MBBS, SBOG,MD
KSA. AL Madinah
Definition:-
Ectopic pregnancy defined as implantation of pregnancy outside the uterine cavity
Risk Factor for Ectopic Pregnancy
- Previous PID – chlamydia infection
- Previous ectopic pregnancy
- Tubal ligation
- Previous tubal surgery
- Intrauterine device
- Prolonged infertility
- Diethylstilbestrol (DES) exposure in-utero
- Multiple sexual partners
1. Conservative
2. Medical treatment by methotrexate
3. Surgical management by Laparoscopy or laparotomy if patient unstable.
Preoperative preparations:
1. Blood investigations and Pre-anesthetic check up
2. X-match
3. Informed consent
4. Preop.antibiotics.
5. Surgical team: Surgeon, Anesthetist, Assistant, Scrub nurse
Equipment and Laparoscopy Tower:
1. Monitor (Desirable 26” HD
2. Light Source and Camera Control Unit (Desirable – LED light source and 3 Chip HD Camera)
3. Insufflator and CO2 Gas Cylinder
4. Electro Surgical Unit (Desirable – High Frequency Generator)
5. Select Pre-set Pressure (Ideal 12 to 15mmHg)
6. Video Recorder & Printer
7. Suction Irrigation system
8. Veress' needle – 12 cm length
9. Ports: One 10mm reusable port with 5mm reducer, two 5mm ports
laparoscopic set :
. Maryland.
. Laparoscopy Aspiration Needle
. Laparoscopic scissors
. A traumatic grasping forceps
. Tissue Dissection forceps
. artery forceps
. Suction Irrigation tubing
. Set of Allis forceps
. Surgical Blade No 11
. Syringe and Normal Saline (10ml)
. No 20 G “spinal Needle or laparoscopic needle.
. Vasopressin 5 unit diluted in 20 ml of saline.
. Monopolar hook.
. Sterile dressing 3
Position of patient:
. Supine position in Trendelenburg position.
Position of the surgical team and equipment:
1. Surgeon on the left, distance from the screen is 5 times diagonal length of the screen which is placed opposite and in front of the surgeon.
2. Assistant on the right of the surgeon.
3. Scrub nurse on the left of the surgeon.
4. Anesthetist in the usual position on the head end.
Procedure:
Site – Inferior Crease of Umbilicus
1. Hold umbilicus with Allis forceps on either side to Evert the inferior crease of umbilicus
2. Make a stab incision of 2mm with No 11 surgical blade
3. Check Veress Needle for spring action and patency
4. Lift up the abdominal wall area below the umbilicus and assess its full thickness
5. Veress Needle is held like a dart at a level of 4 plus thickness of abdominal wall in centimetres by its shaft.
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 patient
7. Veress Needle insertion is aimed at the anus
8. Insertion is achieved with two audible clicks; 1st of the Rectus Sheath and 2nd of the Peritoneum
9. Release the Allis forceps and Abdominal wall
10. Hold the Veress Needle at an angle of 45’ making sure that no further length of needle is advanced
11. Placement of Veress Needle inside peritoneal cavity confirmed by attachment of a 10ml Syringe filled with
12. Normal Saline and performing following tests:
a. Irrigation Test: Injecting 5ml of Normal saline, free flow confirms placement inside the peritoneal cavity
b. Aspiration Test: There should not be any returning fluid, confirms placement inside the peritoneal cavity
c. Hanging Drop Test: Drop of Normal Saline is placed at the hub of the Veress Needle and abdominal wall is lifted. Suction of this drop into the abdominal cavity confirms placement inside the peritoneal cavity
d. Plunger Test: Removing the plunger of the attached syringe; free flow of remaining Normal Saline in to the abdominal cavity confirms placement inside the peritoneal cavity.
13. 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.
