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Task Analysis of Video Assisted Thoracic Sympathectomy

Sun, 31 Dec 2023 10:25:56 +0000

Detailed Step-by-Step Guide to Thoracoscopic Sympathectomy by Dr. Sajal Chaudhary MBBS, MS, MMAS

Preoperative Preparation:
- Obtain informed consent after explaining the risks and benefits of the procedure.
- Conduct a thorough preoperative evaluation, including chest X-ray and pulmonary function tests if needed.
- Ensure the patient fasts according to the standard preoperative guidelines.
Anesthesia:
- Administer general anesthesia with intubation, preferably using a double-lumen endotracheal tube for single-lung ventilation.
- Position the anesthesia equipment and team at the head of the patient.
Patient Positioning:
- Position the patient in a semi-prone or lateral decubitus position, with the side of the planned sympathectomy facing upward.
- Secure the patient’s arms and provide adequate padding to all pressure points.
Team Positioning:
- The surgeon stands at the back of the patient, facing the thorax.
- The first assistant stands at the front of the patient, opposite the surgeon.
- The scrub nurse or technician is positioned at the lower end of the table with the surgical instruments.
Monitor Placement:
- Position the monitor on the opposite side of the patient’s thorax, in direct view of the surgeon.
Establishment of Pneumothorax:
- Create a controlled pneumothorax by insufflating CO2 into the thoracic cavity, if necessary, to collapse the lung and improve visualization.
Port Placement:
- Insert the first 5-mm trocar in the midaxillary line at the level of the fourth or fifth intercostal space for the camera.
- Place two additional 5-mm ports: one in the anterior axillary line at the third intercostal space, and the other in the posterior axillary line at the fifth or sixth intercostal space.
Thoracic Cavity Inspection:
- Insert a thoracoscope through the camera port to inspect the thoracic cavity and identify the sympathetic chain.
Sympathetic Chain Identification:
- Identify the sympathetic chain running along the necks of the ribs.
- Locate the specific ganglia responsible for the symptoms (typically T2-T4 for palmar hyperhidrosis).
Sympathectomy Procedure:
- Use electrocautery or a harmonic scalpel to divide the sympathetic chain at the predetermined levels.
- Ensure hemostasis and avoid injury to surrounding structures.
Inspection and Closure:
- After the sympathectomy, inspect the thoracic cavity for bleeding or other complications.
- Reinflate the lung under direct vision.
- Remove the trocars and close the incisions, typically with absorbable sutures.
Postoperative Management:
- Monitor the patient in the recovery area, paying special attention to respiratory function.
- Manage pain and provide instructions regarding activity, breathing exercises, and wound care.
Chest X-ray:
- Obtain a postoperative chest X-ray to check for pneumothorax or other complications.
Follow-Up:
- Schedule a follow-up appointment to assess the effectiveness of the sympathectomy and address any postoperative concerns.

This procedure should be performed by a surgeon skilled in thoracoscopic techniques. Adaptations to this protocol may be necessary based on individual patient anatomy and intraoperative findings.

Task Analysis of Laparoscopic Splenectomy

Sun, 31 Dec 2023 10:04:26 +0000

Detailed Step-by-Step Guide to Laparoscopic Splenectomy by Dr. Roshni Malhotra MBBS, MS, M.MAS

Preoperative Preparation:
- Obtain informed consent.
- Conduct a complete preoperative workup, including blood tests, imaging studies, and immunizations against encapsulated organisms if splenectomy is elective.
- Ensure the patient fasts according to standard guidelines.
Anesthesia:
- Administer general anesthesia.
- Secure the airway with intubation.
Patient Positioning:
- Position the patient in the right lateral decubitus position, with the left side elevated at about 30 to 45 degrees.
- Secure the patient to the table using appropriate supports to prevent shifting during the procedure.
Team Positioning:
- The surgeon stands at the patient’s abdomen, facing the patient’s back.
- The first assistant stands opposite the surgeon, on the patient's left side.
- The scrub nurse or technician is positioned at the lower end of the table, with the surgical instruments.
Monitor Placement:
- Place the monitor at the level of the patient’s head, directly in the surgeon's line of sight.
Establishing Pneumoperitoneum:
- Create a pneumoperitoneum by insufflating the abdomen with CO2 gas, typically through a Veress needle or a direct trocar insertion at the umbilicus.
Port Placement:
- Insert the first 10-12 mm trocar at the umbilicus for the camera.
- Place three additional ports: a 10-12 mm port in the left subcostal area along the midclavicular line, a 5-10 mm port in the left subcostal area along the anterior axillary line, and another 5-10 mm port in the left lower quadrant.
Exploration and Mobilization:
- Insert the laparoscope and inspect the abdominal cavity.
- Begin mobilizing the spleen by incising its ligamentous attachments, starting with the splenocolic ligament and moving to the splenorenal and splenophrenic ligaments.
Vascular Control:
- Carefully dissect and ligate the splenic artery and vein. Use clips, staples, or vascular sealing devices as appropriate.
Spleen Dissection:
- Continue the mobilization of the spleen, ensuring careful hemostasis.
- Fully mobilize the spleen from all attachments, allowing it to be freely movable within the abdomen.
Spleen Removal:
- Place the spleen in a retrieval bag.
- Morcellate the spleen within the bag, if necessary, and remove it through an enlarged port site or a small additional incision.
Hemostasis and Inspection:
- Inspect the operative field thoroughly for bleeding.
- Achieve hemostasis as needed using cautery, clips, or other hemostatic agents.
Closure:
- Desufflate the abdomen and remove the trocars.
- Close the port sites, with particular attention to larger port sites that may require fascial closure.
- Skin closure is typically performed with absorbable sutures or skin adhesive.
Postoperative Management:
- Monitor the patient in the recovery area for any immediate complications.
- Manage pain and provide care instructions, including activity restrictions and wound care.
Follow-Up:
- Schedule a postoperative follow-up to monitor recovery and address any concerns.

