Barrier and no-touch techniques in gastrointestinal surgery: a best evidence summary

1 Introduction

Surgical site infection (SSI) is one of the most common healthcare-associated infections after gastrointestinal (GI) surgery, accounting for approximately 15%–20% of all such infections (1). Because GI surgery involves entry into the digestive tract, most surgical wounds are classified as clean-contaminated (Class II) or contaminated (Class III), and reported SSI rates after colorectal surgery range from 5% to 26%—far higher than after clean surgery (2). In surgery for GI malignancies, intraoperative tumor cell shedding additionally motivates the no-touch isolation technique (NTIT), although high-quality trials have not confirmed an oncologic survival benefit over conventional techniques (3).

For terminology consistency, “barrier techniques” in this manuscript denote the bundle of intraoperative measures that isolate the surgical field from microbial contamination (hand hygiene, standard precautions, aseptic practice, wound protection, and environmental management), whereas “no-touch isolation technique (NTIT)” refers specifically to measures that avoid direct contact with tumor and contaminated tissue; these two terms are used consistently throughout. Clinical nurses vary considerably in their knowledge and implementation of these techniques, and standardized operational guidance for GI surgery remains lacking. This best evidence summary therefore used an evidence-based nursing methodology to systematically identify, critically appraise, and synthesize the best available evidence on barrier and no-touch techniques for SSI prevention in GI surgery, thereby providing an evidence base for clinical nursing practice.

Although barrier techniques and the NTIT arose from different historical rationales—microbial contamination control and SSI prevention for the former, and minimization of direct tumor manipulation and potential tumor-cell dissemination for the latter (3)—we integrated them into a single research question and evidence framework for three reasons. First, the two approaches converge mechanistically and operationally in GI surgery: the critical moments of microbial contamination (opening of the bowel lumen, handling and retrieval of specimens, anastomosis and reconstruction, and incision closure) are precisely the moments at which NTIT-derived practices (zoned “clean–contaminated” instrument management, glove and instrument changes, and specimen isolation) (4–6) are applied, and both sets of practices are executed by the same surgical and nursing team as one continuous intraoperative workflow. Second, because high-quality evidence has not confirmed an oncologic survival benefit of the NTIT (3, 7), the principal contemporary justification for retaining NTIT-derived practices is their contribution to contamination control and SSI prevention; evaluating them under a common SSI-focused outcome therefore aligns the research question with the outcome for which the supporting evidence is strongest. Third, from a clinical nursing perspective, operating room nurses require a single, coherent operational protocol rather than two conceptually separate rule sets; integrating these conceptually distinct but operationally overlapping interventions into one SSI-focused framework reflects how they are actually implemented in practice and avoids fragmented and inconsistent application.

Regarding the novelty of this evidence synthesis, we acknowledge that individual barrier-related interventions—such as aseptic technique, wound protection, and intraoperative temperature management—have been extensively evaluated and incorporated into established SSI prevention guidelines (e.g., WHO (8), CDC (9), SHEA/IDSA (10), NICE (11), and ASCRS (4). However, important evidence gaps remain unresolved by these guidelines: they address SSI prevention for surgical patients in general or for selected procedures, provide limited GI-specific and minimally invasive or robotic surgery-specific operational detail, are dispersed across multiple documents that clinicians must consult separately, and are written primarily from a surgical rather than a nursing implementation perspective, offering little graded, step-by-step guidance on how barrier and no-touch practices should be operationalized, sequenced, and quality-controlled throughout the entire intraoperative process; moreover, existing SSI guidelines do not systematically address NTIT-derived practices, whose role warrants reappraisal specifically against SSI outcomes (3, 7). The additional clinical and scientific value of this Best Evidence Summary beyond currently available SSI prevention recommendations is therefore threefold: (1) it consolidates scattered recommendations into 30 graded, GI-specific best-evidence statements covering the whole intraoperative workflow, including NTIT-derived contamination-control practices; (2) it critically reappraises and grades each statement using JBI levels of evidence and FAME-based recommendation strength, distinguishing high-certainty “core” measures from lower-certainty “flexible” ones; and (3) it translates the evidence into actionable, tiered implementation strategies for operating room nurses across different hospital levels, thereby providing an operational evidence base for standardized GI-surgery nursing protocols that existing guidelines do not offer.

