1) Take suture length 90 cm for Extracorporeal square knot
2) The Endoski needle are generally preferred than the curved ones.
3) For making an Endoski needle, the needle is hold at the 1/3rdfrom the tip by the needle holder and slightly away from that by the base of artery forceps.
4) This will give you an Endoski needle in which 2/3rd of the needle is straight and 1/3rd is curved.
5) Now insert the Maryland in the reducer completely.
6) Catch hold the tail of the suture and bring it out through the reducer.
7) Re-introduce the Maryland in the reducer by the side of feeded suture and catch the suture near the needle and hide the needle in the reducer.
8) Now introduce the Maryland and the reducer together in the abdomen with suture held near the needle.
9) Drop the needleover the tissue in a way that tip should be left and the tail should be right
10) Align the needle by the Pressing the needle by upper jaw of the needle holder at the junction of one third and two third.
11) Stabilize the tissue by the left hand and prick the tissue by the needle and by rotating the tip of needle to keep it perpendicular to the tissue.
12) Bringing the tip of the needle 1/3rd out and catch it with left hand instrument and keeping the convex end of the instrument towards the tissue.
13) Now take another bite and hold the needle with the Maryland.
14) The suture is now feed inside minimum for the four times.
15) At each feeding minimum of 5cm length of the suture should be inside.
16) During the process of feeding the camera person should focus the telescope towards the tip of cannula.
17) With the help of the Maryland the suture should be taken out.
18) While taking out the suture needle holder should support between the suture so that the tissue does not get cut through.
19) Ask the assistant for the finger on the reducer and take a half knot, apply an artery forceps in the tail end and keep the needle end straight.
20) Keep the Clark Knot pusher near the knot and hook it forward.
21) Slide the knot keeping the needle end of the suture straight and tail end of suture loose.
22) Sliding process should be continuous, any stoppage or withdrawal of Clark knot pusher can make the knot pusher disengaged with the suture.
23) Once Clark knot pusher reaches to the tissue do the past pointing to tighten the first half of square knot.
24) Now again bring the Clark knot pusher out and make another half knot and slide it.
25) While sliding second time, take care that the same needle limb of suture should have to be straight and tail end is sliding.
26) Past pointing is important to make the sliding knot to convert into square locked knot.
27) Now finally take a third time the half knot in similar fashion and each time do past pointing.
28) Once the knot is tightened bring out the knot pusher and take curve scissor and cut the suture.
29) It is basically used for the tissue which are under tension and strong enough to tolerate the past pointing.
30) You should never use extracorporeal square knot for any tubular structure and blood vessels.
31) This knot is useful for Vault closure in TLH, Myomectomy, Fundoplication and Herniorrhaphy.
World Laparoscopy Hospital
Cyber City, DLF Phase II, Gurgaon
NCR Delhi, 122002, India
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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.