This procedure should be carried out by an experienced surgeon proficient in laparoscopic techniques. It's important to note that modifications to this protocol may be necessary based on the patient's anatomy, intraoperative findings, and specific clinical scenarios.

Task Analysis of Lap Chole in Detail

Sun, 31 Dec 2023 09:55:30 +0000

Detailed Step-by-Step Guide to Laparoscopic Cholecystectomy by Dr. Madhuka Shahi MBBS, MS, M.MAS

Preoperative Preparation:
- Ensure informed consent is obtained.
- Perform a complete preoperative workup including liver function tests and ultrasound.
- Instruct the patient to fast according to standard preoperative guidelines.
Anesthesia:
- Administer general anesthesia.
- Secure airway with intubation and ensure proper ventilation.
Patient Positioning:
- Position the patient supine on the operating table.
- The patient’s right arm is extended, and the left arm is tucked.
- Position the table in a reverse Trendelenburg with a slight left tilt to improve the exposure of the gallbladder.
Team Positioning:
- The surgeon stands on the left side of the patient.
- The first assistant stands on the right side of the patient.
- The scrub nurse or technician is positioned at the lower end of the table, adjacent to the patient's feet.
- The monitor is placed near the patient’s right shoulder.
Establishment of Pneumoperitoneum:
- Make a small incision at the umbilicus.
- Insert a Veress needle or a trocar to insufflate the abdomen with CO2, creating a pneumoperitoneum.
Port Placement:
- Insert the primary 10-mm camera port at the umbilicus.
- Place a 10-12 mm port in the epigastrium, just below the xiphoid process for the insertion of the laparoscopic clip applier and other instruments.
- Insert two more 5-mm ports: one in the right subcostal region at the midclavicular line and another at the anterior axillary line.
Exploration and Identification:
- Insert the laparoscope through the umbilical port.
- Inspect the abdominal cavity to confirm anatomy and ensure no contraindications for continuing.
Dissection of Calot's Triangle:
- Carefully dissect Calot's triangle to identify the cystic duct and cystic artery.
- Use laparoscopic graspers, scissors, and electrocautery as needed.
Clipping and Division of Cystic Duct and Artery:
- Double clip the cystic duct and artery with 10-mm clips.
- Divide the duct and artery between the clips using laparoscopic scissors.
Dissection of the Gallbladder:
- Begin dissecting the gallbladder from the fundus downwards towards the neck using a combination of blunt and sharp dissection.
- Carefully peel the gallbladder off the liver bed, using electrocautery for hemostasis.
Checking for Hemostasis:
- Thoroughly inspect the gallbladder bed and the dissected area for any bleeding.
- Achieve hemostasis using cautery or clips as necessary.
Gallbladder Extraction:
- Place the detached gallbladder into a retrieval bag.
- Extract the bag through the enlarged umbilical or epigastric port.
Closure:
- Desufflate the abdomen and remove all trocars under direct vision.
- Close the port sites, with particular attention to the larger port sites which may require fascial closure to prevent hernias.
- Skin closure is typically done with absorbable sutures or skin adhesive.
Postoperative Management:
- Monitor the patient in the recovery room for immediate postoperative complications.
- Manage pain and provide instructions regarding activity, diet, and wound care.
Follow-Up:
- Arrange a postoperative follow-up to evaluate recovery and address any concerns.

Task Analysis of Laparoscopic Rectopexy

Fri, 01 Oct 2021 14:06:46 +0000

DR. MOHAMMAD FAROOQUE

DEPARTMENT OF GENERAL SURGERY

SUMANDEEP VIDYAPEETH

GUJARAT

Rectal prolapse is a debilitating condition that affects 1% of people older than 60 years. Surgical approaches to its treatment include a perineal approach and an abdominal approach. Laparoscopic rectopexy was initially described in the early 1990s and has since become the abdominal procedure of choice for rectal prolapse.

Indications:

Once rectal prolapse is diagnosed, surgical repair is indicated to prevent worsening fecal incontinence and discomfort.

