1) The length of suture used in the extracorporeal knot for free structure is 75 cm.
2) Take the Bhandarkar Knot Pusher in left hand and pass 2cm suture through the eye in the tail end of the Bhandarkar knot pusher by right hand.
3) The knot pusher is now reversely feed in the 3mm reducer. Reverse feeding is important.
4) Once the reducer is feeded the thread is pull out from the eye of the tail of knot pusher. The job of the eye in the tail is just to pass the suture safely from the reducer.
5) Now the other end of the suture is passed through the eye of the head end using right hand.
6) Ask the assistant for a finger and the extracorporeal slip knot is tied.
7) There are three types of extracorporeal knot (A) Roader’s Knot (B) Meltzer’s Knot and the (3) Mishra’s knots. All the knots have different configuration.
8) The configuration of Roader’s knot is 1-3-1. In which the 1st 1 stand for the hitch, 2nd 3 stand for 3 consecutive winds and the last 1 stand for 1 lock (half knot). It is secure up to 8mm tubular structure.
9) The configuration of Meltzer’s knot is 2-3-2. As above the 2 stands for 2 hitch, 3 winds and 2 half knot consecutive lock. This knot is secure up to 12mm tubular structure.
10) The configuration of Mishra’s knot is 1-1-1-1-1-1-1. One hitch 1 wind 1 lock, 2nd wind second lock and again 3rd wind and the final lock. It is the most secure knot among the three for the structure up to 18mm tubular structure.
11) Make the diameter of loop 6cm by sliding the loop by right hands finger and thumb
12) After that hide the knot and its loop under the reducer
13) Now the knot pusher and the reducer is introduced through the 5mm or 10mm port. If it is introduced through the 10-mm port additional 5 mm reducer should be introduce over 3mm reducer to prevent the leakage of the gas.
14) An Atraumatic grasper should also be introduced from the contralateral port.
15) The loop of the knot should go near the free structure.
16) The Atraumatic grasper should have introduced in the loop and after that it should hold the tip of the free structure over which you want to tie.
17) Now the knot pusher should go to feed the loop behind the structure. The same way like our hands goes behind when we put garland on someone’s neck.
18) The knot now can be slide to the desire place where you want to tie the knot by stablishing the knot pusher with left hand and pulling the suture with right hand.
19) It should be done in such a fashion that structure should not know that it is getting tied. Any traction of pulling and pushing should never be exerted over the tubular structure which you are ligating.
20) After tightening the knot consecutively three times the knot pusher and 3mm reducer is pulled and hook scissors is introduced from the same port and the suture is cut leaving 1 cm tail.
21) The extracorporeal knot is very strong knot and one knot is sufficient to tie any tubular structure like appendix, fallopian tube a piece of omentum small pedunculated myoma or paraovarian simple cyst.
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.
