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Task Analysis Of Interval Laparoscopic Abdominal Cerclage

Gynecology / Jul 25th, 2019 4:03 am     A⁺ | a^-

Task Analysis Of Interval Laparoscopic Abdominal Cerclage

Dr. Viveka Mohan


 

Abdominal cerclage is necessary when the standard transvaginal cerclage fail or anatomical abnormalities preclude the vaginal placement. In 1965, Benson and Durfee described an abdominal approach to cerclage. The main interest of this technique is to avoid a laparotomy; thus, reducing the morbidities of laparotomy and also the recovery time post-surgery.A 5-mm non-absorbable needled polyester fiber tape (Mersilene) suture was placed laparoscopically at the level of the internal os as an interval procedure. 
 

Indications 
 

1) congenitally short or extensively amputated cervix, marked scarring of the cervix, 

2) subacute cervicitis,  

3) wide or extensive cervical conisation, and  

4) one or more previous trans-vaginal cerclage failures.         
                           

Contraindications: 

1)bulging membranes 

2)ruptured membranes,  

3)intrauterine infections,  

4)vaginal blood loss,  

5)intrauterine foetal death,  

6)labour,  

7) life-threatening maternal condition. 
 

Pre operative steps 
 

1) Any medical co -morbidities and absolute or relative contraindications  

2) Informed consent 

3) Pre- surgical checklist  
 

Intro operative steps 
 

1. Prophylactic antibiotics half an hour prior to surgery after test dose. 

2. Connect patient for vital signs monitoring and EtCo2 monitor. 

3. Induction with general anesthesia. 

4. Patient in Trendelenburg position. 

5. Preparation of surgical site. 

6. Speculum and uterine manipulator placement 

7. Make sure that all the cables and patient return plate are properly connected and the required energy sources are in working condition. 

8. Pre operative checklist is reconfirmed. 
 

Port placement and pnemoperitonium:
 

Using baseball diamond concept, one 10mm port is placed in the umbilicus and two 5mm ports are placed contra-laterally at distance of 7.5 cm from the umbilicus.  Before inserting check the Veress needle action by pressing the blunt tip of the needle against a hard surface and checking the action of the red indicator.  
 

Steps: 
 

1. For the umbilical port placement, evert the umbilicus by applying two Alleys forceps on lateral margins of umbilicus.  

2. Then a stab incision is given in the midline on the superior or inferior crease of the umbilicus.  

3. Now, hold the Veress needle like a dart in the right hand and lift up the abdominal wall by holding suprapubically. Insert the Veress needle at a 90° angle to the abdominal wall and oblique to the peritoneum and keep the direction of the needle towards the pelvis 

4. There will a sensation of initial resistance and then giving away at two places. Once the peritoneum in pierced confirm it by connecting 5ml syringe to the Veress needle and then aspirate. If nothing is aspirated, then push some saline into the cavity and then aspirate again, if the peritoneal cavity has been reached then no fluid should be aspirated back. Hanging drop test and plunger test can also be done.  

5. Once the position of the needle is confirmed, attach the needle to the insufflator with initial flow rate of 1L/min with preset pressure of 12 to 15mm of Hg.  

8. Once uniform dissension is achieved, enlarge the incision in a curved fashion and insert a 10mm port perpendicular to the abdominal wall by screwing movement . Now, remove the trocar and insert a 30° telescope through the cannula, into the abdominal cavity keeping the light source cable at 12’o clock position and CCD cable at 6’o clock position.  

10. Once the port is inserted, the flow rate can be increased to >/= 6L/min.  

11. Now to put a 5mm port 7.5 cm lateral to the umbilical port, by first making a stab wound on the skin and then inserting the port perpendicular to the skin, under the direct vision via laparoscope. Similarly, put another port 7.5 cm lateral to the umbilicus on the contra lateral side.   
 

Procedure of laparoscopic abdominal cerclage 
 

1)Start by inspecting the abdominal and pelvic cavities for any abnormalities, adhesions and endometriosis.  