BEAHRS ET AL CLASSIFICATION:

1. Incomplete (Mucosal Prolapse)

2. Complete (Full thickness wall prolapsed)

First degree: High or Early, “Concealed”, “Invisible”

Second degree: Externally visible on straining, sulcus evident between rectal wall and anal canal

Third degree: Externally visible

Patient Preparation:

- Proper history taking and clinical examination of the patient

- Routine investigations and additional investigations based on comorbidities

- Anesthetic fitness

- Informed Consent

In preparation for the procedure, the patient is kept on NPO (nil per os) status, beginning the night before surgery. Prophylactic antibiotics are given per Surgical Care Improvement Project (SCIP) criteria.

Periprocedure:

A Foleys catheter is inserted for the duration of the case but is removed before extubation. Clippers are used to remove abdominal wall hair.

Patient Position:

The patient is placed in modified Lloyd Davis position(head down lithotomy) to make bowel fall away from the operative site. Special attention is given to the legs, avoiding excessive posterior or lateral compression, sparing any injuries to the calf muscle and lateral superficial peroneal nerve.

STEPS:

1. After successful pneumoperitoneum with veress, an 11mm smiling incision is made in the inferior crease of the umbilicus using no.11scalpel.

2. Use mosquito forceps to dilate the obliterated Vitello intestinal duct (Scandinavian technique).

3. Insert the 10 mm cannula with trocar with guarded screwing movement, perpendicular to the abdominal wall till give away sensation is perceived.

4. Remove the trocar and push the cannula in.

5. Introduce the 30-degree telescope in after white balancing and focussing at 10 cm distance and visualise the area directly under the port for presence of any bleeding or injury.

6. Transilluminate the abdominal wall and insert one 10 mm port on the left and one 5mm port on the right under vision by the Baseball Diamond concept. You can also use the ipsilateral port with a 7.5 cm distance in between.

7. Do a complete examination of the abdomen and pelvis and push the bowel above the sacral promontory.

8. If the patient has a uterus that is affecting exposure, it can be retracted with a stitch to the anterior abdominal wall.

9. Dissection is started posteriorly(Holy plane of Heald). The plane between the mesorectum and retroperitoneum is identified; the retroperitoneum is usually whiter than the mesorectum.

10. A harmonic scalpel is used to enter the posterior pelvic plane under the superior rectal artery, and the left ureter and hypogastric nerve plexus are identified.

11. Dissection is extended downward through the presacral anatomic space, all the way to the pelvic floor.

12. The dissection must be carried below the rectosacral (Waldeyer) fascia. Often, to facilitate exposure, the right lateral stalk of the rectum is also mobilized.

13. Once the right stalk and posterior areas are mobilized, dissection proceeds anteriorly into the rectovaginal plane.

14. Subsequently, the rectum is mobilized anteriorly to the upper limit of the vagina. During this approach, the nervi erigentes and left lateral ligament are spared.

15. The rectum is then pulled out of the pelvis, and where the fixation will occur is assessed.

16. A window is made on the left side of the rectum to facilitate the rectopexy and dissection on sacral promontory is done to expose it.

17. Posterior placement of mesh approximately of size 12*8 cm is done inserted via the right-lower-quadrant port and is placed all the way down to the pelvic floor, extending cephalad behind the mesorectum.

18. The mesh should cover the posterior part of rectum and some of the lateral stalks of rectum.

19. An overly tight pexy must be avoided to prevent obstruction of the rectosigmoid junction. If suturing is chosen, then use Ethibond suture.

20. It is important to identify the sacral venous plexus before tacking or suturing. The bony promontory and presacral fascia is the ideal location for fixation.

21. Then the mesh is fixed on right and left lateral stalks of rectum with the sutures.

22. Close the fold of peritoneum by continuous intracorporeal suturing so that the mesh is extraperitonealised. You can also use Dundee jamming knot with Aberdeen termination. Care should be taken not to include the mesh while suturing the peritoneum.

23. Desufflation of abdomen done

24. Ports are withdrawn under direct visualisation and optical cannula is withdrawn by sliding over the telescope.

25. Skin incisions are either sutured or stapled.

26. Abdomen is cleaned.

27. Antiseptic dressing done

28. Post-op vitals are noted and the patient is shifted to the recovery room.

Elaborated Steps

Position the patient in the lithotomy position.

Administer general anesthesia.

Secure the endotracheal tube.

Place a Foley catheter.

Preoperative antibiotics are administered.

The abdomen is insufflated using CO2.

The laparoscope is inserted through a 10mm port at the umbilicus.

Place 3-4 additional trocars as required.

The small intestine is retracted to expose the retrorectal area.

The rectum is mobilized by incising the peritoneal reflection.

Mobilize the sigmoid colon by dividing the white line of Toldt.

Identify the sacral promontory.

Dissect behind the rectum to create a tunnel that extends from the sacral promontory to the levator ani muscles.

Insert the mesh into the tunnel created behind the rectum.

Anchor the mesh to the sacral promontory using non-absorbable sutures.

Anchor the mesh to the levator ani muscles using non-absorbable sutures.

Check the position of the mesh to ensure that it is correctly placed and not twisted.

Retract the mesh to ensure that it is taut and not loose.

