Task Analysis Of Sacrohysteropexy
Dr. Rashmi SinghMBBS, MD (OBGY)
Batch October 2019
- After giving general anesthesia to pt, position her in a lithotomy position with head 30˚ down.
- Cleaning, painting, and draping of the abdomen and vagina should be done.
- Bladder to be catheterized.
- The surgeon should stand on the left-hand side of pt, one assistant at the right-hand side and one assistant at the vaginal end.
- Give a 2mm stab incision on the infra-umbilical crease after lifting it up on either side by Alli’s forceps.
- Insert the Veress needle through the incision and appreciate two clicks.
- Confirm intra-abdominal position by injecting 5ml of NS through the needle, suctioning the air out and by hanging drop test.
- Insufflate the abdomen with gas up to 12-15mm Hg of pressure.
- Pull the needle out and enlarge the 2mm incision to 10mm.
- Insert a 10mm trocar and cannula with guarded screwing movements and enter the abdomen.
- Remove the trocar and insert the telescope after having white balance and focus checked.
- Under vision insert one 10mm and one 5mm on contralateral sides, each 7.5cm away from the umbilical port (making use of Baseball Diamond concept).
- One supra-pubic port to be inserted parallel to optical port at least 5cm above the upper border of the pubic symphysis.
- Take a 15× 3 cm polypropylene mesh, pleat it and introduce it through 10mm cannula without the reducer.
- Unfold the mesh with grasper and Maryland in the abdomen.
- The vaginal assistant should insert a uterine manipulator with colpomotizer and lift the uterus to an acute anteverted position at 12’o clock position.
- Take a nonabsorbable suture (silk/Dacron no 1) and take a bite on the vaginal part of one uterosacral ligament, passing the needle from out to in.
- Care should be taken of not taking the cervical canal or vagina into the bite.
- Ask the assistant to hold one end of the mesh. Pass the needle from one corner of the mesh.
- Tie a knot (square or Weston knot). The square knot is pushed with the help of Clarke’s knot pusher and 3-4 knots are taken in a square knot. Cut the suture.
- Repeat the procedure on other side uterosacral ligaments.
- Ask the assistant to hold the free end of mesh against the posterior surface of the uterus.
- Take a bite 2cm above the previous 2 knots through the mesh and seromuscular layer of the uterus, come out through the mesh and tie an intracorporeal surgeon’s knot and cut.
- Take another bite in a similar fashion 2cm above the previous knot.
- The knots should be placed in uterosacral ligaments, isthmus, and the corpus of the uterus in chronological order (it should not reach the fundus of the uterus).
- Now move the bowel up.
- Stretch the peritoneum over the sacral promontory, to the right of the rectum, pull and cut it, using harmonic or monopolar scissors.
- Do the blunt dissection and let the air enter the retroperitoneum space.
- Keep cutting the peritoneum until 2cm below the fimbrial end of the tube on the right side.
- Blunt dissection is to be done and separate the areolar tissue.
- Expose the anterior longitudinal ligament over sacral promontory which is shiny and pearly white in color.
- Be careful of median sacral vessels medially (towards left).
- Ask the assistant to push the uterus inside the abdomen so that the cervix is at least 9cm from the introitus.
- Place the mesh over the anterior longitudinal ligament.
- Using contralateral or suprapubic port either fire a tacker (Protack) or take a bite and tie a square knot. Be careful of slipping off the tacker or breaking the needle at this point.
- Usually, one tacker or a bite should suffice.
- Trim the extra mesh.
- Carefully insert the mesh into the peritoneal tunnel.
- Approximate the cut end of peritoneum on right and cut end of mesorectum on the left side with vicryl no 1, using Dundee jamming knot, continuous suture, and Aberdeen termination, and close the peritoneal tunnel, so that mesh is now in retroperitoneum.
- Inspect the whole abdomen.
- Remove the uterine manipulator.
- Remove the 5mm ports under vision.
- Port closure of 10mm ports to be done by Veress’ or Cobbler’s needle.
- Remove the optical port after having a final look at the port exit.
- Dressing of the wound to be done.
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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.