2)Inspect the uterus, fallopian tubes, ovaries, the pouch of Douglas and uterosacral ligaments for  any congenital anomalies, any visible myomas, cysts, adhesions of the tube or hydrosalpinx 

3)Uterus is held retroverted.The uterovesicle fold of peritoneum is dissected using atraumatic grasper and dissector(scissors,harmonic) to visualize the uterine artery .Blunt dissection is carried out atlas the upto 4 cm on either side to reach the broad ligament. 

4)Uterus is anteverted and the site for needle insertion is delineated.Ideally this is the grey area, roughly 2cm above the uterosacral ligament origin,which corresponds to a point lateral to internal is of cervix and medial to uterine artery.Coagulation is done at this point which also helps to prevent excessive bleeding . 

5)Mercilene tape with 2 needles with a ski configuration is introduced through 5mm port. 

6)The needle is held and taken posterior to uterus.Needle is held at right angles to uterus at the grey area and brought out anteriorly medial to uterine artery on one side.Care should be taken not to injure the uterine vessels.Similarly the step is repeated on the other side .Care should be taken that the tape remains flat posteriorly. 

7)The tape is pulled anteriorly from both sides.The needles are cut off and removed through 5 mm port.A surgeon’s knot is placed by first taking  2 wraps and then two single opposite throws . The knot should be tied snuggly and excessive tension is not needed.The 2 ends of the knot are cut and sutured together with absorbable suture and anchored to cervical fascia. 

8)With the same absorbable suture the UV fold of peritoneum is approximated by continuous sutures and terminated by Aberdin,s knot. 9)Haemostasis is checked. Pnemoperitoneum is reverted followed by closure of all ports. 

 

5 COMMENTS

Dr. Pankaj Kumar Rai

#1

May 22nd, 2020 9:13 am

Awesome Task Analysis, very interesting and full of information, and very Impressive article of Task Analysis of Interval Laparoscopic Abdominal Cerclage.

Dr. Sandeep Varma

#2

May 22nd, 2020 9:22 am

Thank you sir for sharing such an amazing Task Analysis of Interval Laparoscopic Abdominal Cerclage. Thanks for uploading.

Dr Vikash kumar

#3

May 22nd, 2020 9:26 am

This is very educative and informative article of on Task Analysis of Task Analysis Of Interval Laparoscopic Abdominal Cerclage with a clear description it's very useful for me.

Dr. Vinay Pratap

#4

May 22nd, 2020 9:30 am

Great article of Task Analysis Of Interval Laparoscopic Abdominal Cerclage. It was really amazing article step by step of surgery's.This is excellent and very well taught.

Dr. Munmun Das

#5

May 22nd, 2020 9:35 am

This article helps me a lot in my career, Thank you for sharing of Task Analysis of Interval Laparoscopic Abdominal Cerclage is very good too to understand.

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How to Perform and Implement Task Analysis of Laparoscopic and Robotic Procedures

Task analysis is a critical component of any complex surgical procedure, including laparoscopic and robotic surgeries. It involves breaking down the procedure into its constituent tasks, identifying the steps, skills, and cognitive processes required. Task analysis not only enhances the understanding of these intricate surgeries but also serves as a foundation for training, skill assessment, and continuous improvement in healthcare. In this essay, we will delve into how to conduct and implement task analysis for laparoscopic and robotic procedures.

Understanding the Significance of Task Analysis

Before we explore the procedure for task analysis, it's essential to recognize why it is of paramount importance in the realm of surgery, particularly for laparoscopic and robotic procedures.

1. Enhanced Learning and Training: Task analysis helps in developing structured training programs. It breaks down complex procedures into manageable components, making it easier for trainees to learn and practice each step methodically.

2. Skill Assessment: By understanding the tasks and sub-tasks involved, it becomes possible to assess the competence of surgeons and surgical teams. This is crucial for ensuring patient safety and quality care.

