Task Analysis Of Baseball Diamond Concept For Port Position In Laparoscopy
DR.D. PARIVALLAL
FMAS + DMAS
The first technique to learn in laparoscopic surgery is the BASEBALL DIAMOND CONCEPT FOR PORT POSITION IN LAPAROSCOPY. Common problem beginners encounter is where should port to be inserted. If one port in the wrong position, the surgeon will struggle throughout the surgery due to bad Ergonomics. The wrong port position is one of the most common causes of stressful surgery and may lead to conversion and complications.
There are 3 principles in baseball diamond concept
FIRST PRINCIPLE:
Laparoscopic instruments work on lever action. Generally, all laparoscopic instruments should behave like type 1 lever ( half of the instruments should be in and half out). It means fulcrum in center and load is equal and opposite to the force applied. In type 2 lever, a fulcrum is very close to loading arm i.e., port very near to target of dissection hence the maximum length of the instrument is outside which results in tissue tear and avulsions. In type 3 lever. fulcrum is very close to forcing arm i.e., port very far from the target of dissection hence the maximum length of the instrument is inside the body which results in overshooting.
ELEVATION ANGLE:
It is defined as an angle between the instruments and body of the patient. Elevation angle Ideally should be 60 degrees.
If the port is very close to the target of dissection ( type 2 lever), elevation angle will be 90 degrees then surgery cannot be performed as an instrument will not lift the tissue.
If the port is very far from the target of dissection (type 3 lever), elevation angle will be less than 10 degrees then the handle of the instrument will touch the body of the patient.
Steps to achieve the 1st principle\:
Step 1: Find out the target of dissection, for example, calot’s triangle in cholecystectomy
Step 2: Choose the correct length of instruments
Pediatrics: 28 cms
Adult: 36 cms
Morbid Obese: 45 cms
Step 3: keeping the target at the center, draw 2 arc
1st arc 18cm from the target
2nd arc 24 cm from the target
SECOND PRINCIPLE
The telescope should be in the middle of working instruments.
AZIMUTH ANGLE:
It is defined as the angle between the telescope and working instruments i.e., contralateral port position. Ideally, it should be 30 degrees ( normal range 15 to 45 degree)
Benefits:
Linear parallax – Depth perception will be good
Motion parallax – object near will appear to move more and vice versa
Relative size – object far will appear to be small and vice versa
Aerial gradient – object near will appear to have better contrast and color
Texture gradient – near object appear to have detailed surface
Correct shadow – shadowing as the cue for depth
THIRD PRINCIPLE
MANIPULATION ANGLE:
It is defined as the angle between two working hand instruments should be 60 degrees +/- 15 degree
Steps to achieve the 3rd principle
After creating the Pneumoperitoneum, Put the tip of the index finger over the target of dissection and put the tip of thumb over the site of telescope. Position of anatomical snuffbox will give a rough estimation of working port position on both sides in adults.
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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.
