TASK ANALYSIS OF TUBAL LIGATION

DR. ADIL SIEDAHMED IBRAHIM
SMSB clinical MD
ABHA MATERNITY & CHILDREN HOSPITAL
K.S.A

1. Before starting the operation, everything in the check list of the OT should be checked, the  patient should be prepared by not having  solid food for 24 hrs before the operation and given laxative the day before operation ,consent has  been taken.
 2. Operation team, surgeon ,assistant, scrub nurse, anaesthetist.
 3. Equipment needed
 •  Laparoscopic drapes, insufflators, Light source, HD camera with 30-degree telescope (10mm), seven parameter monitor, LCD monitor
 •  Veress needle 12 cm with 10 ml N/S syringe, and 10 ml xylocaine 2% for sub cut injection before doing skin in scion.
 •  One 10 mm port and one 5 mm port
 •  11 number scalpel
 •  Fallope ring applicator preparation and the rings should be ready with the ring pusher. load the ring by ring pusher not more than 10 minute before the application.
 4. Preparation of the patient;
 5. GA or LA, this depends on the anesthetist  decision, sometime epidural could be given, if it is available.
 6. Follys catheter insertion; size 14 or more and sometime ask the patient to void before the operation: to me prefer to insert a catheter.
 7. Put the patient in supine position.
 8. Tilt the patient 15-degree head down.
 9. Quadrimanometric device ready, the preset pressure should not be more than 12 mm and the gas flow rate is 1L/min.
 10. Position of the surgical team: surgeon on the left side of the patient and in coaxial alignment with the target organ (the tubes) and the monitor at a distant about 5*diameter of the monitor & the table height 4.9*surgeon height.
 11. The patient is anaesthetized and muscle relaxant is given.
 12. Disinfect the abdomen from the the  nipple till the pubic symphysis  line  and to the level of  anterior iliac spines laterally.
 13. Xylocine 10 mm is subcutaneously infiltrated  around the umbilicus .
  18. By the use of 11 mm blade, 2 mm incision at the lower umbilical skin crease
 19. Verres needle is checked for valve action and patency by n/s irrigation.
 20. Hold it like a dart and skin thickness is elicited by holding it at the level of umbilicus and add to it 4 cm for needle tenting, needle should be  perpendicular to the abdominal wall and directed toward anus, left hand should hold the lower abdominal  to make it 45 degree toward  patient body.
 21. Two clicks is heard at this time, the rectus & peritoneum entry, then check by irrigation, suction test, hanging drop test.
 22. The insufflator is switched on and connect ed to the veress needle and close the needle valve.
 23. Check the flow rate and the actual pressure at this time, the flow rate not more than 1.5 L/min, the actual pressure increasing gradually, and not exceed preset pressure.
 23. When the actual pressure become equal to the preset pressure, take out the needle, and do 10 mm smiling incision in the lower umbilical crease.
 24. Insert some mosquito forceps to the incision to dilate the vitellointestiinal duct and separate the recti muscles.
 25. Insertion of 10 mm umbilical port by holding it like a pistol & the index finger pointed forward to the half of the tracar shaft to minimize injury incidence, by screwing movement directed toward anus .one click is to be header and whooshing sound and free movement of trocar indicating right position.
 26. Connect the insufflator and close the valve for continuous pneumoperitoneum.
 27. White balancing by dipping the telescope to iodine gauze then cleaning and fix at 10 cm distance from the white gauze.
 28. Insert the10 mm 30-degree telescope and take a panoramic view and check the port pathway and abdomen that there's no injury had   occurred.
 29. 5 mm port is inserted under direct vision in the left iliac fossa 7.5 mm lateral to the umbilicus according to baseball theory at the 18 arc.
 30. Do diagnostic laparoscopy for the abdomen and pelvis in a clock wise fashion in, trendelenberg position starting from the caecum, ascending colon, paracolic gutter, hepatic flexure. Then in reverse trendelenburg position inspects right lobe of liver, gall bladder. transverse colon, left lobe of liver, stomach, spleen, splenic flexure, descending colon, sigmoid colon, uterus, bladder, ovaries, tubes and Douglas pouch, if there's any pathology, we can take a biopsy but no intervention as far there's no consent was taken for therapeutic intervention.
 31.The fallope ring applicator with already inserted ring note more than 10 m beforehand, is inserted through the 5 mm port under the vision of the telescope.
 32.Going behind the uterus, lift it up, then a loop of tube will become clear.
 33. Open the jaws of the applicator and 2 cm lateral to the uterus, take a bite, apply the ring for 5 seconds then release and check ring placement.
 34. The same would be done to the other tube.
 35. Take out the applicator from the abdomen.
 36. Check that everything and rings placed correctly before deciding to take out the trocar.
 37. Take a 5 mm telescope after white balancing and fixation before insertion through the 5mm port.
 38. Prepare the veress needle and make a loop of thread (proline)to use it for closure of the 10 mm port to prevent future hernia.
 39. Close the umbilical 10 mm port under direct vision by no.1 vicryl.
 40. Deflate the abdomen gradually making jerky movement by the 5 mm telescope to avoid intestinal entrapment to the port       
 41. Put a surgical dressing on the port sites.
 42. Documentation is required