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Task Analysis of Transabdominal Preperitonial Hernia Surgery

General Surgery / Sep 22nd, 2017 1:30 pm     A⁺ | a^-

DR. A. SUDHAN KUMAR
 

PRE OPERATIVE ASSESSMENT
 

1) assessment of type of hernia (direct or indirect), unilateral or bilateral, recurrent,complicated (features of obstruction)

2) comorbidites (DM/HTN/COPD/cardiac disease)

3) previous history of smoking, any previous surgery, weight lifting

4) pre anaesthetic evaluation

5) USG abdomen – to know type of hernia, defect size, BPH

 

POSITION OF PATIENT
 

 Trendelenberg position with head low by 15 – 30 Degree

 

ERGONOMICS:
 

1) Operating surgeon, target(hernia site) and the monitor should lie on coaxial arrangement

2)  The height of table should equals 0.49cm x surgeon’s height

3) The surgeon should stand on opposite site of the target (right side for left sided hernia, left side for right sided hernia)

4) Distance between surgeon and monitor should be 5 times the diagonal length of screen

5)check for insuffulators, energy sources, cable wires and  insulation of instruments 

 

PORT POSITIONING:

 

Based on the principles of BASEBALL DIAMOND CONCEPT

 

1) 10mm Optical port placed in  infraumbilical region  

2) two 5mm working ports placed according to baseball diamond concept

   

 Access to peritoneal cavity:
 

1) close technique: (through veress needle)
 

• incision at inferior crease of umbilicus using 11 no. blade.

• Check the patency of veress needle, spring action before insertion

• Hold veress needle like a dart

• Lift the abdominal wall and insert the Veress needle 45o angle to the spine and perpendicular to the lifted abdominal wall. It is guided towards the anal canal as there is hollow sacral curve to prevents injury to bowel and vessels

• Insertion is confirmed by two clicks

• Entry to abdominal cavity confirmed by irrigation,aspiration and hanging drop tests.
 

2) open technique:
 

• Incision at inferior crease of umbilicus 

• Scandinavian technique for safer entry to the intra-peritoneal space. 

• Blunt trocar inserted and secured with lateral stay sutures                                                                                    

 

CREATION OF PNEUMOPERITONEUM
 

1)Insufflation via Veress needle, using CO2

2)check for uniform distension of abdomen. Insuffalation continued until preset pressure reaches12-15mmHg,

3) remove veress

4) the infraumblical incision extended to 11mm.

5)insertion of cannula with trocar by screwing movement perpendicular in direction to abdominal cavity. Once peritoneum preached, turned to the desired site of target 

6)  The camera is white-balanced and then focused at a distance of the focal length

7) 10mm optical port inserted under direct vision

8) insertion of two 5mm working ports by baseball diamond concept

 

Procedural Steps

Diagnostic laparoscopy

Assessment of  hernia site, three ligaments (median, two medial and two lateral umbilical ligaments), triangle of doom, triangle of pain and trapezoid of disaster. 

1) Adhesiolysis in case of severe dense adhesions

2)peritoneal dissection should be started laterally about  6 cm from the outer margin of the hernia defect (right hernia – 2 o clock and left hernia – 10 o clock position)

3) dissection is from lateral to medial side and reach upto hernia site. Do not dissect over hernia sac to prevent injury. 

3) rise the flap upto medial umbilical ligament which is facilitated by the entry of CO2 into preperitoneal space and further medial dissection avoided to prevent injury to bladder . fibrous strands are cut.

4) using peanut, push the fat towards the anterior abdominal wall to prevent injury to vital structures 

5)medial pocket is made and cooper’s ligament (light house) is visualized. Lateral pocket is made and careful dissection should be carried over triangle of doom and triangle of pain. 

6)blunt dissection of sac is done by Maryland and push the cord structures away by giving backward traction and asking assistant tohold testis in scrotum. Pseudosac (condensation of transversalis fascia) to be differentiated from sac and to be separated.

 

Mesh Placement: 
 

1) polypropylene mesh – 10*15 cm mesh used

2) roll the mesh outside the abdomen and push it through 10mm port under vision using needle holder.

3) unroll the mesh. Place the mesh over myopectineal orifice of FRUCHAUD (inguinal,femoral,obturator area)

4) in bilateral hernia, single large mesh is placed covering both the defect 

 

FIXATION OF MESH. NO FIXATION MY BE BETTER THAN FIXATION
 

1) Using tacker or suture 

2) Fixed to cooper’s ligament in medial aspect and laterally fixed to rectus abdominis and anterior abdominal wall. Knotting is preferably done using intracorporeal surgeon’s knot.

4 COMMENTS

Dr. Christopher Alberto

#1

May 26th, 2020 8:57 am

This is a really informative Task Analysis of Transabdominal Preperitoneal Hernia Surgery. Everyone should know this necessary information of Transabdominal Preperitoneal Hernia. Sir Your Article has cleared up my head. I had many doubts before reading the step. Thank you so much for uploading.

Dr. Monaj Rawat

#2

May 26th, 2020 9:04 am

Very very impressive and useful educative step of Hernia surgery's Thanks for posting this Task Analysis of Transabdominal Preperitoneal Hernia Surgery.

Dr Vikash kumar

#3

May 26th, 2020 9:19 am

Great Article! It particularly inspired me because I also want to know step of hernia surgery. Sir your classes are very informative and helpful. Thanks for uploading this Task Analysis of Transabdominal Preperitoneal Hernia Surgery.

Dr Nitish Kumar Yadav

#4

May 26th, 2020 10:51 am

This Article is amazing, Thanks for showing this Task Analysis of Transabdominal Preperitoneal Hernia Surgery. Dr Mishra thank you for teaching suitable techniques use in Laparoscopy surgery in very easy way. Really very helpful.

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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.