Bowel Technique in Surgical Technology

Foundations and Definition of Bowel Technique

• Conceptual Definition: Bowel Technique, also referred to as ‘confinement and containment,’ describes the specialized protocol used to manage instruments and supplies that come into contact with the internal lining of the bowel. This interior surface is considered contaminated due to the presence of fecal bacteria.

• Scope of Application: This technique is employed in the majority of surgical procedures involving structures where controlled entry into or removal of structures along the alimentary canal is performed.

• Duration of Implementation: Bowel technique is a continuous process that begins the moment the bowel is opened and remains in effect until wound closure, ensuring the maintenance of asepsis and sterile conditions throughout.

• Core Actions Included:

  • Changing surgical gloves.

  • Isolating suction tips and sponges used on the bowel.

  • Preventing any contaminated item from re-entering the sterile field.

The Clinical Rationale for Bowel Technique

• Critical Contamination Control: Strict adherence to bowel technique is essential to control the spread of contamination during gastrointestinal (GI) surgeries and is primary in the prevention of infection.

• Prevention of Cross-Contamination: The implementation of these protocols prevents the transfer of harmful microorganisms indigenous to the bowel to clean surgical areas and non-contaminated instruments.

• Patient Safety and Outcomes: Proper execution reduces the risks of surgical site infections (SSIs), sepsis, and various post-surgery complications, thereby ensuring more favorable patient outcomes.

• Professional Responsibility: Maintaining bowel technique reflects the surgical technologist’s accountability, vigilance, and the necessity for teamwork in preserving the sterile field.

Clean versus Contaminated Field Management

• Definition of the Clean Field: The clean field consists of all instruments and supplies that have not been touched by gastrointestinal contents prior to the opening of the bowel.

• Definition of the Contaminated Field: Once the bowel lumen is opened, any item that contacts the bowel tissue or its contents is deemed contaminated and must be isolated immediately.

• Standard for Maintaining Separation: A strict boundary must be maintained between clean and contaminated fields to prevent bacterial transfer.

• Organizational Techniques:

  • Use of designated areas for contaminated items.

  • Utilization of separate basins.

  • Use of distinct instrument sets to define clean-contaminated boundaries.

Principles and Technical Procedures of Bowel Technique

• Mayo Stand Utilization: A separate Mayo stand should be used specifically for the instruments and supplies required during the resection and anastomosis of the bowel.

• Contaminated (Dirty) Instrument Management:

  • All needle holders, forceps, suture needles, and scissors used during resection and anastomosis are considered dirty and must be kept separate from the clean set.

  • Knife handles and blades used to enter the bowel are considered dirty.

  • Scissors used to create an entry for stapler insertion are considered dirty.

  • The stapling device itself is considered contaminated once used on the bowel.

• Soft Goods and Hemostasis: Sponges used to wipe devices or to achieve hemostasis on the open bowel are considered dirty and must be isolated.

• Wound and Draping Protection: Sterile towels may be utilized to surround the exposed bowel and cover the drapes near the incision site to provide additional protection for the wound layers.

• Stoma Creation: If the surgery involves a stoma, this portion of the procedure is performed during the ‘dirty’ phase.

• Transition Point: Bowel technique officially ends once the resection and anastomosis are completed and the site has been checked for leaks.

• CST Disposal Responsibilities:

  • The Certified Surgical Technologist (CST) should place non-disposable dirty items into a basin and hand them off to the circulator.

  • Disposable items must be placed in a biohazard trash bag.

• Re-Gowning and Re-Gloving Protocol:

  • The CST must change into a new sterile gown and new sterile gloves.

  • The CST assists all other members of the sterile team in the re-gowning and re-gloving process.

• Field Resetting for Closure: Before abdominal wound closure, the field must be reset with clean materials, including:

  • New sterile towels placed around the surgical site.

  • New sponges and suction tubing/tips.

  • New light handles and drapes.

  • A new Bovie pencil and tip.

• Stoma Finalization: If a stoma was created, the abdominal wound is closed and dressed entirely before the maturation of the stoma and the application of the ostomy collection device.

Risk Reduction, Counts, and Wound Classification

• Importance of Surgical Counts: Accurate counts are vital to prevent the retention of sponges, sharps, and instruments, especially during complex GI procedures where both clean and dirty items are present.

• Accountability between Fields: Separate counts may be required for clean and contaminated fields to ensure accountability and minimize infection risks.

• Wound Classification Impact:

  • Controlled entry into the bowel typically results in a "clean-contaminated" wound classification.

  • Uncontrolled entry or significant spillage of bowel contents raises the contamination level, potentially changing the classification to ‘contaminated’ or ‘dirty.’

• Surgical Technologist's Role: Technologists must understand how their management of the field directly influences surgical counts and the eventual wound classification.

Communication and Surgical Conscience

• Role of Communication: Effective and clear communication is necessary to identify breaks in technique and contamination quickly.

• Surgical Conscience: This involves the ethical responsibility of the surgical team to speak up about contamination even if it causes a disruption in the surgical workflow.

• Team Coordination: Professional communication ensures the team remains coordinated and can respond rapidly to identified contamination risks.

Questions and Discussion Contexts

• Continuous Process Inquiry: Why is bowel technique considered a ‘continuous process’? It begins at the first incision into the lumen and continues through the closure of the wound layers after the dirty tools have been removed and the field has been reset.

• Consequences of Technique Breakdown: What could happen if technique is broken for even a few seconds? Microorganisms can be seeded into the peritoneal cavity or wound layers, leading to sepsis, abscess formation, or anastomotic failure.

• Identifying Breaks in Technique (Scenario): If you are contaminated and need an instrument from the back table, reaching for it from the clean side is a major break. What should happen next? The CST must not touch the clean table; instead, they should ask the circulator for the item or change their gloves/gown before approaching the clean field to prevent cross-contamination.

• Categorization Exercises (Clean or Dirty):

  • Sponge used on the bowel: Dirty

  • Stapler used for anastomosis: Dirty

  • Suction tip before bowel entry: Clean

  • Babcock used to grasp bowel: Dirty (once bowel is open/entered)

  • Knife and blade used for stab incision into the bowel: Dirty

Postoperative Considerations and Patient Safety

• Sterile Field Breakdown: Proper bowel technique includes the safe removal of contaminated items during the breakdown of the sterile field post-procedure.

• Environmental Protection: Correct disposal and transport of contaminated tools protect healthcare personnel and reduce general environmental contamination.

• Prevention of Specific Complications: Consistent application of these techniques prevents:

  • Surgical site infections (SSIs).

  • Sepsis.

  • Anastomotic failure (breakdown of the surgical connection between bowel segments).