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Task Analysis Salpingoophorectomy And Oophoropexy of Torsion Of Ovary

Gynecology / Dec 23rd, 2019 3:45 pm     A⁺ | a^-

Dr. Indra Gazali Syamsuddin
Specialist Obstetrician Gynaecologist. F.MAS. D.MAS. F.ART. FICRS. INDONESIA
 

INTRODUCTION

 

Ovarian torsion is the twisting of the ovary on its vascular support is the fifth most common gynecologic surgical emergency.1 The condition is more common in premenarcheal females (children or premenarcheal adolescents) constitute up to 15–50 % of adnexal torsion cases.2 The association of an ovarian cyst is a common finding in twisted ovaries, the size of the cyst is usually moderate (i.e. around 5 cm).3.4.5.6  Diagnosis is basically clinical, however, pelvic imaging, primarily by transvaginal ultrasound (TVUS) and Doppler evaluation of ovarian blood flow, confirms the diagnosis and excludes similar conditions.7,8

The gold standard to treat ovary torsion is surgery (laparoscopy and laparotomy.9 An ovarian cystectomy is often performed for a benign ovarian mass. If malignancy is highly suspected, a salpingo-oophorectomy is needed. According to many observational studies, detorsion is associated with preserved ovarian function. 10,11,12,13 

The risk of recurrence after detorsion, but the incidence and causes are unknown. 14,15,16,17 One method is suppression of ovarian cysts by oral contraceptives.18,19 Another method is an oophoropexy by plication of uteroovarian ligament 20,21

 

PRE-OPERATIVE PREPARATION:

 

1. Patient to be under General anesthetized

2. Patient return plate should be attached to the thigh.

3. Abdomen and perineum to be painted and draped

4. The surgeon has to be on the patient’s left side, an assistant on the right side and 2nd assistant if needed in between patients legs for uterine manipulation

5. Monitor to be placed 15 degrees below the visual axis of the surgeon on the opposite side. 

6. All the equipment placed on the opposite side of the surgeon

7. Camera, light source, insufflator, and electrosurgical unit to be plugged into their respective equipment and all cables tied over upper drape using a gauze and towel clip.

8. Telescope with a camera attached to the light source.

9. Laparoscopic mode to be “on “on the camera cable attachment instrument

10. White balancing and focussing of camera done by placing the camera at a focal length of 10cm from gauze piece.

OPERATIVE STEPS PROPER:

PNEUMOPERITONEUM

1. Over inferior crease of the umbilicus, place 2 Allis tissue holding forceps on either side and give 2mm stab incision with No.11 blade.

2. Dilate rectus muscle until rectus sheath with mosquito forceps 

3. Check Veress Needle of 12 cm for its spring action and patency

4. Lift up the abdominal wall at the umbilicus and assess its full thickness,

5. Veress Needle is held like a dart the thickness of the abdominal wall from its distal end.

6. Insertion of veress needle through the incision site in a manner that the veress needle makes an angle of 90’ with the abdominal wall and an angle of 45’ with the body of the patient, pointing towards the anus.

7. Insertion is achieved with two audible clicks; first of the Rectus Sheath and second of the

Peritoneum

8. Release the Allis forceps from the Abdominal wall

9. Hold the Veress Needle at an angle of 45’ making sure that no further length of the needle is advanced.

10. Confirm the intraperitoneal placement of the veress needle by aspiration test, irrigation test and hanging drop test.

11. Ensure that the Gas tubing is attached to the Insufflator and the Insufflator is switched ON. This will remove air from the Gas tubing and fill the gas tubing till its tip with CO2 gas.

12. Confirm Pre-Set Pressure to 15mmHg on the Insufflator and Attach the gas tubing to the veress needle and start the flow of CO2 gas at 1 liter per minute

13. Confirm obliteration of liver dullness and generalized distension of abdominal wall

14. Keep watch on patient’s vital parameters and EtCO2 readings during insufflation.

15. The total amount of gas and actual pressure should rise in a linear fashion.

16. When actual pressure has reached pre-set pressure and amount of gas used might vary between 1.5 to 6 liters for an averagely build young patient

17. Once the pressure reaches the pre-set pressure, remove the veress needle and use size 11 blade to make skin incision to fit a 10mm port. This can be prechecked by placing a 10mm port on the skin for estimation of incision size

 

PORT PLACEMENT

 

1. Insert the 10mm cannula with trocar by oscillatory screwing motion, the direction being

perpendicular till give way sensation is perceived and then change the direction towards the pelvis. Once you are in, the trocar should be removed and the telescope should be inserted to confirm the intraperitoneal placement

2. Connect the insufflator to the optical port and switch on the gas.

3. To begin with, an overview inspection of the entire abdomen must be done and noted.

4. Then reach out to the target organ (ovary of affected side), just about to touch it with the tip of the telescope, and trans-illuminate the anterior abdominal wall to delineate the site of the target.

