Dr. Ali Ahmed Ali AbdulRaheem
Appendicitis is one of the most common surgical problems. Laparoscopic appendectomy is one of the surgical options for treatment of acute appendicitis.
The procedure consisted of numbers of critical steps:
1- Prepping and Draping:
Cleaing the abdomen from the level of breasts to the mid thigh using Petadine or chlorhexidine solution, urinary catheter inserted under aseptic technique to insure complete emptying of urinary bladder which in turn will reduce the risk of urinary bladder injury and facilitates the exploring of the pelvic organs and structures, then the patient is covered with draping (green sheet) or ready-made disposable drape.
2- OR Setting:
The procedure is 2 surgeon procedure, a camera man and operating surgeon. The ergonomics concept must be considered, where the target (appendix) and surgeons eyes and the screen is perfectly aliened in a straight line, the distance between the surgeons eyes and the screen must be comfortable preferably 3 times the diagonal measure of the screen, the screen is kept at the same level of his eyes. The instruments, light source cable, insufflators cable and the diathermy or Hormonic scalpel are set according to the standard way.
3- Placement of Ports and Pneumoperitoneum:
A small transverse incision is made at supra umbilicus area, and the abdominal cavity is insufflated using veress needle after being checked for function errors or factory defects, the abdominal wall is lifted up, the needle is inserted at 90 degree to the abdominal wall with tip directed to the anus, to clicks sounds must be hared, drop test and suction irrigation test can be performed to insure safe and correct insertion of the needle. The CO2 gas insufflation is started at rate of 1L/min till reaching the target intra-abdominal pressure which is between 12 to 15 mmHg, later one can be maintained at 4-5 L/min. Once the target pressure has been reached, a 10 mm trocar is inserted followed by the 10 mm 30 degree camera after being checked installed and white balanced by the assisting surgeon. Under vision, a 5 mm trocar is placed at the suprapubic area, and another second 5-mm trocar is placed at the LLQ, this allows triangulation and ergonomic instruments handling in the conventional manner, the ports insertion is following the baseball diamond concept.
4- Laparoscopic Exploration and Appendectomy:
The intra abdominal area is inspected to orient the surgeon to the position of the appendix. Inspection will also alert surgeon to any anatomic variation or other pathological conditions such as ruptured hemorrhagic ovarian cyst, Mickle's Diverticulum ..etc. Many findings can be reported during exploration such as presence of pus, adhesions, biogenic membranes. Once the appendix found inflamed, appendectomy must be carried out immediately. The bowel is gently retracted away from the field of dissection for better view and safe dissection, the patient position on table is changed to insure that the appendix is situated at the highest point in the field, so head must be down and patient tilted to left side. Atraumatic grasper is used to hold the appendix. The mesoappendix is coagulated using Hormonic scalpel, the coagulation must be done close to the body of the appendix to avoid cecal injury, the mesenteric fat will be coagulated in this process till the base of the appendix, this will insure coagulation and selling of appendicular artery. Prior to dividing the appendix from the cecum, 2 PDS endoloops, are placed proximal to the cecum, and the second loop is placed 1-2 cm distally to the later. The appendix is then divided between the two loops using scissors. The appendix then placed in retrieval Endobag and extracted. The abdominal cavity may be irrigated thoroughly with normal saline and suctioned clean several times in case of perforation and pus formation, pelvic drain maybe kept in the pelvis in certain cases.
5- Final Inspection and Closure:
The abdominal and pelvic organs must be inspected once before defilation of the abdomen, in this step, the surgeon must look for signs of infection such as missed pocket of pus, or other potential complications of which the surgeon might need to be aware. Before defilation of the abdomen, the surgeon must inspect the port sites while removing them looking for possible bleeding which can be controlled under vision. Following deflation of CO2, the 10 mm port at mid-line (supra umblicus port), must be closed with Prolene 1, or PDS-0, the skin is closed with prolene 3-0 interrupted sutures or clips followed by dressing.
written by Dr.Dr. Ali Abdul Raheem
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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.
