Task Analysis Of Laparoscopic Myomectomy
Dr. Babalola Olajide Emmanuel MBBS (Ogbomoso), FMCOG (Nigeria) F.MAS, F.ART, DMAS.2. Position of patient: at the time of the pneumo-peritoneum by Veress needle, patient should be placed supine with 10 to 20 degree head down (steep Trendelenburg's position) or supine position if the Veress needle will be inserted perpendicular, if the uterine manipulator will be used then patient will be in lithotomy position, during the surgery head should be 30 degrees down.
3. Patient return plate should be attached to the thigh.
Instruments and equipment required:
• Monitor CCD-camera, light source, insufflator with CO2 cylinder, electrosurgical generator, and suction irrigation system -all in one cart.
• 10mm port, 5mm ports x3, Veress needle, 10mm 30 degree telescope, Maryland, atraumatic-grasper, semi-traumatic grasper, monopolar hook, bipolar grasper, harmonic scalpel, cold scissors, 5mm myoma screw, 2 needle holder, 10mm tenaculum, motorized morcellator, suture material no1 Vicrly, knot pushers and suction cannula and tubing , vasopressin 5ml in 100ml NS.
Position of the surgical team:
Surgeon should stand in the left side of the patient during Veress needle insertion and opposite to the side of pathology to start surgery, monitor, target organ and surgeons visual axis in coaxial line, Camera assistant should be in the right side of the surgeon, 2 assistant surgeons one in the right side opposite to the main surgeon and the second for holding uterine manipulator, scrubbed nurse should be in left side of the surgeon, Preparation of parts done by scrubbing and draping under aseptic techniques.
Preparation of equipment::
Insufflator is turned on to remove air from tubing and set pressure is set at 20mm Hg, set flow rate set at 1 l/min, the camera is turned on focusing to be done at 10 cms, white balance to be adjusted. Set up the connections of require instrument bipolar/harmonic with the electrosurgical generator.
Operative Steps proper:
1. Take Veress needle and check for its spring action and patency.
2. Take 2 Allis forceps to evert and hold each side of the umbilicus.
3. Use number 11 blade to place small horizontal stab wound to the inferior crease of umbilicus.
4. Mosquito clamp to dissect away subcutaneous adipose and expose rectus sheath.
5. Measure abdominal wall thickness and add 4cm for distance to hold Veress needle.
6. Veress needle should be held like a dart.
7. The abdominal wall should be held full thickness with help of thenar, hypothenar and the entire four fingers.
8. At the time of insertion of Veress needle, there should be 45-degree elevation angle and the distal end of the Veress needle should be pointed toward the anus and also perpendicular to the abdominal wall.
9. The surgeon can hear and feel two clicks sound and Maintain a 45-degree angle.
10. Confirm correct Veress needle placement by irrigation test, aspiration test, plunger test and hanging drop test.
11. Connect CO2 gas tube to Veress needle and turn on CO2 and allow a flow rate of 1 L/min, insufflations pressure ideally should be 12 mmHg.
12. Observe Quadro-manometric indicators which include the preset insufflation pressure, actual pressure, gas flow rate and volume of gas consumed.
13. Once pneumo-peritoneum is achieved extend skin incision smiling shape and 11 mm in size.
14. Hold 10mm port like a gun and insert it perpendicular to abdomen & tilt to 60-70 degree towards pelvis when there is loss of resistance.
15. Confirm intra-abdominal placement of primary port with escaping air sound and an audible click and take out trocar.
16. Set the flow rate at 6 liters/minute.
17. Connect gas tubing to the primary port.
18. Insert telescope and inspect entry point to exclude any bowel or vessels injury.
19. Request for Trendelenburg of 30 degrees position.
20. Camera cable should be at 6 o’clock and the light source should be at 12 o’clock.
21. Apply the baseball diamond shape principle for lateral port insertion.
22. If the uterus is less than 12 wks size primary port is kept at the inferior umbilical crease, if the uterus is 14 to 18 wks size then the primary port will be supra-umbilical if the uterus is 20 wks size primary port should be placed at the palmar point.
23. Transilluminate at the target organ, the uterus with fibroids.
24. Incise skin along Langer lines for secondary ports x 2.
25. Insert lateral ports (5mm x 2 at LIF and RIF) at position of snuff box which is about 8cm from umbilicus should be placed high and outside the epigastric vessels so that good access is provided in case of ipsilateral ports -5mm port in left iliac fossa 3cms above the anterior superior iliac spine, another 5 mm port above and medial to previous port in LIF 5 cms away
26. All ports should be inserted perpendicular to the abdomen.
27. Diagnostic laparoscopy should be done first.
28. Relation of fibroid with the uterus and fallopian tube should be carefully assessed after inserting the primary port and then secondary ports should be decided according to the baseball diamond concept.
Task analysis after Access:
Incision of the myometrium and exposure of the Myoma:
• Vasopressin 5ml of 1 in 100 dilutions injected at the stalk of the fibroid or considers preventive occlusion of the uterine artery.
• Now look for blebbing and pallor on fibroid due to vasopressin injected .this acts for 20-30 minutes.
• In case of an anterior myoma use oblique hysterotomy and in posterior myoma use sagittal hysterotomy.
• In the case of multiple fibroids, an incision is planned in such a way that maximum Myomas can be removed from one incision.
• The hysterotomy is direct up with the myoma with harmonic scalpel or low voltage monopolar current in cutting mode until the capsule of the myoma is visualized
Enucleation of myoma:
• With 2 graspers, cut edges are pulled so that the capsule is exposed and myoma screw is inserted.
• Now with myoma screw give gradual traction preferably anteromedial traction and counter traction with a blunt instrument like suction cannula and blunt dissection is done.
• Position of myoma screw is changed from time to time to apply traction on cleavage line until enucleation is done.
• The large feeding vessels at the base of the fibroid are cauterized with bipolar and cut with scissors or harmonic scalpel.
• Care is taken not to open the cavity.
• Undue use of cautery is avoided as it leads to defective healing and weak scar formation.
• Myoma after removal is placed in the cul-de-sac or para-colic gutters.
Hysterotomy suture:
• Reconstruction of myoma bed is done with no 1 Vicryl suture.
• The main aim of suturing is to obliterate the dead space to avoid hematoma formation.
• Extracorporeal knotting technique is preferred.
• Start from one angle first suture should be placed beyond the angle.
• The rest of the defect is closed.
• The last suture should be beyond the other angle.
• The serosal layer is closed with Dundee jamming continuous suturing with Aberdeen termination.
Extraction of myoma
• One of the ports is converted to 12mm and morcellator inserted.
• The myoma is held with a tenaculum and is fed to motorized morcellator.
• Take care not to move morcellator near the tissue instead of tissue to be fed to morcellator with a tenaculum.
• A meticulous lavage is given; hemostasis is checked and preceded for port closure.
• Port closure is done under vision with an outer sheath of Veress needle after slightly deflating the abdomen so that sutures are not in tension
• The last port to be closed is the telescope port, done after completely defeating the abdomen, and keeping the telescope in and removing the cannula followed by a telescope at last.
• The skin incision is closed with staplers and dressing done.
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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.