Inspect the mesh for any defects or tears.

Remove the laparoscope.

Close the ports.

Deflate the abdomen.

Remove the trocars.

Close the incisions with sutures or staples.

Apply sterile dressing to the incisions.

The patient is awakened from anesthesia.

Extubate the endotracheal tube.

Move the patient to the post-anesthesia care unit.

Administer analgesics for pain management.

Monitor vital signs and urine output.

Check the dressing for bleeding or drainage.

Observe the patient for any signs of infection or complications.

Initiate a clear liquid diet.

Remove the Foley catheter once the patient is able to void.

Discharge the patient when stable.

Instruct the patient on postoperative care.

Prescribe antibiotics and analgesics as needed.

Instruct the patient to avoid strenuous activity for 2-4 weeks.

Advise the patient to eat a high-fiber diet and drink plenty of fluids.

Advise the patient to avoid constipation and straining during bowel movements.

Schedule a follow-up appointment.

Evaluate the patient's postoperative course.

Monitor for any complications, such as bleeding or infection.

Evaluate the patient's bowel function.

Adjust medication as needed.

Evaluate the healing of the incisions.

Monitor the patient for any signs of mesh erosion or bowel obstruction.

Recommend physical therapy as needed.

Provide the patient with a detailed report of the procedure and postoperative care.

Advise the patient on any potential complications or side effects of the procedure.

Provide the patient with instructions on follow-up appointments and monitoring.

Advise the patient on when to resume normal activities, such as driving, work, and exercise.

The patient follows up with the surgeon at regular intervals.

The surgeon evaluates the patient's healing and progress at each follow-up appointment.

The surgeon orders any necessary imaging or laboratory tests to evaluate progress.

The surgeon adjusts medications or treatment as needed.

The surgeon monitors the patient for any signs of complications or side effects.

The surgeon communicates with the patient's primary

The surgeon communicates with the patient's primary care physician to ensure continuity of care.

The surgeon provides the patient with information on any further treatment or follow-up care.

The patient continues to follow the surgeon's instructions and attend regular follow-up appointments.

The patient reports any changes in symptoms or complications to the surgeon.

The patient reports any changes in medications or health status to the surgeon.

The surgeon evaluates the patient's healing and progress at each follow-up appointment.

The surgeon orders any necessary imaging or laboratory tests to evaluate progress.

The surgeon adjusts medications or treatment as needed.

The surgeon monitors the patient for any signs of complications or side effects.

The surgeon communicates with the patient's primary care physician to ensure continuity of care.

The surgeon provides the patient with information on any further treatment or follow-up care.

The patient continues to follow the surgeon's instructions and attend regular follow-up appointments.

The patient reports any changes in symptoms or complications to the surgeon.

The patient reports any changes in medications or health status to the surgeon.

The surgeon evaluates the patient's healing and progress at each follow-up appointment.

The surgeon orders any necessary imaging or laboratory tests to evaluate progress.

The surgeon adjusts medications or treatment as needed.

The surgeon monitors the patient for any signs of complications or side effects.

The surgeon communicates with the patient's primary care physician to ensure continuity of care.

The surgeon provides the patient with information on any further treatment or follow-up care.

The patient continues to follow the surgeon's instructions and attend regular follow-up appointments.

The patient reports any changes in symptoms or complications to the surgeon.

The patient reports any changes in medications or health status to the surgeon.

The surgeon evaluates the patient's healing and progress at each follow-up appointment.

The surgeon orders any necessary imaging or laboratory tests to evaluate progress.

The surgeon adjusts medications or treatment as needed.

The surgeon monitors the patient for any signs of complications or side effects.

The surgeon communicates with the patient's primary care physician to ensure continuity of care.

The surgeon provides the patient with information on any further treatment or follow-up care.

The patient continues to follow the surgeon's instructions and attend regular follow-up appointments.

The patient reports any changes in symptoms or complications to the surgeon.

The patient reports any changes in medications or health status to the surgeon.

The surgeon evaluates the patient's healing and progress at each follow-up appointment.

The surgeon orders any necessary imaging or laboratory tests to evaluate progress.

The surgeon adjusts medications or treatment as needed.

The surgeon monitors the patient for any signs of complications or side effects.

The surgeon communicates with the patient's primary care physician to ensure continuity of care.

The surgeon provides the patient with information on any further treatment or follow-up care.

The patient continues to follow the surgeon's instructions and attend regular follow-up appointments.

The patient reports any changes in symptoms or complications to the surgeon.

The patient reports any changes in medications or health status to the surgeon.

The surgeon evaluates the patient's healing and progress at each follow-up appointment and provides any further treatment as necessary.

Task Analysis For Management Of Interstitial Pregnancy

Thu, 02 Sep 2021 15:06:21 +0000

About 1-2% of all pregnancies may be ectopic which is a very risky and possibly life-threatening condition. Of these, 95-97% occur in the fallopian tubes. Recent advanced techniques in diagnosis and management have reduced the mortality rates by almost half.

