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Task Analysis of Laparoscopic Pectopexy for Prolapse Uterus

Gynecology / Oct 30th, 2019 5:17 am     A⁺ | a^-

Dr. ELAVARASI.E DGO, DNB ( D.MAS OCT 2019)
 

INTRODUCTION:
 

1. Laparoscopy is the gold standard for the management of uterine prolapse except for procidentia. 

2. Laparoscopically we can correct uterine prolapse by either sacrohysteropexy or pectopexy. Both methods are equally  good. 

3. In young women who have not completed the family, laparoscopic sacrohysteropexy is better. 

4. Laparoscopic pectopexy is preferred especially in obese women because of the difficulty in assessing the sacral promontory. 

5. Pregnant women who have undergone laparoscopic pectopexy or sacrohysteropexy earlier should be delivered only by elective cesarean section. 

6. During cesarean, care should be taken to avoid the mesh and the incision on the uterus should be above the level of mesh.

 

PRE OP EVALUATION:
 

1. Proper history taking and clinical examination of the patient

2. Routine investigations and additional investigations based on comorbidities

3. Urodynamic study with MRI contrast lateral view

4. Anesthetic fitness 

5. Informed Consent

 

 INSTRUMENTS NEEDED:
 

1. 11 no. scalpel

2. Veress needle

3. Two 10 mm and one 5 mm port

4. 10 mm telescope

5. Harmonic 

6. Atraumatic grasper

7..Maryland

8. Needle holder 

9. Dacron ( Ethibond) or silk 1 no suture

10. Scissors

11.Uterine manipulator

12.T shaped mesh ( ultra-fine polypropylene or vypro mesh)

 

13. Tackers

14. Staplers

 

PROCEDURE OF PECTOPEXY:
 

1. UV fold of peritoneum is opened up to the deep ring on either side. 

2. The vertical limb of  the T shaped mesh is attached to the cervix

3. Both the horizontal limbs are attached to the Cooper’s ligament on the respective side

4. UV fold of peritoneum closed. 

5. The mesh should not be too tight so that once fibrosis develops and mesh shrinks, it will give needed support and keeps the uterus anteverted.

 

COMPLICATIONS OF SURGERY:
 

1. Vaginal mesh extrusion/ visible mesh

2. Vaginal pain/ painful intercourse

3. Mesh erosion of bladder or rectum

4. Infection/abscess of mesh

 

PREOPERATIVE CHECKLIST - confirmed

 

PATIENT POSITION- :
 

30-degree Trendelenburg, 

Lithotomy 

Bladder catheterised

 

SURGICAL TEAM:
 

The Surgeon on the left, 

1 st Assistant on  the right

2nd  Assistant between the legs for uterine manipulation

Anesthetist  on the head end

Scrub nurse as usual

 

PORT- 3 port technique, 

Either Contralateral or Ipsilateral

 

SURGICAL STEPS PROPER:
 

1. After successful pneumoperitoneum with veress, an 11mm smiling incision is made in the inferior crease of the umbilicus using no.11scalpel.

2. Use mosquito forceps to dilate the obliterated Vitello intestinal duct (Scandinavian technique).

3. Insert the 10 mm cannula with trocar  with guarded screwing movement, perpendicular to the abdominal wall till give away sensation is perceived.

4. Remove the trocar and push the cannula in.

5. Introduce the 30-degree telescope in after white balancing and focussing at 10 cm distance and visualise the area directly under the port for presence of any bleeding or injury.

6. Transilluminate the abdominal wall and insert one 10 mm port on the left and one 5mm port on the right under vision by the Baseball Diamond concept. You can also use the ipsilateral port with a 7.5 cm distance in between.

7. Do a complete examination of the abdomen and pelvis and push the bowel above the sacral promontory.

8. Introduce the uterine manipulator carefully under vision and keep the uterus retroverted at 6o’ clock position.

9. Lift and stretch the utero vesical fold of peritoneum in the midline with an atraumatic grasper and dissect the uv fold of peritoneum on the right side up to the deep inguinal ring with harmonic or scissors.

10. Gently dissect the space between the medial umbilical ligament and deep ring and reflect the medial umbilical ligament medially. Care should be taken not to cut the medial umbilical ligament or the peritoneum medial to the medial umbilical ligament to avoid bladder injury.

11. Repeat the same steps on the left side to identify the cooper’s ligament on the left side. 

12. Bladder dissection is done adequately by holding the bladder with atraumatic forceps and gently dissecting and pushing the bladder down by blunt dissection and harmonic wherever necessary. 

13. Fold the T shaped mesh and hold the tip with a grasper and introduce it through the 10 mm port.

14. Spread the mesh in such a way the vertical limb of T lie over the cervix

15. Make an Endoski needle with 20 cm Dacron or silk and introduce it through the 10 mm port. 

16. Take 3 rows of intracorporeal surgeon’s knot on either side of cervix fixing the vertical limb of mesh firmly over the cervix.

17. Take a transverse bite on the right Cooper’s ligament and a bite on the right end of the horizontal limb of mesh and tie intracorporeal surgeon’s knot.

18. Take a bite on the left side horizontal limb of mesh and a transverse bite on left Cooper’s ligament and tie intracorporeal surgeon’s knot.

19. You can alternatively fire tacker and fix the mesh on both the cooper’s ligament. But tacker should not be fired on the cervix and vagina. In the case of using vypro mesh, tackers do not hold well and sutures should be taken.

20. Close the utero vesical fold of peritoneum by continuous intracorporeal suturing. You can also use Dundee jamming knot with Aberdeen termination. Care should be taken not to include the mesh while suturing the peritoneum.

21. Desufflation of abdomen done

22. Ports are withdrawn under direct visualisation and optical cannula is withdrawn by sliding over the telescope

23. Skin incisions are either sutured or stapled.

4 COMMENTS

Dr. Sanjive Kumar

#1

May 21st, 2020 3:12 am

My words are less to describe this article. This is a very informative article. Thanks for providing great information about Laparoscopic Pectopexy for Prolapse Uterus.

Dr. Minakshi Jain

#2

May 22nd, 2020 4:42 am

Thank you so much,This article is well organized and presented, which helped me to learn new knowledge, brilliant and detailed explanation step by step of Task Analysis of Laparoscopic Pectopexy for Prolapse Uterus.

Dr. Mamta Kulkarni

#3

Apr 28th, 2021 11:20 am

Thank you so very much for providing this task analysis to all of us! It is super! Thanks for sharing Task Analysis of Laparoscopic Pectopexy for Prolapse Uterus

Dr. Sujata Sen

#4

Apr 28th, 2021 11:45 am

I am really happy to say it’s an interesting post to read. I learn new information from your article, you are doing a great job. Thanks for sharing this educative post of Laparoscopic Pectopexy for Prolapse Uterus

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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.