Dr.Smita Batni
World Laparoscopy Hospital
FMAS & DMAS, November 2016
1. Surgical team: Gynaecologist as primary surgeon, Anaesthetist, Assistant, Scrub nurse2. Equipment needed:
a. Laparoscopic tower with insufflator, Light source, HD camera with 30 degree telescope, monitor and bipolar machine.
b. Ports: One 10mm reusable port with 5mm reducer, two 5mm ports
c. Suction and irrigation
d. Basic laparoscopic set with Maryland , atraumatic grasper, scissors, harmonic,bipolar.
e. Vicryl 0.0 and 3.0 round needle, size 11 blade and BP handle, 10mm syringe with normal saline and sterile dressing 3.
3. Method of anaesthesia: General Anaesthesia
4. Setting of the equipment
a. Pre-set pressures of the insufflator to 12 – 15mmHg
b. White balancing with white gauze and focusing at about 10cm range
5. Position of patient:
a. Supine position in Trendelenburg position.
6. Position of the surgical team and equipment:
a. Surgeon on the left, distance from the screen is 5 times diagonal length of the screen which is placed opposite and in front of the surgeon.
b. Assistant on the right of the surgeon.
c. Scrub nurse on the left of the surgeon.
d. Anaesthetist in the usual position on the head end.
7. Attainment of pneumoperitoneum and introduction of ports
a. Painting and draping done.
b. Surgeon is to hold the lateral eges of the umbilicus by two allis forceps and then make a stab wound with size 11 blade at the inferior crease of umbilicus.
c. Surgeon should check the spring action of veress needle as well as patency with normal saline in 10mm syringe.
d. Surgeon must grab the entire thickness of the midline infra-umbilical wall of abdomen and assess its thickness and then lift up this part.
e. Veress needle must be held like a dart with gaurding at 4 cm more than assessed thickness of anterior abdominal wall of the patient.It should be pointing towards anus, perpendicular to lifted abdominal wall and 45 degrees to the supra-umbilical abdominal wall.
f. Surgeon must advance the veress needle and feel 2 clicks (one on rectus sheath and one on peritoneum) or give-way sensation.
g. Surgeon then must carry out the injection/aspiration test and saline hanging drop test with a 10mm syringe with normal saline,this is to confirm correct positioning of veress needle.
h. After fully satisfied,the insufflator must be switched on and observe the quadro manometric parameters to monitor that the insufflator is confirming correct positioning of veress needle i.e.intraperitoneal.
i. Once pressure reaches the pre-set pressure, Surgeon must remove the veress needle and use size 11 blade to make a smiling skin incision on the infra umbilical crease, to fit a 10mm port. This can be pre-checked by placing a 10mm port on the skin for estimation of incision size.Using an artery forceps the tip should be inserted in this incision and then tip opened to successively dilate the urachus as per the scandinavian technique of primary port placement.
j. Surgeon must insert the 10mm canula with trocar by osccillatory screwing motion, direction being perpendicular till give way sensation is perceived and then change the direction towards the pelvis.Once in, then the trocar is to be removed and telescope inserted and confirm the intraperitoneal placement of this port,only then insufflator should be conneced to it and gas switched on.
k. To begin with an overview inspection of the entire abdomen must be done and duly noted.
l. Surgeon must then reach out to the target organ (fallopian tube of affected side), just about to touch it with tip of telescope, and trans-illuminate the anterior abdominal wall to delineate the site of the target.
m. Surgeon must then use the baseball diamond concept to mark the position of the additional 5 mm ports.
n. Surgeon must use trans illumination to avoid any vessel injuries in prospective port sites,after which use the size 11 blade to make small incisions to fit the 5mm ports at the pre-marked sites as per Baseball diamond concept.
o. Surgeon should insert both the 5mm ports under direct vision and using principles same as that used for primary port to avoid inadvertent visceral and vascular injuries.
8. Identification of fallopian tube with ectopic pregnancy in situ:
a. Surgeon should find the affected side fallopian tube by using grasper and a maryland as probes only.The contralateral tube must also be inspected to determine healthy or not.The affected side must be clearly visualized with ectopic complex in situ.
9. Mesosalpinx
a. With the help of the bipolar and scissors succesively, the meso-salpinx and meso-ovarian are coagulated and cut, while the left hand holds the fallopian tube with an atraumatic grasper.
b. While coagulating and cutting direction must be from lateral to medial and care must be taken to stay close to the tube and stop about 6 mm lateral to the tubo-cornual junction.
10. Insure haemostasis
a. After the tube is removed the area operated upon must be visualized for perfect haemostasis,if needed bipolar can be used to coagulate mesosalpinx.
11. Tissue retrieval-Removed fallopian tube with ectopic in situ
a. It can be delivered by grabbing the cut end with maryland forceps through 10mm port on the umbilicus, under vision with the 5mm telescope in the lateral port.
12. The two 5mm ports should be removed under direct vision and port sites must be inspected for bleeding if any.
13. The 10mm umbilical port fascia must be closed using a veress needle as a suture passer(Suture used is vicryl 0.0).Before tying the suture the port is to be removed together with the telescope and all gas let out.
14. The 10mm port is closed with subcutaneous vicryl 3.0 on a cutting needle.
15. The 5mm ports only skin is closed with vicryl 3.0.
16. Occlusive aseptic sterile dressing is applied on all 3 skin wounds.
17. Patient monitored till comes out of general anaesthesia and post op vitals and operative findings must be duly noted in patient case sheet.Tissue retrieved must be sent for histopathological examination and patient once stable must be shifted to post op care area for further management.Attendants must be informed of the same and counselled appropriately.
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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.