Laparoscopic management is offered when:

1. patient is hemodynamically stable

2. beta HCG >10,000 mUI/ml

3. mean sac diameter>=4cm

4. contraindication to medical management by methotrexate

5. patient cannot be followed up adequately post medical management

Steps:

1. Veress needle checked for spring action and patency. Other instruments were also checked for proper functioning.

2. Patient in the supine position

3. General anaesthesia given

4. Painting and draping done

5. Umbilicus everted with Allis after selecting the port site:

a.Intra umbilical in obese patients

b.Supra umbilical in patients with previous surgery

c.Inferior crease of umbilicus in all other patients

6. With the aid of a No.11 blade, a stab wound was given of approximately 2mm in the selected port site..

7. Lift the loose part of the abdomen using thenar, hypothenar, and all fingers of both surgeon and assistant.

8. Hold the veress like a dart by shielding it at a distance of abdominal wall thickness plus 4cm and insert it.

9. Hear the two clicks. First of the piercing of the rectus sheath and second of the piercing of the peritoneum.

10. Confirm correct placement of the veress needle by:

(a)Irrigation test

(b)Suction test

(c)Hanging drop test

(d)Plunging test

11. Connect the insufflation cable to veress and create pneumoperitoneum with a set pressure of 12-15mmHg.

12. Check the pneumoperitoneum by:

(a)liver dullness

(b)distention of abdomen

(c)Actual flow rate of ‘0’

While keeping a watch on the patient’s EtCO2.

13. Remove the veress needle.

14. Make a marking of 10mm trocar and then increase the incision up to 11-12mm.

15. Dilate the urachus with artery forceps as per the Scandinavian technique

16. Insert the 10mm trocar with cannula held like a piston with the index finger pointing to control the depth of insertion, head of the trocar on the thenar eminence, and middle finger wrapped around the gas channel with screwing motion of the wrist while lifting the abdominal wall till give away feeling and then change the direction towards the pelvis. At this point, a hissing sound is heard of the air leaking out.

17. Remove the trocar.

18. Clean the cannula with a gauze held in a grasper for clear passage of the telescope.

19. Check for any injury during the passage of the veress and trocar and get a general view of the pelvis.

20. Look for any sign of ruptured ectopic pregnancy:

(a)presence of hematoma

(b)presence of clots

21. Decide the target of the surgery by inspecting bilateral tubes.

22. Using the baseball diamond concept, make a secondary port 7.5cm away from the primary port on the same arc under vision by transilluminating the area over the ectopic.

23. Using an atraumatic grasper in the secondary port and the telescope in the primary port, perform a diagnostic lap inspecting the following:

a. Right iliac fossa

b. Caecum

c. Appendix

d. Right hypochondrium

e. Ascending colon

f. Hepatic flexure of colon

g. Anterior pouch

h. Bladder

i. UV fold of peritoneum

j. Median ligament

k. Medial ligament

l. Cooper ligament

m. Posterior pouch

n. Uterosacral ligament

o. Rectum

p. Uterus- fundus, anterior and posterior surface

q. Bilateral adnexal- ovaries, tubes, round ligament, IP ligament, ovarian

fossa, and ligaments

r. Sacral promontory

s. Right and left pelvic sidewalls, deep ring, ureter, the triangle of doom,

trapezoid of disaster

t. Right lobe of the liver

u. Gall bladder

v. Stomach

w.Falciform ligament

x. Left lobe of the liver and left hypochondrium

y. Spleen

z. Left iliac fossa and sigmoid colon

24. Another port is inserted along the same arc, 7.5cm lateral to the secondary port to achieve two ipsilateral ports under vision.

25. Identify the diseased fallopian tube with the aid of an atraumatic grasper and a Maryland.

26. Contralateral tube inspection is also done.

27. Affected tube is mobilized by dissection of the mesosalpinx using a bipolar or harmonic if needed. Retraction of the fallopian tube in anterior and medial direction is done to give adequate space for dissection and to avoid injury to the pelvic wall. Avoid injury to the ovarian artery (causes devascularisation of ovaries).

28. Five units of vasopressin in 20ml normal saline are injected to minimize bleeding with a 20 gauge spinal needle in the area of the tubal segment containing trophoblastic tissue and the uterine surface adjacent to it. Notice the blanching of the tissue.

29. Stabilize tube with a grasper in the left hand.

30. Circumfentially incise around the cornua containing the ectopic pregnancy. Traction and counter traction is maintained to develop a plane of dissection.

31. The products of conception are placed in the posterior cul de sac for removal later.

32. The defect is repaired in multiple layers. Usually, two layers of the myometrium and then the third layer of serosa is repaired separately.

33. Close inner myometrium by continuous suturing using barbed suture or 2-0 vicryl.

34. Outer myometrium is closed by baseball suturing with 1-0 vicryl or absorbable braided suture.

35. Serosa is repaired by baseball suturing.

36. Salpingectomy is done with the help of bipolar and scissors successively of the affected tube since the cornua were resected and hence the fallopian tube will not be normal. The mesosalpinx and meso ovarian are coagulated and cut with the right hand while the left-hand holds the fallopian tube with an atraumatic grasper. This dissection must be from the lateral to the medial side.

