1) The length of the suture for Extra Corporeal Knot for the Continuous structure used is 90 cm.
2) Before start tying extracorporeal knot for continuous structure make a Window by dissecting tissue plane where you want to ligate this extracorporeal knot.
3) Hold one end of the 90cm suture with the Maryland and then feed and hide 1/3rd of the Maryland and suture in the 5mm reducer and introduce Maryland and suture both togetherthrough 10 mm port.
4) Introduced Atraumatic grasper in another 5-mm port.
5) The suture should pass through the window and should be hold by the atraumatic grasper.
6) The job of the camera person is crucial here. The light cable should be towards the right and should flyover towards the window/target to show the tip of Maryland to the surgeon.
7) The suture which is held by grasper is now transfer back from the grasper to the Maryland.
8) The suture is now feed inside the abdomen minimum four timesby atraumatic grasper to bring 20cm suture length inside abdomen.
9) During the process of feeding the camera person should focus the telescope towards the tip of the cannula.
10) At each feeding minimum of 5cm length of the suture should be pulled inside.
11) Once feeding of suture is complete bring the grasper back again in between the suture loop and tissue.
12) With the help of the Maryland the suture should be taken out keeping the grasper in between the loop and tissue.
13) While taking out the suture grasper should have kept steady between the suture so that the tissue does not get cut through due to shearing effect.
14) Once tail end of suture is out through the reducer, ask the assistant to keep the finger on the washer of reducer in between the two suture to prevent gas leek.
15) Now tie extracorporeal knot and the assistant finger should cover the reducer so that the gas leak can be prevented.
16) You can use any of the extracorporeal knot slip knot (Roader’s, Meltzer’s or Mishra’s knot) depending upon diameter of structure and quality of your suture material.
17) The suture is feed from the head end of the Bhandarkar knot pusher and is taken out from the tail end of the knot pusher.
18) The knot pusher is now reversely feed in the 3mm reducer.
19) The knot pusher and the reducer is introduced inside the 5mm reducer by asking the assistant to remove finger from reducer and knot pusher is pushed in the abdomen under vision.
20) Knot pusher is pushed and the suture is pulled to make loop shorter.
21) Keep the tip of the knot pusher where you want to tie the knot.
22) The knot will automatically slide to the desire place where you want to tie the knot and where tip of the knot pusher is kept.
23) Pushing of knot pusher and pulling of the suture should be done in such a fashion that structure should not know that it is getting tied.
24) After tightening the knot consecutively three times the knot pusher and 3 mm reducer is pulled and hook scissors is introduced from the same port and the suture is cut leaving 1 cm tail.
25) The extracorporeal knots are very strong knot and one knot is sufficient to tie the continuous structure like cystic duct, cystic artery, renal artery, splenic artery.
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.
