Small gauze, big skills—the application of gauze in laparoscopic gastrointestinal surgery

In the process of learning laparoscopic gastrointestinal surgery, young surgeons always pay attention to the dissection and digestive tract reconstruction. Learning how to expose the operative field and cooperate harmoniously with the operators are very important for the assistants. However we rarely pay attention to the way the operator using his left hand to assist with the surgery.

I usually analog laparoscopic surgery to a duel which needs capable of both attack and defense. Harmonic scalpel and electrome are our swords for the tissue dissection. The instruments of laparoscopic surgery are mostly sharp and hard, it is sophisticated but also easy to damage the normal tissues and organs. We recommend soft gauze as shield during the laparoscopic surgery. It can make up for the shortcoming of the laparoscopic instruments, help us complete a preferable laparoscopic gastrointestinal surgery, reducing vice injury.

We use gauze on daily basis, but seldom considering much about how to choose it. A piece of perfect gauze should meet the following criteria:

• Strong absorbing capability, can absorb the blood, and make a clear view of the operation.
• Proper size, suitable for the operation of laparoscopic, and could access 12 mm trocar freely. We choose 20 cm × 4 cm gauze as a dedicated laparoscopic gauze, accord with most of the reports in literature abroad.
• Clear mark, can be identified easily during the operation.
• X-ray developable mark line, it can be identified and positioned with X-ray.
• Based on my personal experiences, several methods are summarized here regarding how to use gauze in laparoscopic gastrointestinal surgery, and hope could be useful for surgical professionals.

Compression

Compression is the most commonly used function of gauze in surgery, and also it is one of the most important functions of gauze. When faced with small ooze blood in laparoscopic surgery, it’s easy to damage the surrounding tissue if we using harmonic scalpel and electrome blindly, such as normal intestinal wall, ureter, presacral tissue, spleen, etc. (Figures 1,2). If conditions allows, it is more effective to use hemostatic gauze.

Figure 1 Superior spleen bleeding.

Figure 2 Gauze compression.

Blockage

Exposure is important in laparoscopic gastrointestinal surgery. But there are times we unable to make the small intestine away from our operative field by position changes. We use a gauze to fend off the small intestine as the terminal ileum always interfere in the operative field when we dissected the left Toldt’s space (Figures 3,4). At the same time, as the gauze is just around the operative field, it is ready at hand when we encounter a small bleeding.

Figure 3 Use gauze to fend off the small intestine.

Figure 4 Operative field without interference.

Cushion

The laparoscopic instruments are sharp and hard, it is easy to damage the normal tissue during the surgery, especially by the time we meet the pancreas, liver and other organizations (Figures 5,6,7). We can use gauze to increase the contact area and reduce the damage to the organization, increase the exposed area and expand the space of operation at the same time.

Figure 5 Liver injury.

Figure 6 Liver injury reduced after using gauze.

Figure 7 Protect the pancreas.

Indication

Different from traditional open abdomen operation, laparoscopic gastrointestinal surgery separates space first and then removes the upper tissue. Due to the limitations of laparoscopic vision, we could only judge the anatomical level through observation. There is a certain difficulty in the confluence of two levels and it is easy to damage the lower normal tissue. We usually placed gauzes to indicate the level of the clearance. For instance, we put a gauze in the dissected Toldt’s space during the sigmoidectomy to avoid injury of ureter (Figures 8,9). Gauzes covered on pancreatic head and duodenum during the dissection of hepatocolic ligament (Figures 10,11).

Figure 8 Put gauze into the left Toldt’s space.

Figure 9 Separate the left paracolic sulci.

Figure 10 The right hemicolectomy, gauzes instruct the right Toldt’s space.

Figure 11 The right hemicolectomy, see the gauzes placed in the right Toldt’s space.

Prevention

Subsidiary-injury is the biggest issue that confronts the beginners. Besides the influence of human factor, we could use some little tips to protect surrounding tissues from being injured. Method which was often used is utilizing gauze to fend off surrounding tissues. For example, in addition to indicating the Toldt’s clearance, gauzes we put at the juncture of the left Toldt’s clearance and the left ureter during the operation sigmoid could also protect the left ureter from being injured when we separate the left paracolic sulci (Figure 12). In the same way, the small gauzes could not only support the Toldt’s clearance, but also keep the duodenum and the head of pancreas unharmed during the right hemicolectomy.

Figure 12 Cover on the head of pancreas.

Blunt dissection

The laparoscopic instrument “Peanut” (Figure 13) used to perform blunt dissection in surgical space. In our institute, for a lot of reasons, “Peanut” is unavailable. We use the ultracision clamping a gauze to accomplish blunt dissection. Gauze has a large contact area which is an advantage comparing to the “Peanut” in expanding Toldt’s space (Figure 14). Furthermore, you can manage the hemorrhage immediately by using the ultracision during the blunt dissection.

Figure 13 “Peanut”.

Figure 14 Expanding Toldt’s space.

Insulation

After the surgery, normal saline (NS) is usually utilized to irrigate the operating field. When we use a suction, it usually plugged, in this moment, a small gauze placed on the area for suction is significant. This application would not only protect the surrounding tissue but also make the use of siphoning of the gauze (Figure 15).

Figure 15 Gauze can enhance the aspirator efficiency.

Gauze is a good helper, but it can be a tragedy if it is not used properly.

Remnant of gauze is the nightmare to patience and surgeons! To avoid that, my suggestion is: (I) when using gauzes, they should be placed at a place without the intestine and omentum interference, such as hepatorenal recess, presacral space, spleen fossa and the place easy for searching; (II) if it is allowed, it would be optimal to follow the “one by one” principle, which means to remove the gauze after using it. It will reduce the chance of mistakes.

Acknowledgments

Funding: None.

Footnote

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/ales.2017.03.15). The authors have no conflicts of interest to declare.

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