36. The products and tube are removed by either pulling through the 10mm port site by aligning the tissue longitudinally or by using an endo bag.

37. Hemostasis is achieved.

38. Suction and irrigation are done if there is any spillage of blood.

39. Final inspection of the tube is done.

40.10mm port is closed using a veress needle or cobbler needle.

41. All ports are removed slowly to avoid any fascial injury or entrapment of the omentum or bowel.

42. Superficial closure of all port sites is done.

43. Abdomen is cleaned.

44. Antiseptic dressing done

45. Post-op vitals are noted and the patient is shifted to the recovery room.

46. Tissue that is retrieved is sent for histopathology.

Elaborated Steps

Position the patient in the supine position with both arms tucked.

Administer general anesthesia.

Place a Foley catheter to empty the bladder.

Preoperative antibiotics are administered.

Place a uterine manipulator to manipulate the uterus.

Insufflate the abdomen using CO2.

The laparoscope is inserted through a 10mm port at the umbilicus.

Place 2-3 additional trocars as required.

Identify the round ligament and fallopian tube.

Dissect the round ligament to enter the broad ligament.

Identify the interstitial portion of the fallopian tube.

Place a uterine artery clamp across the proximal part of the tube.

Divide the tube proximal to the clamp.

Remove the products of conception from the interstitial space.

Use suction to remove the contents of the pregnancy.

Inspect the tube and cornual area for bleeding.

Control bleeding by electrocoagulation or suturing.

Use suction to clear any remaining blood clots.

Inspect the surrounding structures for any additional bleeding.

Place a drain to monitor any potential bleeding or fluid accumulation.

Remove the uterine manipulator.

Remove the laparoscope.

Close the ports.

Deflate the abdomen.

Remove the trocars.

Close the incisions with sutures or staples.

Apply sterile dressing to the incisions.

The patient is awakened from anesthesia.

Extubate the endotracheal tube.

Move the patient to the post-anesthesia care unit.

Administer analgesics for pain management.

Monitor vital signs and urine output.

Check the dressing for bleeding or drainage.

Observe the patient for any signs of infection or complications.

Advise the patient to avoid strenuous activity for 2-4 weeks.

Advise the patient to avoid intercourse for 2-4 weeks.

Schedule a follow-up appointment.

Evaluate the patient's postoperative course.

Monitor for any complications, such as bleeding or infection.

Evaluate the patient's recovery of bowel and bladder function.