2 Methods

2.1 Question formulation

The PIPOST framework was applied to formulate the evidence-based question as follows: Population (P) included adult patients (≥18 years) undergoing elective or emergency GI surgery—open or minimally invasive procedures such as radical gastrectomy, radical colorectal resection, and intestinal obstruction surgery—for benign or malignant disease; Intervention (I) involved surgical barrier techniques (e.g., hand hygiene, standard precautions, aseptic technique, NTIT-derived contamination-control practices, wound protection, intraoperative irrigation, and intraoperative temperature management); Professionals (P) comprised healthcare personnel participating in GI surgery; Outcomes (O) included the incidence of SSI and pass rates for theoretical knowledge and practical application of barrier and no-touch techniques among operating room nurses; Setting (S) encompassed operating rooms at various hospital levels; and Type of evidence (T) consisted of guidelines, evidence summaries, systematic reviews, expert consensus statements, narrative reviews, and randomized controlled trials.

2.2 Search strategy

2.2.1 Information sources

Following the “6S” evidence pyramid model, a top-down literature search was conducted across the following resources: international organizations and guideline websites (WHO, CDC, NICE, SHEA/IDSA, APIC, GIN, NGC, SIGN, RNAO, and medlive.cn); evidence-based databases (The Cochrane Library and JBI Evidence Synthesis); trial registries (ClinicalTrials.gov); English-language databases (PubMed, Web of Science, Embase, and CINAHL); and Chinese databases (CBM, CNKI, VIP, and WanFang).

2.2.2 Search terms

The search terms included: gastrointestinal surgery/digestive tract surgery/abdominal surgery/colorectal surgery; surgical barrier/barrier technique/aseptic technique/no-touch isolation technique/infection control/intraoperative infection prevention/surgical site infection prevention/wound protector; and perioperative nursing/intraoperative care/surgical nursing/operating room nursing.

The search period extended from database inception to March 1, 2026.

2.3 Inclusion and exclusion criteria

2.3.1 Inclusion criteria

The inclusion criteria were as follows: (1) adult patients (≥18 years) undergoing elective or emergency, open or minimally invasive GI surgery involving the stomach, small intestine, colorectum, and other GI organs, for benign or malignant indications; (2) studies evaluating at least one intraoperative barrier or protective measure implemented in the operating room to prevent contamination and SSI; (3) clinical decision support documents, guidelines, expert consensus statements, evidence summaries, systematic reviews, meta-analyses, narrative reviews, and randomized controlled trials (RCTs); (4) publications in Chinese or English; and (5) when multiple versions of similar evidence were available, studies published between 2021 and 2026 were preferentially included.

2.3.2 Exclusion criteria

The exclusion criteria were as follows: (1) publications written in languages other than Chinese or English; (2) studies for which the full text was unavailable; and (3) studies that did not meet the predefined quality appraisal criteria. All retrieved records were independently screened by two researchers trained in evidence-based methodology. Any disagreements were resolved through discussion until consensus was reached; if consensus could not be reached, a third researcher trained in evidence-based methodology was consulted for arbitration.

2.4 Quality appraisal tools

Guidelines were assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. Expert consensus statements and narrative reviews were appraised using the 2016 Joanna Briggs Institute (JBI) Critical Appraisal Checklist for Text and Opinion Papers. Systematic reviews and RCTs were evaluated using the corresponding 2016 JBI critical appraisal checklists. Study designs were classified according to the design reported by the original authors and verified against the full text; evidence syntheses without a systematic search and critical appraisal of primary studies were classified as narrative reviews rather than systematic reviews.

