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Laparoscopic Repair of Ventral Hernia by IPOM Technique : Task Analysis

General Surgery / Jan 22nd, 2018 1:36 pm     A⁺ | a^-

Laparoscopic Repair of Ventral Hernia by IPOM Technique : Task Analysis

Dr. Jeevan G.S. MBBS, DNB (Gen Surg), MRCS (Eng), F.MAS

 

Introduction

 

Any protrusion of viscera through anterior abdominal wall is called as Ventral hernia. It is categorised as spontaneous or acquired 

Spontaneous –primary defects in abdominal fascia includes.
 

1. Umbilical & paraumbilical hernia 

2. Epigastric hernia 

3. Spigelian hernia  
 

Acquired 
 

1. Incisional hernia 

2. parastomal hernia

 

The laparoscopic approach shortens the operating time and the hospitalisation of the patient while the incisions cause less pain and there is a faster return to normal daily activities. Relative contraindications of this surgery include extremely large hernias with loss of abdominal domain or those associated with extensive, dense intra- abdominal adhesions.

 

Approach Considerations

 

The basic surgical principles of laparoscopic repair include the following: no tension technique, appropriate trocar placements and the use of mesh. The number of trocars used and their placement are related to the location and the size of the hernia, as well as the surgeon’s experience and choice. 

 

Preoperative Preparation

 

The patient must be free of skin infections and the respiratory function must be evaluated and optimised before the operation. If the hernia contains parts of the gastrointestinal tract such as bowel, appropriate imaging and endoscopy may be performed in order to avoid any intraoperative complications. The patient may be given a bowel preparation prior to surgery.

 

Anesthesia

 

General Anesthesia with endotracheal tube is required.

 

Operative Preparation

 

Perioperative antibiotics should be given according to the most recent national guidelines. The stomach must be decompressed with an orogastric tube, a Foley catheter must be placed and stockings are applied. The skin is prepared in a routine manner using antiseptics.

 

Position

 

The patient is placed in a supine position.

 

Instruments and Surgeon Position

 

All devices and instruments needed for the operation must be checked for proper function. The surgeon’s position must follow the principles of ergonomics in laparoscopic surgery i.e. suitable table height at 0.49 of surgeon’s height, alignment of surgeon, hernia and monitor, placement of monitor at a distance of 5 times its diagonal diameter and at a height no less than approximately 20cm from his/her visual axis.

 

 Incision and Exposure

 

The 10mm port of the laparoscopic telescope and the 5mm instrument ports are a function of the position of the hernia defect and the preference of the surgeon. The “Diamond-Baseball” principle of port placement should be followed for better ergonomics. Good exposure, traction, counter traction and good working angles between the instruments and the patient must never be compromised in an attempt to use fewer trocars. The ports need to be placed at a distance no less than 5cm with each other. One of the operating ports could be 10mm in size. 
 

The surgeon must decide where the entrance to the peritoneal cavity should be. A safe site for primary entrance would be Palmer’s point at 2-3 cm below the left costal margin in the mid-clavicular line. Access to the peritoneal cavity is gained using either the closed or the open technique.

 

 Closed technique access

 

• Make an incision on the skin, 2mm using a scalpel blade No. 11

• Lift the abdominal wall and insert the Verres needle through the    incision at a 45o elevation angle but perpendicular to the abdominal wall.

• After you hear the three click sounds, do ascertainment tests (irrigation, aspiration and hanging drop tests) to check the correct placement of the needle

• Insufflate the peritoneal cavity with CO2 through the Verres needle according to the principles of insufflation.

• Observe the rise of the intra-abdominal pressure and the total volume of gas as the abdomen distends uniformly and hernia pops out.

• Take the needle out of the abdomen.

• Enlarge the incision upto 10mm.

• Slowly screw the cannula with the trocar into the peritoneal cavity.

• The camera is white-balanced and focused.

• The telescope is advanced down the port into the abdomen

•  All four quadrants of the abdomen are explored

•  The hernia and its contents are evaluated

•  Additional unrecognised hernia defects may be found

•  Omental and other adhesions to the abdominal wall are visualized

•  The 5mm instrument ports are placed after transillumination of the abdominal wall using the telescope, to show any regional  vessels within the abdominal musculature

 

Procedure

 

Adhesiolysis and reduction of contents of the hernia sac:

Typically, If the content is bowel it would assume a pyramidal shape or a flyover shape and if the content is momentum, it would appear as a treetop.

 

If Omentum as contents
 

• Grasp the omentum near the abdominal wall with the grasper.

• Apply gentle traction.

• Incise sharply the junctions of the omentum with the peritoneum of the abdominal wall using laparoscopic scissors or using monopolar hook or else with harmonic scalpel.

• Reduce the sac into the abdominal cavity.