Task Analysis of Laparoscopic Removal of Large Submucous Myoma

Thu, 19 Aug 2021 14:08:30 +0000

Dr. Rini Nikhil

General anesthesia is to be given.
The patient should be given a lithotomy position and bladder drained.
Painting and draping of abdomen and perineum to be performed
Connect and check the monitor, CCD, camera, light source.
Do focusing at a 10cm distance for a 10mm telescope after completing white balancing.
Insufflator is turned on to remove air from the tubing, preset pressure is kept at 15mmHg.
Connect and set up required instruments – bipolar/ harmonic, with the electrosurgical generator.
Attach and verify the suction irrigation system.
Positioning of surgical team and monitor in accordance with the hierarchy and port positions; e.g.: If left-sided ipsilateral ports are used, operating surgeon stands on the left side of the patient, camera assistant on surgeon’s right side and two assistant surgeons one on the right side and second person for holding uterine manipulator.
Take Veress needle and check patency and spring action.
The primary port position is decided – supraumbilical for palpable uterus (14- 18 weeks of the gravid uterus) and inferior crease of the umbilicus for normal-sized uterus (less than 14 weeks size).
Take two Allis forceps to evert and hold the lower margin of the umbilicus
Use No. 11 blades to place a small vertical stab wound on the skin.
Assess the abdominal wall thickness and add 4cm to it for distance to hold the Veress needle.
Hold the Veress needle like a dart.
Lift the abdominal wall by its full thickness using thenar and hypothenar regions of the hand and four fingers.
Insert the Veress needle at a 90-degree angle to the lifted abdominal wall and 45-degree to the body of the patient, tip pointing towards the anus.
Proceed with insertion till two clicks are felt, maintaining 45-degree.
Confirm correct placement of Veress needle by irrigation, aspiration, hanging drop, and plunger test.
Connect the insufflator tubing to the Veress needle, turn on CO2, and allow flow at 1 liter per minute with a preset pressure of 12-15mmHg.
Observe and analyze the Quadro manometric indicators
Once the desired pneumoperitoneum is attained remove the Veress needle.
Extend the skin incision to 11mm horizontally; if required, by marking the circumference of the 10mm cannula at the port site.
Hold 10mm port by the right technique like a pistol, insert it perpendicular to the inflated abdominal wall by gentle screwing movements from the elbow level and tilting it towards the pelvis when there is loss of resistance.
Confirm intra-abdominal placing of the port by the hissing sound of air escaping through the eye of the trocar.
Increase the flow rate of insufflation to 6litre/minute after connecting the gas tubing to the primary port.
Insert telescope, inspect entry point, rule out any bowel or vessel injury and perform diagnostic laparoscopy.
Keep the camera cable at 6 O’clock and the light cable at 12 O’clock positions.
Convert the table position to 30-degree Trendelenburg.
Place the lateral ports following the baseball diamond concept, cutting along Langer lines and inserting perpendicular to the abdominal wall.
Assess the relation of fibroid with the uterus and other pelvic structures.
Dilute 5ml (5IU per ml) Vasopressin in 100ml saline and inject it at the maximum prominent part of the uterus, into the myometrium using an aspiration needle.
Look for blebbing and pallor on fibroid with vasopressin injection.
Perform hysterotomy by an oblique or sagittal incision through the serosa and myometrium of the fundus, using a Harmonic scalpel or low voltage monopolar cutting current, avoiding the cornual region and fallopian tubes.
Open the myometrium using a harmonic scalpel, myoma screw, and myoma rod till a plane of dissection is obtained.
Enucleate the myoma by manipulating it using a myoma screw each time inserted it towards the base of the myoma in the incision than the center of the visualized myoma for better traction.
Use harmonic scalpel or monopolar cutting in the other hand for aiding dissection, without avulsing but carefully cutting to avoid bleeding.
Repair the endometrial cavity using continuous No 1 Vicryl sutures through the basal layer and minimal myometrial tissue, without entering the endometrial cavity.
Close the inner myometrium by continuous suturing with No: 2-0 Vicryl (50cm) or Barbed sutures completely obliterating the dead space to avoid hematoma formation.
Close the outer myometrium and serosa by baseball or continuous suturing with No: 1 Vicryl or absorbable violet Braided Suture (returning with the same suture material)
Terminate by surgeon’s knot with the tail of inner layer suture.
Convert one of the ports, preferably closer to the pelvis, into 15mm.
Check and insert the morcellator through the 15mm port.
Proceed with morcellation by holding the myoma by tenaculum, feeding it to the motorized morcellator, taking care not to move the morcellator towards the tissue, instead, keeping the tissue being morcellated away from the abdominal viscera to avoid injury.
Do irrigation and aspiration, confirm hemostasis, and proceed with port closure.
Do closure of 15mm port used for morcellation with No-1 Vicryl using laparoscopic Cobbler needle, the cannula of Veress needle or suture passer, under visualization and avoiding tension on the sutures.
Remove the instruments and the other ports except for the one for the telescope.
Deflate the abdomen completely keeping the telescope inside, remove the cannula, And then the telescope.
Close the skin incision with staplers and do dressing.

Steps 1- 30: Access
Steps 31-44: Myomectomy
Steps 45-49: Closure

Elaborated Steps:

Position the patient in the lithotomy position.

Administer general anesthesia.

Place a Foley catheter to empty the bladder.

Preoperative antibiotics are administered.

Insufflate the abdomen using CO2.

The laparoscope is inserted through a 10mm port at the umbilicus.

Place 2-3 additional trocars as required.

Identify the uterus and the location of the myoma.

Use a uterine manipulator to manipulate the uterus and improve visualization.

Dissect the round ligament and the broad ligament.

Dissect the uterine artery and vein.

Enter the uterus using a monopolar electrosurgical device.

Incise the myometrium overlying the myoma.

Use the hysteroscope to guide the dissection of the myoma.

Use a resectoscope to remove the myoma.

Coagulate the blood vessels using the monopolar electrosurgical device.

Remove the myoma in pieces or as a whole.

Use suction to clear any remaining blood clots.

Inspect the surrounding structures for any additional bleeding.

Place a drain to monitor any potential bleeding or fluid accumulation.

Close the uterine defect using an absorbable suture.

Close the serosa using an absorbable suture.

Place a haemostatic suture in the uterine artery.

Use the monopolar electrosurgical device to coagulate the suture.

Repeat the same on the other side.

Remove the uterine manipulator.

Remove the laparoscope.

Close the ports.

Deflate the abdomen.

Remove the trocars.

Close the incisions with sutures or staples.

Apply sterile dressing to the incisions.

The patient is awakened from anesthesia.

Extubate the endotracheal tube.

Move the patient to the post-anesthesia care unit.

Administer analgesics for pain management.

Monitor vital signs and urine output.

Check the dressing for bleeding or drainage.

Observe the patient for any signs of infection or complications.

Advise the patient to avoid strenuous activity for 2-4 weeks.

Advise the patient to avoid intercourse for 2-4 weeks.

Schedule a follow-up appointment.

Evaluate the patient's postoperative course.

Monitor for any complications, such as bleeding or infection.

Evaluate the patient's recovery of bowel and bladder function.

Adjust medication as needed.

Evaluate the healing of the incisions.

Monitor the patient for any signs of uterine perforation or infection.

Provide the patient with a detailed report of the procedure and postoperative care.

Advise the patient on any potential complications or side effects of the procedure.

Provide the patient with instructions on follow-up appointments and monitoring.

Advise the patient on when to resume normal activities, such as driving, work, and exercise.