2.5 Evidence extraction, synthesis, and grading

Two researchers trained in evidence-based nursing independently performed literature screening, quality appraisal, evidence extraction, and evidence grading. Evidence was initially graded using the 2014 JBI Levels of Evidence and Grades of Recommendation for Intervention Studies. To make the grading process reproducible, the following rules were prespecified before extraction: (1) each evidence statement was assigned the level of its highest-level supporting source; (2) statements supported directly by a systematic review or meta-analysis of RCTs were graded 1a, and those supported by an individual RCT were graded 1b; (3) statements derived from evidence-based guidelines were assigned the evidence level reported for the corresponding guideline recommendation, and where the guideline did not report an evidence level—or where a statement was supported only by expert consensus statements or narrative reviews—the statement was graded 5b (expert consensus); (4) recommendation strength was then determined independently by the two researchers according to the FAME (Feasibility, Appropriateness, Meaningfulness, and Effectiveness) framework, with Grade A (strong recommendation) assigned only when all four FAME criteria were judged to be satisfied and Grade B (weak recommendation) assigned otherwise; and (5) any disagreement in grading was resolved by a third evidence-based nursing expert. When discrepancies existed among different sources of evidence, priority was given to evidence from higher levels of the evidence hierarchy, studies of superior methodological quality, and the most recent authoritative publications.

3 Results

3.1 Literature search results

A total of 18 publications were ultimately included, comprising 5 guidelines, 3 expert consensus statements, 1 evidence summary, 3 systematic reviews, 3 narrative reviews, and 3 RCTs. The literature screening process is illustrated in Figure 1, and the characteristics of the included studies are summarized in Table 1.

Table 1. Characteristics of the included studies (n = 18).

3.2 Quality appraisal results

The quality appraisal results are presented in Tables 2–5.

Table 2. Quality appraisal of guidelines (n = 5).

Table 3. Quality appraisal of expert consensus statements and narrative reviews (n = 6).

Q1: Clear source of opinions; Q2: Opinions based on analysis; Q3: Derived from influential experts; Q4: Centered on the interests of relevant populations; Q5: Logically expressed opinions; Q6: Consistent with previous literature.

Table 4. Quality appraisal of systematic reviews (n = 3).

Q1: Clear research question; Q2: Appropriate inclusion criteria; Q3: Appropriate search strategy; Q4: Sufficient information sources; Q5: Appropriate quality appraisal criteria; Q6: Appraisal by ≥2 reviewers; Q7: Appropriate synthesis methods; Q8: Publication bias assessed; Q9: Conclusions supported by analysis; Q10: Heterogeneity fully discussed; Q11: Appropriate recommendations.

Table 5. Quality appraisal of RCTs (n = 3).

Q1: True randomization; Q2: Allocation concealment; Q3: Comparable baseline between groups; Q4: Blinding of participants; Q5: Blinding of intervention providers; Q6: Blinding of outcome assessors; Q7: Identical interventions across groups; Q8: Complete follow-up; Q9: Intention-to-treat analysis; Q10: Identical outcome measurement methods across groups; Q11: Reliable outcome measurement methods; Q12: Appropriate data analysis methods; Q13: Appropriate study design.

3.2.1 Guidelines

The AGREE II assessment revealed standardized scores of ≥60% in all domains for the five guidelines, indicating high overall quality. All guidelines were graded A and recommended for direct clinical application.

3.2.2 Expert consensus statements and narrative reviews

The JBI appraisal indicated that consensus statement C112 fulfilled all six criteria. C213 and C35 did not fulfill criterion Q6 (consistency with previous literature). C2 represents a comprehensive ERAS guideline, of which only some sections are directly related to barrier techniques. C3 addresses general sterile techniques for operating rooms without specific reference to GI surgical barriers; yet, its core recommendations concerning hand hygiene, aseptic technique, and glove changes align well with specialty guidelines. Among the narrative reviews, NR16 and NR218 fulfilled all six criteria, whereas NR322 did not fulfill criteria Q2 (opinions based on analysis) and Q6 (consistency with previous literature); evidence from NR3 was therefore used only to corroborate, never to solely support, an evidence statement. Overall, the quality of all three consensus statements was acceptable, and thus all were included.

3.2.3 Evidence summary

The single included evidence summary thoroughly traced and evaluated its original references, demonstrating high overall quality, and was therefore included.

