M.B.B.S; D.G.O; F.MAS; D.MAS;
Karad Satara Maharashtra
Introduction
Hysterectomy means removal of uterus. By open or laparoscopic way. There are many indications for hysterectomy most common are fibroid uterus, Dysfunctional uterine bleeding, uterine prolapse. Laparoscopic hysterectomy classified by Garry & Reich in to 9 types. Subtotal, supra cervical hysterectomy is type 6. First laparoscopic hysterectomy performed by Dr. Reich in 1989.
Summary of supracervical hysterectomy
For laparoscopic supracervical hysterectomy you have to take at least 3 port 4 port. after ligation of uterine pedicel and vessels by monopolar and bipolar energy sources uterus is cut from cervix. It is said that its having few advantages over total hysterectomy like maintenance of libido, in many cases patients have cyclic bleeding for 1-2 yrs after subtotal hysterectomy,no bowel/bladder complaints, no chances of vault prolapse,as anatomy of pelvis not disrupted but patient of supra cervical hysterectomy must do regular follow up to avoid cervical cancer.
CONTRAINDICATION
1- Severe COPD, cardiac diseases
2- Generalized peritonitis
3- Hypo or hyper coagulation
4- Huge broad ligament myoma
5- These are relative contraindications for laparoscopic surgeries.
PRE-OPERATION PREPARATIONS
1. Written informed consent
2. Peglac powder with a glass of water at night before surgery
3. NBM by last night before surgery.
4. Prepare parts
5. Bolus IV Antibiotics before surgery
6. Inform OT and anaesthetist
HARDWARE REQUIRED FOR SURGERY
**= Telescope 10mm 30degree,Electrosurgical unit, or ultrasonic dissector like harmonic,
**= Uterine manipulator
**= Grasper 5mm, scissors 5mm, dissectors like Maryland
**= Suture material vicryl no 1 for securing uterine vessels.
**= CO2 insufflator, Boils apparatus with ETCO2 monitoring.
Procedure of subtotal / supracervical hysterectomy
1. Shift patient to OT after all preanesthetic check up.
2. Check Camera, Light Source, CO2 Insufflator & CO2 cylinder
3. All connections of electrosurgical unit checked.
4. Patient taken on operation table,preanaesteic medications given.
5. Painting & draping done after lithotomic position.
6. SRC done.
7. General anesthesia inj. scoline given & patient intubated.
8. Surgeon is on left side of patient, assistant towards right and head end of patient. Coaxial alignment confirmed. OT Tablet ilted 0 degree down.
9. Patency of veres needle confirmed.
10. Two allis forceps applied at lower ridge of umbilicus, by 11 number blade small 2mm nick taken on skin veres needle hold like
dart & its inserted by directing towards pelvis.
11. Saline & bubble sign confirmed.
12. CO2 insufflator connected at a rate of 1litre/min and liver dullness and uniform abdominal dictation confirmed.
13. Veress needle removed incision extended up to 11 mm. Trocar inserted in perpendicular manner to skin after holding like pistol.
14. 10 mm telescope inserted light & camera joined to it, video recording started, white balancing done. CO2 tube connected & low rate increased.
15. Diagnostic laparoscopy done and target organ ia examined and two 5 & 10mm trocar inserted under illumination.
16. Uterine manipulator inserted for uterine stability & movements as per surgeons need.
17. Bipolar or harmonic in one port & semi traumatic Grasper, Maryland in other port inserted.
18. Round ligament at 4cm infundibulopelvic at 3cm and ovarian ligament at 2 cm cooked with bipolar forceps. If fallopian tube & ovaries to be removed remove same time otherwise they can disturb vision.
19. Now anterio & posterior folds of round ligament opened by blunt dissection.
20. Now UV fold opened with harmonic as it works on ultrasonic vibration and give bloodless dissection & bladder pushed down.
21. Posterior peritoneum 2 cm above cervical part of utero sacral ligament opened.
22. Uterine vessels secured with extracorporeal knot like mishra’s knot.
23. Now by using Bipolar, Enseal or thunderbeat uterine artery is cooked & cut and proper hemostasis assured.
24. Uterus cut from cervix by using monopolar hook.
25. Endothelium of cervix burned with energy sources.
26. Irrigation & suction done. Hemostasis confirmed.
27. Uterus taken out by morcellation..
28. 10mm ports closure done with veres needle applied suture material.
29. Dressing of the wound done.
30. Keep watch on ETCO2 level during surgery.
31. Extubate patient & shift patient to recovery room.
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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.
