ROBOT ASSISTED LEFT OVARIAN CYSTECTOMY
Dr. Manisha Singh1. The patient for robotic ovarian cystectomy should be performed under General Anesthesia
2. The patient is identified & side and site marking for surgery are confirmed.
3. The patient is positioned supine, with the arms tucked by the side & pressure points padded.
4. A bladder catheter is placed or the patient is asked to void just prior to surgery. Patient is administered General Anaesthesia.
5. A per vaginum examination under general anaesthesia is performed before commencement & fidings are noted.
6. Initial step are those for diagnostic Laparoscopy. The Laparoscopic monitor is positioned at the foot of the bed towards the side of the cyst and the surgeon stands opposite to the side.
7. The placement, position and adequate contact area of patient return plate is confirmed.
8. The sites of ports are marked & instilled with local anaesthesia 2% Xylocaine 5 ml each site. An infraumbilical 2 mm incision is placed and Verees Needle is inserted. Correct intra-abdominal position is confirmed with a saline filled syringe. Initial aspiration, followed by instillation of 5 ml saline and reaspiration of bubbles. Finally a hanging drop test is performed.
9. An insufflation gas tube is connected to the Verees needle and the flow rate is started at 1 L/min. Pressure changes in the insufflator device is monitored.
10. As per patient body habitus Approx 1.5 - 6 L CO2 is insufflated with an end point of reaching set pressure of 15mm Hg.
11. Once the pneumoperitoneum is established, the 2 mm incision is extended to 10 mm and a sharp 10 mm port is inserted. A 30 degrees 10 mm scope is then introduced & intra-abdominal cavity is visualized along with any signs of injury while establishing pneumoperitoneum or access.
12. Patient is positioned in the Trendelenburg head-low position in order to move the small bowel out of the surgical field.
13. Using base ball diamond concept two ports of 10 mm are placed under vision at the distance of 10cm from the telescope.These would be used for introduction of Robotic Arms.
14. The diagnostic laparoscopy is concluded by examination of the site of pathology, involvement of surrounding structures & The opposite side.
15. Once the diagnostic Laparoscopy confirms the pathological findings & operability the da Vinci Robot is used.
16. Docking of the da Vinci Robot patient cart is done from the side of the pathology, in place of the Laparoscopy Vision cart.
17. 2 Endo-instruments are used: Bipolar Graspers in the left and endo scissors in right.
18. A nick is placed superficially on the cortex of the left ovary with bipolar grasper.
19. The upper margin of the cut cortex is held and separate the cortex using dissecting endo scissors.
20. Care should be taken not to puncture the cyst to avoid uncontrolled spillage into abdominal cavity.
21. In case of very large cyst, it is punctured & the contents are aspirated & lavage is given.
22. In case of adherence / involvement of surrounding structures a careful dissection is carried out with sharp instrument & cautery current combination.
23. Stripping of the cortex is done using bipolar grasper and scissors alternatively till ovarian cyst is completely enucleated.
24. Check the cyst and look out for any left out part.
25. One may need to perform a formal oophoretomy if the remanent is very small or in case of bleeding.
26. At this stage the robotic arms are undocked and the Laparoscopic Vision cart is repositioned. The Laparoscopic instruments are reintroduced
27. Introduce an endo bag inside the abdominal cavity from right side port.
28. Put the enucleated cystic structure inside the bag.
29. Catch the open ends of the endo bag with grasper and pull it out through the incisional site of the right port.
30. Enlarge the incision as required. Rarely a Pfannensteil incision needs to be placed & contents removed without spillage.
31. Suction and irrigation from the right port into the abdominal cavity done.
32. A thorough lavage done.
33. Hemostasis is confirmed. No drains are routinely placed.
34. CO2 insufflation is stopped and the Pneumoperitoneum is evacuated. The trocars are removed under direct vision. And the optical port is removed last with camera in the port to prevent any herniation.
35. The patient position is made supine. The defect of the sub-umbilical trocar site (& the pfannensteil incicion, if made) is closed under direct visualization using an absorbable suture.
36. Skin is closed with suture / stapler / Glue and dressing applied.
37. Ryles tube is removed, if inserted, provided the bowel handling & adhesiolysis was minimal.
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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.
