By Dr WAEL ABU SIAM
1. Place patient in dorsal lithotomy position
2. Reverse Trendelenburg to about 30 degree
3. Camera—insert port one third from the umbilicus to xiphoid just left of midline
4. Examine abdomen—search for abnormal pathology, injuries from port placement
5. Surgeon’s left hand—insert port at right subcostal margin, midaxillary line
6. Surgeon’s right hand—insert port at left subcostal, midaxillary line
7. Assistant retractor—insert port at left anterior axillary line, level of umbilicus
8. Liver retractor—insert port at subxiphoid or at right anterio axillary line at level of umbilicus
9. Visualize insertion of trocars
10. Retract left lobe of liver anteriorly and toward the patient’s right Assistant retract stomach towards left foot
11. Distract gastrohepatic ligament on tension
12. Incise gastrohepatic ligament(cautery or harmonic)
13. Identify right crus
14. Dissect right crus from esophagus
15. Assistant retract stomach caudally and posteriorly
16. Dissect anterior aspect of esophagus from crus
17. Identify/protect anterior vagus nerve
18. Assistant retract stomach caudally and to the right
19. Identify left crus
20. Dissect left crus from esophagus
21. Dissect posteriorly down left crus toward crural decussation
22. Dissect fundus from left crus
23. Assistant regrasp near gastroesophageal junction and retract anteriorly and to the left
24. Complete dissection of right crus down to inferior crural decussation Identify/protect posterior vagal nerve
25. Develop posterior esophageal window
26. Pass penrose drain through created window to use as retractor
27. Secure both penrose tails together with suture
28. Assistant retract esophagus with penrose anteriorly and to the left Complete posterior window and left and right crural
dissection
29. Dissect into mediastinum around esophagus to obtain a minimum of 2 cm intra-abdominal length
30. Develop 2nd window posterior to esophagus
31. Pass a 2nd penrose through this new window
32. Secure both tails of 2nd penrose together with suture and remove 1st penrose
33. Place multiple figure of 8 sutures to close crura
34. Place most inferior suture first and proceed anteriorly
35. Complete all sutures now or add last suture after creation of fundoplication
36. Suspend gastrosplenic omentum between assistant’s retractor and surgeon’s left hand
37. Pick a point 1/3 down the greater curve to incise gastrosplenic omentum
38. Sequentially ligate short gastric arteries moving towards gastroesophageal junction
39. Dissect any posterior fundic gastric attachments
40. Complete dissection of any remaining gastric attachments to crus or diaphragm
41. Retract greater curve of stomach anteriorly towards liver
42. Measure 6 cm along greater curvature from GE junction and 2 cm from the edge of the curvature down the posterior fundic
wall
43. Mark this location with a loosely tied 3-0 silk suture
44. Pass suture and posterior fundic wall of stomach through posterior esophageal window
45. Grasp anterior fundic wall of stomach and drag anteriorly towards patient’s right
46. Kissing/shoeshine maneuver to orient fundoplication into final position—fundic edges meet on right side without twisting and
with short gastric in natural position
47. Relax penrose retraction of GE junction
48. Pass 60 French bougie
49. Re confirm configuration of wrap
50. Insert first suture into abdominal cavity—a double armed, pledgeted suture
51. first suture (1st needle) through anterior fundus then esophagus at 11 o’clock then posterior fundus
52. Pass 2nd arm of 1st suture as above
53. Place 2nd pledget and tie
54. Pass 2nd suture through anterior fundus then posterior fundus cranial to 1st suture
55. Pass 3rd suture through anterior fundus then posterior fundus caudal to 1st suture
56. Remove bougie
57. Examine crural closure, insert final suture to a gap of approximately 5mm(one instrument pass)
58. Remove penrose retractor
59. Pass nasogastric tube
60. Remove ports under direct visualization and close ports sites
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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.