5. Use the baseball diamond concept to mark the position of the additional 5 mm ports.

6. Make 15 to 30 degree Trendelenburg tilt aids in moving the bowel to the upper abdomen.

7. The surgeon must use transillumination to avoid any vessel injuries in prospective port sites. Use the size 11 blade to make small incisions to fit the 5mm ports at the pre-marked sites as per Baseball diamond concept.

8. Based on the baseball diamond concept, 2 ipsilateral 5mm secondary ports made. 1stport is 7.5cm from primary port and 2ndport, 7.5cm from 1stport along the 18 cm arc.

9. Insert both the 5mm ports under direct vision and using principles same as that used for the primary port to avoid inadvertent visceral and vascular injuries.

10. These ports have to be placed such that the manipulation angle is 60degrees, elevation angle is 30 degrees and azimuth angle from 30 degrees to a maximum of 60 degrees as they are ipsilateral ports

 

 

SURGICAL STEPS:

 

SALPINGOOOPHORECTOMY

 

1. The uterine manipulator can be used to lift up the uterus for proper visualization.

2. Grasp the ovary which has undergone torsion with an atraumatic grasper and with tritome puncture the cyst and aspire the contents.

3. Undo the torsion with the help of 2 graspers and wait for 3-5 minutes for the blood supply to return.

4. If the ovarian tissue has become gangrenous and has to be removed and so proceed with salpingooopharectomy with coagulate and cut infundibulo pelvicum ligament

5. Coagulate and cut ovarian ligament mesovarium, fallopian tube

6. Coagulate and cut mesosalpinx 3cm lateral to the uterus

 

OOPHOROPEXY

 

1. Oophoropexy  by suturing continues  and tightening the proximal to the distal end of the ovarii proprium ligament to prevent further torsion in the future

2. Take it out the cyst with endobag / take it out to the posterior fornix posterior wall vaginal with colpotomy 

3. Clean the peritoneal cavity with suction irrigation.

4. Keep watch on ETCO2 level during surgery

5. Deflate the abdomen, remove the ancillary port under the vision and the primary port removed along with trocar.

6. Close 10mm port with veress needle or port closure after desuffation

7. Extubate patient and shift patient to recovery room

Elaboration of 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 ovary and fallopian tube.

Assess the degree of torsion of the ovary.

If the ovary is viable, perform an oophoropexy by suturing the ovary to the surrounding tissue.

If the ovary is non-viable or the torsion is severe, perform a salpingoophorectomy by ligating the ovarian vessels and removing the ovary and fallopian tube.

Use a monopolar or bipolar electrosurgical device to coagulate the ovarian vessels.

Use a laparoscopic grasper to clamp and divide the ovarian vessels.

Remove the ovary and fallopian tube.

Use a laparoscopic grasper to retract the uterus.

Inspect the surgical site for any bleeding or hematomas.

Close the peritoneum with sutures.

Deflate the abdomen and remove the trocars.

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 lifting heavy objects 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.

The surgeon evaluates the patient's healing and progress at each follow-up appointment.

The surgeon orders any necessary imaging or laboratory tests to evaluate progress.

The surgeon adjusts medications or treatment as needed.

The surgeon monitors the patient for any signs of complications or side effects.

The surgeon communicates with the patient's primary care physician to ensure continuity of care.

The surgeon provides the patient with information on any further treatment or follow-up care.

The patient continues to follow the surgeon's instructions and attend regular follow-up appointments.