3.2.4 Systematic reviews

3.2.5 RCTs

3.3 Evidence synthesis, grading, and recommendations

Content analysis of the included studies was conducted with a focus on SSI prevention and intraoperative contamination control. Thirty best-evidence statements were synthesized across six domains. Evidence grades and recommendation strengths are presented in Table 6. After grading under the prespecified rules, three statements—wound protection, mechanical bowel preparation plus oral antibiotics for elective colorectal surgery, and intraoperative temperature management—were supported by level-1 evidence and assigned Grade A recommendations. Most NTIT-derived contamination-control statements were supported by expert-consensus evidence (level 5b) and were accordingly downgraded to Grade B, reflecting the absence of direct RCT evidence for these practices against SSI outcomes.

Table 6. Summary of best-evidence statements.

Evidence levels (2014 JBI Levels of Evidence): 1a = systematic review/meta-analysis of RCTs; 1b = individual RCT; 5b = expert consensus (evidence-based guidelines without a reported evidence level, expert consensus statements, and narrative reviews). Recommendation strength (FAME framework): Grade A = strong recommendation (all four FAME criteria satisfied); Grade B = weak recommendation.

4 Discussion

4.1 Specificity of barrier and no-touch techniques in GI surgery

Barrier techniques in GI surgery differ substantially from those in clean general surgery. Because GI procedures involve exposure to digestive contents and intestinal flora such as E. coli, Enterococcus, and Bacteroides spp., most incisions are clean-contaminated or contaminated and carry a markedly higher SSI risk. Existing authoritative guidelines (WHO (8), CDC (9), ASCRS (4) address SSI prevention for general or specialty-specific surgery but—with the exception of the colorectal-specific ASCRS guideline—do not provide GI-specific barrier protocols, forcing nurses to consult multiple documents and contributing to fragmented and inconsistent practice. This summary therefore integrates the available evidence into a unified, SSI-focused framework covering the entire intraoperative process of GI surgery.

4.2 Evidence-based recommendations for the NTIT

Critical appraisal of the NTIT evidence reveals an important controversy. Although biologically plausible, the 6-year follow-up of the JCOG1006 phase III trial (853 colon cancer patients) found no significant differences in disease-free (70.3% vs. 69.4%) or overall survival between NTIT and conventional techniques (1, 7). In our interpretation, the enduring value of NTIT-derived operational practices—zoned “clean-contaminated” instrument management and glove and instrument changes after anastomosis—lies less in proven oncologic benefit than in their contribution to contamination control and SSI prevention, which justifies their retention in this SSI-focused framework; either technique may therefore be selected according to surgeon experience. We emphasize, however, that this retention should not be misread as evidence of superiority: NTIT-derived statements in Table 6 (Domain 1) were therefore re-graded to reflect their actual evidence base—expert consensus (level 5b)—and are assigned weak (Grade B) recommendations, to be implemented as contamination-control practices rather than as oncologically beneficial techniques. In minimally invasive surgery, retrieval bag use is strongly recommended because specimen extraction through small incisions may contaminate the wound (23), whereas evidence on pneumoperitoneum-related dissemination and smoke filtration remains inconclusive and constitutes an important evidence gap.

4.3 Important value of wound protectors in SSI prevention in GI surgery

The strongest evidence identified in this best evidence summary concerns wound protectors. A 2025 meta-analysis of 19 RCTs (4,779 abdominal surgery patients) showed that wound protectors significantly reduce SSI (RR = 0.63, P = 0.0001), with a larger effect in the GI surgery subgroup (RR = 0.49, P < 0.00001; moderate-certainty evidence) (17), and a 2024 multicenter RCT confirmed an approximately 47% SSI risk reduction with double-ring plastic protectors vs. traditional gauze in open GI surgery (19); the ASCRS guideline recommends wound protectors in colorectal surgery4, whereas other included guidelines do not issue a specific recommendation for or against their use. We nevertheless note that most included trials enrolled open rather than laparoscopic procedures, so generalization to minimally invasive surgery remains uncertain. Cost and reimbursement barriers may also limit routine use in primary hospitals in China. We therefore propose tiered adoption—routine use of double-ring protectors in tertiary hospitals, and prioritized use of single-ring protectors for high-risk procedures (e.g., low anterior resection and emergency surgery for intestinal obstruction) in secondary hospitals as a transitional strategy—consistent with the feasibility dimension of the FAME framework. Only products certified under national medical device registration standards should be selected.