• Any bleeding that might occur should be controllled.

 

If bowel as contents use laparoscopic scissors for a sharp dissection and avoid electrosurgical devices as far as possible.

 

Mesh Placement 

 

• A dual mesh would be ideal choice to prevent bowel adhesions.

• Make a measurement of the perimeter of the defect and make sure there is clear zone for attachment of the mesh and for applying the sutures or tackers.

• Deflate the abdomen and identify/mark the edges of the defect on the abdominal wall. If measurements are made with the abdomen fully inflated, the mesh will be too large

• Measure the defect’s size

• Choose the size of the mesh as defect + 12 cm on all sides.

• Place anchoring sutures at four corners of the mesh or four sutures each at 12,3,6,9 o clock positions in case of circular mesh.

• Tie each suture in its midpoint and leave the long tails intact

• Mark the sites of the skin corresponding to the sutures

• Roll the mesh

• Introduce the mesh to the abdominal cavity through the 10mm 

• Unfold and orient the mesh by making sure the right surfaces are facing towards the hernia and the abdomen

• Make a 2mm skin stabs at the marked sites using No.11 blade.

• Pull the sutures through the abdominal wall muscles with a suture passer instrument

• Secure the preattached sutures at the four quadrants setting the knot deeply

• Use an endoscopic stapling device such as a tacker to secure the   exposed perimeter of the mesh

• Place the tacks 1 cm apart, applying external counterpressure with the hand while tacking best approach is to create a double-circle configuration with the outer line located close to the edge, to prevent the mesh from folding on itself and inner crowning around the fascial defect.

• Do not apply tackers over the fascial defect.

 

Upon completion of the procedure:

 

• Inspect the abdomen for any bleeding sites

• Remove the operating ports under direct vision checking for bleeding sites

• Release the pneumoperitoneum

• Close the fascia of the 10mm trocar site with NO.1 absorbable sutures

• Approximate the skin with subcuticular sutures

• Apply dry sterile dressings.

 

Postoperative Care
 

• Remove the orogastric tube before the patient awakens

• Discontinue the Foley catheter when the patient is able to void

• Give Painkillers

• Advance diet as tolerated by the patient, starting with fluids within 1 day

• The use of an abdominal binder for 1 month is recommend by some surgeons

 

Complications

• Intra operative bleeding
• Bowel perforation
• Prolonged ileus
• Hematoma at Port site / Tacker site
• Seroma
• Port site infection
• Abscess
• Mesh Infection
• Bowel adhesion and obstruction

 

Bibliography 

 

1. Task Analysis of Laparoscopic procedures, World Laparoscopy Hospital Retrieved from: https://www.laparoscopyhospital.com/index.htm

 

2. Guidelines for laparoscopic ventral hernia repair, SAGES. Retrieved from:

 https://www.sages.org/publications/guidelines/guidelines-for-laparoscopic-ventral-hernia-repair/

 

3. Laparoscopic Ventral Hernia Repair, WebSurg. Mar 2014; 14(03) Retrieved from:

http://www.websurg.com/Laparoscopic_ventral_hernia_repair_(LVHR)-vd01en4221.htm 

5 COMMENTS

Dr. Swapnil Patil

#1

May 24th, 2020 10:48 am

Thank you sir for teaching us this superb technique, The way of your Explaining and demonstration of laparoscopic Repair of Ventral Hernia by IPOM Technique using Task Analysis really Awesome. This is an wonderful video presentation. Thank you for posting such a useful video and very informative and educative and useful task Analysis.

Dr. Bijon Thomas (Chennai)

#2

May 24th, 2020 10:53 am

Very good Article with a clear and simple explanation! Thanks for sharing this Task Analysis of Laparoscopic Repair of Ventral Hernia by IPOM Technique. Thanks..very interesting lesson..so much to learn yet. A very interesting and motivating topic. Thanks for Sharing.

Dr. Mallarvannan Ramaswamy

#3

May 24th, 2020 10:59 am

Excellent Task Analysis of Laparoscopic Repair of Ventral Hernia by IPOM Technique. This is a very Informative and Educative for laparoscopic doctors. I have benefited from reading this Task Analysis.
Thanks for uploading.

Dr. Devashish Sarkar

#4

May 24th, 2020 11:09 am

So wonderful Task Analysis of Laparoscopic Repair of Ventral Hernia by IPOM Technique. Prof Dr. R. K. Mishra i am so greatful to your teaching and well explanation onTask Analysis.

Dr. Gaurav Tiwari

#5

May 24th, 2020 11:48 am

Thank you very much for the Article! It's really amazing. This helped me out so much!, Thanks for posting this Task Analysis Laparoscopic Repair of Ventral Hernia by IPOM Technique.

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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.