily have barrier protection. In order to eliminate the strike-through through the cuffs, surgical gloves are worn pulled up over the cuffs so that the cuffs must fit snugly. One of the latest solutions to keep the gown wrist in place are thumb loops [3, 14].

#### **3.2 Neck closures**

The necklines of the gowns are closed in various ways: Tie, snaps, and hook and loop neck closures, all of which provide some adjustability for fit. The different types of closures are shown in **Figure 4**.

The most commonly used method is the tie back closure. The back contains a tie band at the neckline edge and another inside the neckline near the shoulder. The corresponding ties are located outside the left back piece, near the shoulder or at the edge [14]. The reusable surgical gowns made of slippery materials tend to slide down when worn. The back tie(s) can sometimes become loose, which would cause the surgical gown to slide down slightly and make the medical staff feel

**Figure 3.** *Different cuff designs.*

**Figure 4.** *Different closure types.*

#### *A New Approach to Surgical Gowns DOI: http://dx.doi.org/10.5772/intechopen.98563*

uncomfortable [24]. For this reason, Chang et al. [24] proposed a new combined tie fastening method for the reusable surgical gowns with two tie straps to prevent the tendency of the surgical gowns to loosen and slide down.

Snap fasteners provide closure of the gown neckline. The right back includes two male snap components, while the female components are located near the neckline of the left back. The snap components are spaced 1–1.5 inches apart to provide four adjustment options and flexibility in fit. Closer spacing of the snaps allows for more precise adjustment of the neckline area [14].

Some gowns with hook and loop neck closures are made for easy adjustability. This type of neck closure allows for easy adjustment of the neckline to fit a variety of sizes. The look components of the tape are located at the neckline of the left back. The corresponding hook component is located on the right back piece. Hook and loop closures offer great ease, flexibility, and accuracy in neckline fit, but often cause discomfort to surgical staff as hair is easily caught in the closure [3, 14].

It has been observed that reusable surgical gowns are subjected to heavy washing and sterilization steps after each use and various difficulties are encountered in models with hook and loop and snap fasteners. Due to the rough surface of the hook and loop fastener, it is difficult to clean its surface, it can be deformed quickly, and its outer surface can cause linting. In addition, the hook and loop can get caught in the garment during the washing process, which can cause damage. On the other hand, snaps can damage both the garment and the machine during wash and sterilization cycles. If the snap is damaged, it is unlikely that it can be repaired. There is also the possibility that the snap will not provide the desired degree of closure. So there is a risk that the gown will be tight/loose for the user. Since the tie is made from the fabric structure of the gown or a more durable fabric, there are no problems during washing and sterilization. It also ensures a complete closure for people of different sizes and avoids the problem of loose/tight fit.

### **3.3 Sizing/fit**

Sizing/fit is also one of the features that is critical to surgeon protection and comfort. Gowns must allow the surgeon adequate freedom of movement, fit a variety of body shapes and sizes, and be easy to put on and take off without contaminating the worker or the workplace. Poorly fitting gowns can cause blood to easily get on the skin or other clothing [3].

Nowadays, surgical gowns are made with different size options (medium, large, extra-large, etc.) in addition to the universal fit (one size fits all). One-size-fits-all gowns are designed to fit a range of people with different sizes. However, they are usually not efficient for surgeons and are too large. The CDC recommends that multiple gown types and sizes be available in a healthcare facility to ensure adequate coverage for staff.

#### **3.4 Stitches-seam**

The characteristics of the seams of surgical gowns determine the overall performance of the product as a barrier to the spread of microorganisms. The seam provides a barrier against particulate, liquid, and gas/vapor, as well as potential chemical resistance and a biological barrier [22].

Traditional sewing with needles and threads is the most widely used method to join textiles together. Most of the reusable gowns are partially joined using traditional stitches and seams, usually a 401 double-thread chain stitch with a simple superimposed seam. Exceptions to this generalization include a reusable gown assembled with a lapped seam structure and two parallel rows of 401 stitches [14]. A low stitch density is used to minimize puncturing of the fabric and needle holes to avoid loss of barrier effect. Traditional sewing is not preferable in the manufacture of reinforced surgical gowns or some critical zones, such as sleeve seams, as needles can leave holes and cause seam leakage, leading to loss of barrier effect of the gowns [22, 25].

Eryuruk et al. [26] found that in traditionally sewn garments with membrane reinforcement, water can penetrate through the seams due to the needle holes in the fabric, which poses a risk to medical personnel in real-life use of the garment. To prevent this, the seams need to be sealed or a new joining technique based on welding such as ultrasonic welding can be used to create a fully sealed seam. Ultrasonic sewing is even more preferred than other conventional sewing methods in the manufacture of nonwoven based products. By using ultrasonic welding, seams with high waterproof properties can be obtained [25, 27, 28].

Mistik et al. compared the tensile properties of ultrasonic, lock and chain sewing methods. In their study, woven fabric was used, and the result of their study shows that the tensile properties of ultrasonic sewing were lower than traditional sewing methods [27]. Eryuruk et al. [29] compared bond strength and permeability properties of ultrasonically welded nonwoven fabrics with traditional sewing techniques. They found that ultrasonic welding technique is a suitable method for joining layers in the manufacture of surgical gowns, with acceptable bonding strength. Moreover, no water penetration was observed in the ultrasonically welded joints of the membrane-reinforced fabrics [26].

As a result, it can be said that while traditional sewing methods are preferred for reusable gowns, ultrasonic welding gives better results for disposable gowns. Although the seam strength values obtained in traditional sewing are high, the ultrasonic welded seams show higher performance in terms of liquid impermeability.