4.4 Application value of bundle measures in GI surgery SSI prevention

Perioperative care bundles are associated with a reduced risk of SSI (15), and the Chinese ERAS guidelines (2021) (13) endorse integrating multiple interventions into standardized protocols. Based on the synthesized evidence, we recommend a GI-surgery SSI prevention bundle comprising mechanical bowel preparation plus oral antibiotics for colorectal surgery (4, 22), standardized temperature management, timely preoperative antibiotic administration, intraoperative aseptic barrier and wound protection, 48-hour postoperative sterile dressing management, hand hygiene, and daily SSI risk assessment (4). Because the certainty of evidence differs across components, we further propose a “core-flexible” two-tier structure when designing such bundles: high-certainty measures (wound protectors, mechanical bowel preparation plus oral antibiotics, and temperature management) should constitute the core, whereas lower-certainty or uncertain-benefit measures (e.g., routine peritoneal irrigation, pneumoperitoneum smoke management, and NTIT-derived operational details) may be applied flexibly according to clinical conditions, so as to prioritize high-level evidence and avoid overly complex and unsustainable protocols.

4.5 Evidence translation and practice: challenges and recommendations

This best evidence summary has several limitations. Only Chinese- and English-language publications were searched, and gray literature may have been missed; only three RCTs were eligible, no eligible cohort studies were identified, and most NTIT-derived contamination-control practices are supported only by expert-consensus (level 5b) evidence, so the corresponding recommendations are necessarily weak (Grade B); blinding was incompletely reported in some primary studies. Important evidence gaps remain: guideline recommendations for laparoscopic and robotic barrier techniques are relatively general; high-level evidence on pneumoperitoneum management and trocar-site protection is lacking; and NTIT evidence derives predominantly from colon cancer, with limited data for gastric and rectal subgroups.

Future research should prioritize GI-specific barrier protocols for minimally invasive and robotic surgery (including retrieval bag use, trocar-site isolation, and pneumoperitoneum smoke evacuation); multicenter implementation-science studies evaluating barriers, facilitators, and cost-effectiveness of tiered, FAME-guided bundle strategies across hospital levels; and the development of tiered training curricula and competency-based assessment indicators for operating room nurses, supported by a whole-process quality monitoring system covering preoperative preparation, intraoperative cooperation, and postoperative handover.

5 Conclusions

This best evidence summary synthesized 18 high-quality publications into 30 best-evidence statements across six domains of intraoperative barrier and no-touch practice for SSI prevention in GI surgery. The strongest evidence supports routine use of wound protectors in open GI surgery, mechanical bowel preparation combined with oral antibiotics in colorectal surgery, maintenance of intraoperative normothermia; these measures should form the core of GI-surgery SSI-prevention bundles. Most NTIT-derived contamination-control practices are supported mainly by expert-consensus evidence and are conditionally recommended (Grade B) pending higher-quality studies; they should be implemented as contamination-control measures rather than as oncologically beneficial techniques. In contrast, evidence remains limited or conflicting for the oncologic benefit of the NTIT, pneumoperitoneum and smoke management, optimal irrigation regimens, and barrier practices specific to laparoscopic and robotic surgery; recommendations in these areas should be applied flexibly. Clinical translation should follow the FAME framework within a “core-flexible” two-tier structure adapted to hospital resources and individual patient conditions. Priorities for future research include GI-specific barrier protocols for minimally invasive and robotic surgery, validation in gastric and rectal cancer subgroups, and multicenter implementation-science studies of barriers, facilitators, and cost-effectiveness.

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Footnotes

Edited by: Gabriel Sandblom, Karolinska Institutet (KI), Sweden

Reviewed by: Ketan Vagholkar, Padmashree Dr. D.Y. Patil University, India

Vinayak Kshirsagar, Dr. D. Y. Patil Medical College, Hospital and Research Centre, India

Rajpal Singh Sisodiya, Netaji Subhash Chandra Bose Medical College, India