3. Workflow Optimization: Task analysis can reveal inefficiencies in surgical workflows. Identifying these bottlenecks allows for process improvements, potentially reducing surgical times and enhancing outcomes.

4. Error Reduction: Recognizing potential points of error is vital for preventing surgical complications. Task analysis can highlight critical steps where errors are more likely to occur, leading to proactive measures to mitigate risks.

Procedure for Task Analysis of Laparoscopic and Robotic Procedures:

Task analysis for laparoscopic and robotic procedures involves several steps:

Step 1: Define the Surgical Procedure

Begin by clearly defining the surgical procedure you wish to analyze. Whether it's a laparoscopic cholecystectomy or a robotic prostatectomy, having a specific procedure in mind is essential.

Step 2: Gather Expert Input

Engage experts in the field, including experienced surgeons, nurses, and other surgical team members. Their input is invaluable in identifying and detailing the tasks involved.

Step 3: Identify the Tasks and Sub-Tasks

Break down the surgical procedure into tasks and sub-tasks. For instance, in a laparoscopic cholecystectomy, tasks could include trocar placement, camera insertion, gallbladder dissection, and suturing. Sub-tasks under "trocar placement" might involve choosing trocar sizes, making incisions, and inserting trocars.

Step 4: Sequence the Tasks

Establish the chronological order of tasks. Determine which tasks are dependent on others and identify any parallel processes. Sequencing tasks is essential for understanding the flow of the procedure.

Step 5: Define Task Goals and Objectives

For each task and sub-task, define the goals and objectives. What should be achieved in each step? For instance, in gallbladder dissection, the goal might be to safely detach the gallbladder from the liver while preserving nearby structures.

Step 6: Skill and Equipment Requirements

Specify the skills and equipment required for each task. Consider the level of expertise needed, such as basic laparoscopic skills or advanced robotic manipulation. Document the instruments and technology involved.

Step 7: Cognitive Processes

Identify the cognitive processes involved, such as decision-making, spatial orientation, and problem-solving. Understanding the mental aspects of surgery is critical for training and error prevention.

Step 8: Consider Variations and Complications

Acknowledge potential variations in the procedure and anticipate complications. How would the surgical team adapt if unexpected issues arise? Task analysis should encompass both the standard procedure and potential deviations.

Step 9: Develop Training and Assessment Tools

Use the task analysis results to create structured training modules. These modules should align with the identified tasks, objectives, and skill requirements. Additionally, design assessment tools to evaluate the competence of trainees and surgical teams.

Step 10: Continuous Improvement

Task analysis is not a one-time endeavor. Regularly revisit the analysis to incorporate new techniques, technology, and best practices. Continuous improvement is vital for staying at the forefront of surgical care.

Implementing Task Analysis Results:

Once task analysis is complete, it's crucial to implement the findings effectively:

1. Training Programs: Develop and deliver training programs based on the task analysis. These programs should encompass both simulation-based training and real-life surgical experience.

2. Skill Assessment: Use the assessment tools developed during task analysis to evaluate the skills of surgical teams. This can be done through structured evaluations and objective metrics.

3. Quality Improvement: Task analysis can reveal areas for process improvement. Work with the surgical team to implement changes that enhance efficiency and patient outcomes.

4. Error Prevention: Utilize the identified points of error to develop strategies for error prevention. This might involve checklists, preoperative briefings, and enhanced communication protocols.

5. Research and Innovation: Task analysis can also guide research efforts, leading to the development of new techniques and technologies that improve surgical procedures.

In conclusion, task analysis is an indispensable tool in understanding, teaching, and advancing complex surgical procedures such as laparoscopic and robotic surgeries. By meticulously dissecting each task and sub-task, identifying skill requirements, and considering cognitive processes, healthcare professionals can enhance patient safety, optimize surgical workflows, and continually improve the quality of surgical care. Task analysis is not merely an analytical exercise; it is a pathway to excellence in surgical practice.