DM WIMS , MEPPADI WAYANAD.
Task analysis for laparoscopic appendicectomy
A) Surgical team:
1) Surgeon 2) Anaesthetist 3)camera person 4)Scrub nurse
B) Instruments required
1. Laparoscopic tower with insufflator, Light source, HD camera with 30 degree telescope, bipolar machine, unipolar machine
2. Ports: One 10mm reusable port with 5mm reducer, two 5mm ports
3. Suction and irrigation
4. Basic laparoscopic appendectomy set with Marilyn, semi-atraumatic graspers, hook, scissors, harmonic,.
5 endo loop , size 11 blade, 10mm syringe and skin staples
C) Method of anaesthesia: General Anaesthesia
D) Setting of the equipment
1. Pre-set pressures of the insufflator to 12–15mmHg
2. White balancing with white gauze and focusing at about 10cm range
E). Position of patient:
1. Supine position in Trendelenburg position and 15 degree tilt to the left
F. Position of the surgical team and equipment:
1. Surgeon on the left, in line with target (appendix) and monitor, 5 times diagonal length of the screen
2..Assistant on the right of the surgeon
3. Sister on the left of the surgeon
4. Anaesthetist on the usual position, cephalad
G). Attainment of pneumoperitoneum and introduction of ports
1. Surgeon makes a stab wound with size 11 blade at the inferior crease of umbilicus
2. Surgeon check the spring of veress needle as well as patency with saline in 10mm syringe
3. Surgeon grab entire thickness of the infra-umbilical midline wall of abdomen
4. Veress needle pointing towards anus, perpendicular to entry point and 45 degrees to the supra-umbilical abdominal wall
5.. Surgeon advances the veress needle and feels 2 clicks (one on rectus sheath and one on peritoneum
6.. Surgeon carry out the injection/aspiration test and saline drop test with a 10mm syringe with saline, to confirm correct positioning of veress needle
7. Switch on the insufflator and monitor that the insufflator is confirming correct positioning of veress needle
8. Once pressure reached pre-set pressure, Surgeon uses size 11 blade to make a smiley skin incision in the infra umbilical crease, to fit a 10mm port. This can be pre-checked by placing a 10mm port for estimation of incision.
9. Surgeon insert the telescope and inspect the entire abdomen
10. Surgeon reach out to the target organ (appendix), just about to touch it with tip of telescope, and trans-illuminate the anterior abdominal wall to delineate the site of the target.
11. Surgeon uses baseball diamond concept to mark the position of the additional 5 mm ports
12. Surgeon uses the 11mm blade to make small incisions to fit the 5mm ports at the pre-marked sites as per Baseball diamond concept.
13. Surgeon inserts the 5mm ports under direct vision
H. Identification of Appendix:
. Surgeon finds the caecum and follow tinea coli to the base of appendix
I. Mesoappendix
1. With the help of the harmonic, making sure that the silicon jaw is towards important structures like bowel, the meso-appendix is coagulated and cut, while the left hand holds the appendix with atraumatic grasper
2. The meso-appendix is coagulated and cut up until the base of the appendix
J. Appendicectomy
1. with endoloop and delivered into the abdomen through the 5mm port.
2. The appendix is delivered into the loop and the loop tightened at the base of the appendix with a knot pusher
3. With the help of the harmonic, the appendix is sealed at about 0.5mm above the knot. There is no need for a second suture
K. Delivery of the appendix
1. A simple appendix can be delivered by grabbing the cut end with ovum forceps through 1mm port on the umbilical, under vision with the 5mm telescope
2. An inflamed, swollen, infected appendix can be delivered through the 10mm port in the umbilicus
L. Lavage of the abdomen: Eespecially in cases of complicated appendix is done, with 3 to 6L of saline needed in ruptured appendix
M. Placement of Drain in cases of ruptured appendix, by placing naso gastric tube through a separate stab incision on the right iliac fossa
N. Port Closure: The 10mm umbilical port facia is closed using a veress needle as a suture passer.
O. Removal of Port: The two 5mm ports are removed under direct vision. The 10mm port is removed together with telescope
Q. Port wound closure: The 10mm port wound closed with staples
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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.
