Task Analysis of Laparoscopic Fallopian Tubal Recanalisation
DR.LAKSHMI SREE ATMURI [ MS OBGY, F.MAS, D.MAS]
TUBAL RECANALISATION:
Surgical approximation of tubal segment after tubal sterilization or excision of an occluded or diseased portion of the fallopian tube
INDICATIONS: Desire for fertility
REQUIREMENTS:
Normal semen analysis
Age more than 40yrs
Tubal sterilization previously by modified Pomeroy, fallopian rings, Filshie Clips
HSG to assess the length of the fallopian tube
CONTRAINDICATIONS:
Age more than 40 yrs
Decreased ovarian reserve
Ovarian failure
Extensive tubal damage
Tubal length less than 3cm
Severe male factor infertility
IMPORTANCE:
Respect to the delicate nature of the tissue
Minimum use of energy sources
Irrigate abdominal cavity with normal saline to minimum drying or adhesion
PROCEDURE:
- Patient in lithotomy position under general anesthesia
- Foleys catheterization
- Check veress needle for its spring action and patency
- Take 2allis forceps to evert and hold each side of umbilicus
- Use number 11 blade to place small horizontal stab wound on the inferior crease of umbilicus
- Mosquito artery to dissect subcutaneous adipose tissue and expose rectus sheath
- Measure abdominal wall thickness and add 4cm for distance to hold veress needle
- Veress needle should be held like a dart
- Lift suprapubic part of abdominal wall with the left hand
- Insert veress needle in stab incision with 45-degree elevation angle and distal end pointed towards anus and perpendicular to the abdominal wall
- The surgeon can hear 2 click sound and maintain the 45-degree angle
- Confirm correct veress needle placement by irrigation test, aspiration test, and hanging drop test
- Connect carbon dioxide gas tube to veress needle
- Check quadromanometry for intraperitoneal placement of veress needle
- Ideal preset pressure of 12mmhg, maximum of 15mmhg
- The flow rate of 1lit/min
- Check uniform distension of abdomen and obliteration of liver dullness
- Once pneumoperitoneum is achieved remove veress needle
- Take cannula of 10mm and mark its impression on the skin
- Extend incision to the size of cannula impression
- Introduce 10mm port by holding it like a piston, perpendicular to the abdomen
- Confirm intraabdominal placement of port by escaping air sound and audible click
- Take out trocar
- Set flow rate increased to 6lit/min
- Connect gas tubing to the primary port
- Insert telescope
- Inspect entry point to exclude any bowel or vessel injury
- Request for Trendelenburg of 30-degree position
- Perform diagnostic laparoscopy with special attention to tubes
- Insert uterine manipulator to aid ease of suturing fallopian tubes
- Secondary and tertiary port placement with help of baseball diamond principle
- Ipsilateral port placement may be desired
- Vasopressin 5IU diluted in 20ml normal saline is injected into mesosalpinx with help of aspiration needle
- Dissecting scissors in the dominant hand
- Maryland forceps on another hand
- Excise occluded area of the tube
- Freshen up the ends of the fallopian tube
- Minimize injury to mesosalpinx
- Preferred suture 4-0 vicryl cutting edge needle
- First Mesosalpinx is to be approximated, to prevent tension over the tube and also anastomosis becomes easy
- Surgeon knots to be applied
- Avoid torsion of tube
- Avoid catching tube directly with a grasper or any other instrument
- Seromuscular sutures are placed at 6, 10, 2* clock position on right fallopian tube
- Seromuscular sutures are placed at 6, 10, 2* clock position on left fallopian tube
- Patency of the tube can be checked
- stop insufflation
- remove all ports under the vision
- close port sites 10mm port with help of veress needle, or port closure devices
Elaborated Steps:
Position the patient in the supine position.
Administer general anesthesia.
Insert a urinary catheter to empty the bladder.
Preoperative antibiotics are administered.
Make a 10-12mm incision at the level of the umbilicus.
Use a Veress needle to insufflate CO2 into the abdomen.
Insert a 10mm trocar through the incision.
Insert a laparoscope through the trocar and visualize the abdominal cavity.
Identify the fallopian tubes and the site of previous sterilization.
Use a monopolar or bipolar electrosurgical device to make an incision at the site of previous sterilization.
Use a laparoscopic grasper to grasp the proximal end of the fallopian tube.
Use microscissors to make a small incision in the proximal end of the fallopian tube.
Repeat the same procedure for the distal end of the fallopian tube.
Use a microforceps to remove any scar tissue or sutures that may be present at the site of previous sterilization.
Use a guide wire to cannulate the proximal end of the fallopian tube.
Use a catheter or balloon catheter to dilate the proximal end of the fallopian tube.
Use a guide wire to cannulate the distal end of the fallopian tube.
Use a catheter or balloon catheter to dilate the distal end of the fallopian tube.
Use a 10-0 or 9-0 nylon suture to perform the anastomosis between the proximal and distal ends of the fallopian tube.
Use interrupted sutures to ensure a watertight closure.
Use a dye test to confirm patency of the anastomosis.
Inspect the pelvic organs and surrounding structures for any signs of bleeding.
Remove the laparoscope.
Remove the trocars.
Deflate the abdomen.
Close the incisions with sutures or staples.
Apply sterile dressing to the incisions.
The patient is awakened from anesthesia.
Extubate the endotracheal tube.
Move the patient to the post-anesthesia care unit.
Administer analgesics for pain management.
Monitor vital signs and urine output.
Check the dressing for bleeding or drainage.
Observe the patient for any signs of infection or complications.
Advise the patient to avoid strenuous activity for 2-4 weeks.
Advise the patient to avoid intercourse for 2-4 weeks.
Schedule a follow-up appointment.
Evaluate the patient's postoperative course.
Monitor for any complications, such as bleeding or infection.
Evaluate the patient's recovery of bowel and bladder function.
Adjust medication as needed.
Evaluate the healing of the incisions.
Provide the patient with a detailed report of the procedure and postoperative care.
Advise the patient on any potential complications or side effects of the procedure.
Provide the patient with instructions on follow-up appointments and monitoring.
Advise the patient on when to resume normal activities, such as driving, work, and exercise.
The patient follows up with the surgeon at regular intervals.
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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.
