Task Analysis of Laparoscopic Splenectomy
Dr. Nada Aziz
PROCEDURE STEPS:
- Patient put under general anaesthesia .
- Patient preparation and positioning.
- Surgeon, patient, and monitor should be at coaxial alignment.
- Establishment of the access by Veress needle.
- Gas insufflation with CO2.
- Ports insertion.
- Surgical steps.
- Specimen retrieval.
- Ports closure.
- Deflation of the abdomen.
- Skin closure.
- Patient extubation.
Executional steps :
- General Anaesthesia :
- The Patient should be under GA.
- NGT to be inserted and suction of gastric contents.
- Position the patient in a supine position.
- Availability of the following instruments should be checked :
- Access instruments: Blade 11, Veress needle, one 10 mm port, two 5 mm ports.
- Optical instruments: 10 mm telescope, camera, light cable.
- Operating instruments: Maryland, semi-traumatic grasper, endo-GIA stapler, endoclips, Curved end scissor, endobag.
- Energy instruments: Harmonic.
- Check the function of the monitor, insufflator, light source, amount of gas cylinder, harmonic setting frequency between 3-5, and check the monopolar function for cutting and coagulation.
- Patient and surgeon Positioning :
- Table height should be adjusted to the surgeon height (0.49 X surgeon height).
- The patient should be prepped form the nipples to the mid-thighs. Patient draping and cable arrangement.
- The surgeon should stand at the right side of the patient, the monitor at the left side of the patient
- The monitor, target organ and surgeon should be aligned in coaxial alignment.
- The monitor should be at 15 degrees below the surgeon eyes and 5 times of its diagonal diameter away from the surgeon.
- Access and Insufflation:
- Position the patient in right lateral decubitus with blankets put between the chest and the pelvis to elevate the area between the ribs and pelvis to have more visualization of the spleen.
- With 11 blades a 2mm incision is made at 10 cm lateral to the umbilicus midclavicular line a Size 10 Veress needle is inserted perpendicularly to the abdominal wall: starting with checking the veress needle function and patency by flushing it with NS and hearing 2 clicks of the valve.
- The length of the needle which should be inserted should be 4cm + abdominal wall thickness. Veress Needle should be held as a dart at 90 degrees. Will feel 2 areas of resistance, should be intra-abdominal after you passed the 2nd area.
- Check the position of the Veress needle by 3 ways:
- Flush the needle with NS which should go easily.
- Aspirate, nothing should come.
- Hanging drop test: drops of NS are placed at the cannula of the needle, should sink when the lower abdominal wall is lifted.
a.Set pressure 12 and flow 1 L / min.
6. The gas tube should be flushed with CO2 before attaching it the veress needle.
7. The gas tube to be attached to the veress needle and start insufflation, making sure that the abdomen is tympanic and distended equally in all quadrants. Insufflators parameters should be observed carefully during insufflation.
8. Once the actual pressure reaches the set pressure of 12 mmHg, Veress needle will be removed.
9. At the verses needle insertion wound, it is increased to 10mm.
10. 10mm port is inserted and attached to the gas tube.
11. 30 degrees Camera to be adjusted in terms of white balance, and focus.
12. Camera to be inserted and check for any bleeding, adhesion or bowel injury. Determine the spleen hilum
- Working ports insertion :
- Based on baseball diamond concept working ports sites are determined after visualizing the hilum and two 5mm ports are inserted under direct visualization to be contralateral in their position.
- Liver retractor can be added at the epigastric area if needed
- Surgical steps :
- Determine the splenocolic and phernocolic ligament and both of them will be dissected using harmonic starting with splenocolic.
- The lower part will be mobilized and the spleen will be lifted up. The hilum and short gastric will be exposed
- Using harmonic the short gastric (gastrosplenic ligament) are dissected and separated from the spleen.
- Increasing one of the 5mm ports to 12 mm to insert an endo-GIA stapler.
- After inserting the endo-GIA, the splenic hilum vessels which include the splenic artery and vein are ligated using it. (It is preferred since the vessels lie parallel to each other, so the chance of AV fistula is less)
- After the hilum vessels are ligated the phernosplenic ligament is dissected and the spleen is freely mobile in the abdomen
- Ensure that hemostasis is maintained.
- Using the 12mm incision a size D Endo bag is inserted and the spleen is extracted through it. (If needed the spleen can be morcellated inside the endo bag using sponge forceps)
- Ports removal and closure:
- Under direct vision, the 5mm port is removed.
- The 10mm and 12 mm incisions facia is closed using Vicryl 0 by suture passer.
- Gas insufflation is stopped, the abdomen is deflated
- All Skin incisions are closed using Vicryl or staplers
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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.