 

REFERENCE:
 

1. Balci O, Icen MS, Mahmoud AS, Capar M, Colakoglu MC (2010) Management and outcomes of adnexal torsion: a 5-year experience. Arch Gynecol Obstet 284(3):643–646. doi: 10.1007/s00404-010-1702-zPubMedCrossRefGoogle Scholar

2. Pansky M, Abargil A, Dreazen E, Golan A, Bukovsky I, Herman A (2000) Conservative management of adnexal torsion in premenarchal girls. J Am Assoc Gynecol Laparosc 7(1):121–124PubMedCrossRefGoogle Scholar

3. D.W. Swenson, A.P. Lourenco, F.L. Beaudoin, D.J. Grand, A.G. Killelea, A.J. McGregorOvarian torsion: case–control study comparing the sensitivity and specificity of ultrasonography and computed tomography for diagnosis in the emergency department Eur J Radiol, 83 (4) (2014), pp. 733-738

4. Varras M, Tsikini A, Polyzos D, Samara CH, Hadjopoulos G, Akrivis CH, et al. Uterine adnexal torsion: Pathologic and gray-scale ultrasonographic findings. Clin Exp Obstet Gynecol 2004;31:34-8.  

5. Pansky M, Smorgick N, Herman A, Schneider D, Halperin R. Torsion of normal adnexa in postmenarchal women and risk of recurrence. Obstet Gynecol 2007;109:355-9

6. Houry D, Abbott JT. Ovarian torsion: A fifteen-year review. Ann Emerg Med 2001;38:156-9.

7. Pansky M, Smorgick N, Herman A, Schneider D, Halperin R. Torsion of normal adnexa in postmenarchal women and risk of recurrence. Obstetrics & Gynecology. 2007;109(2, Part 1):355–9.

8. C. Huchon, A. FauconnierAdnexal torsion: a literature review Eur J Obstetr Gynecol Reprod Biol, 150 (1) (2010), pp. 8-12

9. Hubner N, Langer JC, Kives S, Allen LM. Evolution in the management of pediatric and adolescent ovarian torsion as a result of quality improvement measures. J Pediatr Adolesc Gynecol 2017;30:132-37.

10. Arkins G. Ovarian torsion treated with untwisting: Second look 36 hours after untwisting. J Minim Invasive Gynecol 2007;14:270.

11. Mashiach S, Bider D, Moran O, Goldenberg M, Ben-Rafael Z. Adnexal torsion of hyperstimulated ovaries in pregnancies after gonadotropin therapy. Fertil Steril 1990;53:76-80

12. Bider D, Mashiach S, Dulitzky M, Kokia E, Lipitz S, Ben-Rafael Z, et al. Clinical, surgical and pathologic findings of adnexal torsion in pregnant and nonpregnant women. Surg Gynecol Obstet 1991;173:363-6.

13. Oelsner G, Bider D, Goldenberg M, Admon D, Mashiach S. Long-term follow-up of the twisted ischemic adnexa managed by detorsion. Fertil Steril 1993;60:976-9

14. Germain M, Rarick T, Robins E. Management of intermittent ovarian torsion by laparoscopic oophoropexy. Obstet Gynecol 1996;88:715-7.

15. Crouch NS, Gyampoh B, Cutner AS, Creighton SM. Ovarian torsion: To pex or not to pex? Case report and review of the literature. J Pediatr Adolesc Gynecol 2003;16:381-4.

16. Ozcan C, Celik A, Ozok G, Erdener A, Balik E. Adnexal torsion in children may have a catastrophic sequel: Asynchronous bilateral torsion. J Pediatr Surg 2002;37:1617-20

17. Grunewald B, Keating J, Brown S. Asynchronous ovarian torsion – The case for prophylactic oophoropexy. Postgrad Med J 1993;69:318-9.

18. Functional ovarian cysts and oral contraceptives. negative association confirmed surgically. A cooperative study. JAMA 1974;228:68-9.

19. Grimes DA, Godwin AJ, Rubin A, Smith JA, Lacarra M. Ovulation and follicular development associated with three low-dose oral contraceptives: A randomized controlled trial. Obstet Gynecol 1994;83:29-34

20. Kaleli B, Aktan E, Gezer S, Kirkali G. Reperfusion injury after detorsion of unilateral ovarian torsion in rabbits. Eur J Obstet Gynecol Reprod Biol 2003;110:99-101

21. Fuchs N, Smorgick N, Tovbin Y, Ben Ami I, Maymon R, Halperin R, Pansky M. Oophoropexy to prevent adnexal torsion: how, when and for whom? J Minim Invasive Gynecol 2010;17:205–8.

5 COMMENTS

Dr. Madhu

#1

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Dr. Srikant Rai

#2

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Dr. Samvedna Singh

#3

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Dr. Hemant Shahi

#4

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#5

Apr 29th, 2021 4:06 am

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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.