MBBS,DGO,MS(OBG)
Consultant Obstetrician & Gynaecologist
Mahesh surgical & maternity centre
Tumkur, KARNATAKA-572103
TASK ANALYSIS FOR DIAGNOSTIC LAPAROSCOPY FOR INFERTILITY
1. Surgical team: Surgeon, Anaesthetist, Assistant, Scrub nurse
2. Equipment needed:
a. Laparoscopic drapes, insufflator, Light source, HD camera with 30 degree telescope(10mm),
Seven parameter monitor, LCD monitor
b. Veress needle
c. Ports: One 10mm reusable port , one 5mm port
d. Basic laparoscopic instruments - Atraumatic grasper, punch biopsy forceps, suction –
irrigation cannula with apparatus.
e. Speculum, vulsellum, uterine manipulator. Rubin’s cannula, methylene blue dye, 10ml
syringe
f. Vicryl 2-0 , size no.11 blade, BPL handle,10mm syringe with saline, 10ml
syringe with 2%xylocaine , needle holder, straight scissor, 2 alley’s.
3. Method of anaesthesia: General Anaesthesia
4. Setting of the equipment
a. Pre-set pressures of the insufflator to 12 – 15mmHg
b. White balancing with white gauze and focusing at about 10cm range
5. Position of patient:
Modified lithotomy with head end low by 15 degree.
6. Position of the surgical team and equipment:
a. Surgeon on the left side of patient, in line with target and monitor, 5 times diagonal length of
the screen(co- axial)
b. Assistant on the right of the surgeon
c. Assisting nurse in-between legs of patient
d. Anaesthetist on the cephalad position
7. Attainment of pneumoperitoneum and introduction of ports
a. Surgeon makes a stab wound with size11 blade at the inferior crease of umbilicus
b. Surgeon check the spring of veress needle as well as patency with saline in 10mm syringe
c. Surgeon grab entire thickness of the infra-umbilical midline wall of abdomen & measure
thickness of abdominal wall. He holds veress needle like a dart at a distance equal to 4cm plus
abdominal wall thickness, from tip.
d. Insert Veress needle pointing towards anus, perpendicular to entry point and 45 degrees to the
body of patient.
e. Surgeon advances the veress needle and feels 2 clicks (one on rectus sheath and one on
peritoneum
f. Surgeon carry out the injection/aspiration test and saline drop test with a 10mm syringe with
saline, to confirm intraperitoneal positioning of veress needle
g. Switch on the insufflator and connect the tube to veress needle with flow rate of 1L/min.Monitor
that the insufflator is confirming correct positioning of veress needle.
h. Once pressure reached pre-set pressure, Surgeon uses size 11 blade to make a smiley skin
incision in the infra umbilical crease, to fit a 10mm port. This can be pre-checked by placing a
10mm port for estimation of incision.
i. With artery forceps open obliterated vitellointestine duct till rectus sheath & insert 10mm port
holding it like a Gun with tip of index finger at half way distance from piercing end, middle
finger wrapping gas port & then thenar eminence pressing trochar against cannula.
j. With clockwise & anticlockwise screwing movement enter abdominal cavity perpendicularly &
hear for single click. Take out cannula & hear for hissing sound of gas which confirm
intraperitoneal placement.
k. Surgeon inserts the telescope and confirms intraperitoneal position.
j. Surgeon inserts the 5mm ports under direct vision in left iliac fossa avoiding vessels.
k. Inserts atraumatic grasper through 5mm port.
8. Inspection
Inspects the entire abdomen in steep trendelenberg position in clockwise direction i.e., first structures just below umbilicus& then caecum, appendix,ascending colon, paracolic gutter, hepatic flexure. Then in reverse trendelenberg position inspects right lobe of liver, gall bladder, withdraw telescope little to cross falsiform ligament& then look transverse colon, left lobe of liver, stomach, spleen, splenic flexure,descending colon, sigmoid colon,walk over small intestine. Inspects pelvis-3 false ligaments, 3true ligaments, 3 dangerous areas,uterus, fallopian tubes, ovaries, bladder, POD.
9. Assistant at pelvic end injects methylene blue dye through rubin’s cannula. Surgeon looks for free flow of dye through bilateral fimbrial ends .
10. If any pathology is found, take tissue for biopsy or fluid for cytology. Also take video or photo of pathology found. If consent for operative procedure was taken prior, can proceed. Otherwise don’t proceed.
11. 5mm port is removed under direct vision
12. The 10mm port is removed together with telescope
13. The 10mm umbilical port facia is closed with vicryl 2-0
14. The 5mm ports, only skin is closed with vicryl 2-0
15. The 10mm port is closed with subcutaneous vicryl 2-0.
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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.
