A few weeks back, I was preparing to start a surgery. We’d brought the patient into the operating room. The OR was ready to go with an open surgical back table. The scrub tech was already gowned, and my team and I were walking in to help. A minute later the anesthesiologist walked in, but he had not donned his facemask.

For a second, part of me wanted to yell, “Put on your facemask you crazy person!” This came from the deeply ingrained part of me that had been trained from many encounters in the OR to take all the common modern day precautions. Wearing a facemask was, of course, one of them.

In the next second, the other part of me, the questioning, skeptical, thoughtful part took over and asked the question, “Are facemasks really necessary in the OR?” Some of you may think this question is heretical. “How can we not wear masks in the OR?” you ask. “The absence of such would increase the risks of postoperative infections,” you argue.

But, would it? Would it really? How do we know for sure that masks are necessary in the operating room?

Let’s be heretical for a moment and ask that question. Do we need face masks in the OR? In our era of evidence-based practice, we may find an answer by examining the medical literature.

Before we do so, let me make a few stipulations. First, I’m going to focus on issues regarding the patient rather than providers (we’re not looking at surgeon contamination by the patient). Second, for the sake of simplifying the discussion I’m going to assume that surgeons who don’t wear masks during a procedure increase the chance of infection if they, say, drool or sneeze into the field. Masks would obviously be helpful in that situation. Third, the only outcome measure that really matters is postoperative infection, so we’ll stick to that.

Initially, during my preliminary research, I found an Australian study by Webster, et al¹. I first thought this one would be sufficient for our discussion, but then I found the mother load of good answers, the Cochrane Database of Systematic Reviews! Let’s use this to answer our question.

The authors of this systematic review searched for randomized and quazi-randomized clinical studies that compared disposable surgical masks with no masks in both scrubbed and nonscrubbed OR team members. From an initial 13 studies that met basic criteria and eliminating lower quality studies, they found a grand total of three clinical trials that met their inclusion criteria^1,3,4. Out of these three studies, there were a total of 2,106 patients that underwent clean surgery.

Here’s a quick table that shows the three studies’ outcomes:

None of these studies found there to be a significant difference in outcomes between the groups with masks and those without. The surface answer to our question, then, is that face masks in the operating room do not have any effect on postoperative infections. There’s your answer in a nutshell: lose the face masks.

It’s worthwhile, though, to make a few comments.

Unfortunately, it’s not possible to give a final black and white answer, and we have basically one good study that addresses the question. So…our best evidence is that surgical masks probably have no effect on infection rates in clean surgery, but more quality research needs to be done.

I know. It’s kind of anticlimactic, but this result is similar to many of the medical questions we attempt to consider rationally. There just isn’t strong evidence for many of our practices. On a hopeful note, some evidence is better than none. For now I think we’ll have to stick to wearing masks. Perhaps some future intrepid researcher will put this one to bed. Until then, mask up.