14. Confirm Pre-Set Pressure to 15mmHg on the Insufflator
15. Attach the gas tubing to the veress needle and start the flow of CO2gas at 1 liter per minute
16. Confirm obliteration of liver dullness and generalised distension of abdominal wall
17. Keep watch on patient’s vital parameters and EtCO2 readings during insufflation
18. The total amount of gas and actual pressure should rise parallel to each other
19. When actual pressure has reached pre-set pressure and amount of gas used is 1.5 to 6 litres for an averagely build young patient
20. Once pressure reaches the pre-set pressure, remove the veress needle and use size 11 blade to make a smiling skin incision on the infra umbilical crease, to fit a 10mm port. This can be pre-checked by placing a 10mm port on the skin for estimation of incision size. Using an artery forceps the tip should be inserted in this incision and then tip opened to successively dilate the urachus as per the Scandinavian technique of primary port placement.
21. Insert the 10mm cannula with trocar by oscillatory screwing motion, direction being perpendicular till give way sensation is perceived and then change the direction towards the pelvis. Once in, the trocar removed and telescope inserted and confirm the intraperitoneal placement
22. Then insufflator should be connected to it and gas switched on.
23. To begin with an overview inspection of the entire abdomen must be done and noted.
24. Then reach out to the target organ (fallopian tube of affected side), just about to touch it with tip of telescope, and trans-illuminate the anterior abdominal wall to delineate the site of the target.
25. Use the baseball diamond concept to mark the position of the additional 5 mm ports.
26. Surgeon must use transillumination to avoid any vessel injuries in prospective port sites, after which use the size 11 blade to make small incisions to fit the 5mm ports at the pre-marked sites as per Baseball diamond concept.
27. Insert both the 5mm ports under direct vision and using principles same as that used for primary port to avoid inadvertent visceral and vascular injuries.
Identification of fallopian tube with ectopic pregnancy in situ:
1. find the affected side fallopian tube by using atraumatic grasper and a maryland as probes only. The contralateral tube must also be inspected to determine healthy or not.
2. The affected tube is identified and mobilized to minimize bleeding, 5to8 ml diluted solution containing 5 unit vasopressin in 20 ml of normal saline is injected with a 20 gauge spinal or laparoscopic needle , it should be injected in the mesosalpinx just below the ectopic and over the antemesentric surface of the tubal segment containing gestational product.
3. After stabilizing the tube by grasper in one hand and microelectrode in other ,a linear incision is made on the antimesenteric surface extending one tow centimeter over the thinnest portion of the tube .
4. The fine needle tip should be used in the cutting mode , and should barely touch the tissue surface.
5. It is important to remain aware of the location of underlying or adjacent strucures..
6. The product usually should protrude through the incision and slowly slips out of the tube , it may be teased gently out using hydro dissection or laparoscopic atraumatic forceps .
7. As pregnancy is pulled out or extruded from the tube and can be placed in a plastic or endobag and removed through 10mm port on the umbilicus, under vision with the 5mm telescope in the lateral port..
8. After the pregnancy is removed the area operated upon must be visualized for perfect hemostasis.
9. The 10mm umbilical port fascia must be closed using a veress needle as a suture passer(Suture used is vicryl 0.0).Before tying the suture the port is to be removed together with the telescope and all gas let out.
10. Precaution while removing Primary port - Do not abruptly remove the port.
11. Keep the telescope in the abdominal cavity and start withdrawing the cannula
12. Continue to observe this withdrawal process on the monitor
13. Once the cannula has reach within the abdominal wall then start withdrawing the telescope
14. Remove the cannula and the Telescope under vision.
15. This process will avoid entrapment of Omentum or Bowel within the Primary port wound
16. Primary Port fascia and Skin closed; Secondary Port Skin closed
17. Skin closed with fine Monofilament suture
18. Abdomen cleaned and Port site wound dressing applied
19. Patient monitored till comes out of general anesthesia and post op vitals and operative findings must be duly noted in patient case sheet.
Tissue retrieved must be sent for histopathological examination and patient once stable must be shifted to post op care area for further management.
Provide Surgery Photos or Surgical Video to the patient.
• Provide Discharge Summary documenting Insitu findings of the surgery .
| Older Post | Home | Newer Post |
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.