The patient follows up with the surgeon at regular intervals.

The surgeon evaluates the patient's healing and progress at each follow-up appointment.

The surgeon orders any necessary imaging or laboratory tests to evaluate progress.

The surgeon adjusts medications or treatment as needed.

The surgeon monitors the patient for any signs of complications or side effects.

The surgeon communicates with the patient

Task Analysis of Laparoscopic Cholecystectomy

Sun, 29 Dec 2019 16:37:08 +0000

Dr. Amit Kr Singh MBBS, MS General surgery
Kolkata West Bengal

General Anaesthesia :
The patient should be under GA.
Position the patient in the supine position.
Availability of the following instruments should be checked :
Access instruments: Blade 11, Veress needle, two 10 mm ports, two 5 mm ports.
Optical instruments: 10 mm telescope, camera, light cable.
Operating instruments: Maryland, Traumatic grasper, semi traumatic grasper, endoclips, Curved endoscissor, Vicryl suture, endobag.

Energy instruments: Harmonic, hook connected with monopolar.
Check the function of the monitor, Insufflator, light source, amount of gas cylinder, harmonic setting frequency between 3-5, and check the monopolar function for cutting and coagulation.
Patient and surgeon Positioning :
Table height should be adjusted to the surgeon height (0.49 X surgeon height).
The patient should be prepped form the nipples to the mid-thighs: patient draping and cable arrangement.
The surgeon should stand on the left side of the patient. The monitor at the right side of the patient,1st assistant, should be on the left side of the surgeon and the 2nd assistant at the right side of the patient.
The monitor, target organ, and surgeon should be aligned in coaxial alignment.
The monitor should be at 15 degrees below the surgeon's eyes and 5 times of its diagonal diameter away from the surgeon.
Access and Insufflation:
Umbilicus to hold With Allys Forceps, then using blade 11, 3 mm incision to be made at the inferior crease of the umbilicus.
Size 10 Veress needle insertion: start with checking the veress needle function and patency by flushing it with NS and hearing two clicks of the valve.
The length of the needle which should be inserted should be 4cm + abdominal wall thickness. Veress Needle should be held as a dart at 45 degrees, left the abdominal wall in a way that veress needle should be perpendicular to it and pointed toward the anus. Will feel two areas of resistance, should be intrabdominal after you passed the 2nd area.
Check the position of the Veress needle in three ways:
Flush the needle with NS, which should go easily.
Aspirate, nothing should come.

Hanging drop test: drops of NS are placed at the cannula of the needle, should sink when the lower abdominal wall is lifted.

5. Qudrimanometric 40 liters Insufflator to be on, the following setting should be applied:
a. Set pressure 12 and flow 1 L / min.
6. The gas tube should be flushed with CO2 before attaching it to the veress needle.
7. The gas tube to be attached to the veress needle and start insufflation, making sure that the abdomen is tympanic and distended equally in all quadrants. Insufflator's parameters should be observed during insufflation.
8. Once the actual pressure reaches the set pressure of 12 mmHg, the Veress needle will be removed.
9. At the same umbilical, inferior crease, Using a 10 mm cannula, the area is marked for the incision, then the incision increased to 10 mm, smiley incision.
10. The vetelinointestinal tract is opened and dilated with artery forceps.
11. 10mm port is inserted through the tract and attached to the gas tube.
12. 30 degrees Camera to be adjusted in terms of white balance, and focus.
13. Camera to be inserted and check for any bleeding, adhesion or bowel injury.

Working ports insertion :

Based on the baseball diamond concept, working ports sites are determined and inserted under direct visualization as follows:
10 mm port at the epigastric area at the line between xiphisternum and umbilicus. This port should be inserted left to the falciform ligament but piercing the membranous part and should come out right to it.
5 mm port at the right midclavicular line, around 2 cm below the costal margin.
5 mm port at the right mid-axillary line, around 5-8 cm below the costal margin.

Surgical steps:

Position the patient in the left lateral, head up.
Through the lateral 5mm port, Using the traumatic grasper, the fundus of the gallbladders should be retracted upward and toward the right shoulder of the patient.
The gall bladder is retracted anteromedially, With the help of the grasper the Hartmans pouch exposed, all adhesions are released with blunt dissection or Harmonic use.
The Gallbladder infundibulum is retracted toward the left shoulder so the anterior peritoneum is exposed.
Making sure that we are above the Rouviere’s Sulcus, dissection to be started at the anterior peritoneum at the Hartmans pouch level using the harmonic.
Then the infundibulum is retracted to the right side, and anterior lateral posterior peritoneum is exposed and dissected.
By this time, a window is created below the infundibulum connecting the anterior and posterior openings.
The critical view of safety (cystic duct, CHD, and the edge of the liver) is viewed, Cystic duct is identified, dissected, and isolated from the artery. Always avoid over traction, to prevent CBD injury.
Using Vicryl suture with Mishra's knot, the cystic duct is ligated near the CBD. Moreover, clips are applied at the distal end of the duct. Using the scissor, the cystic duct is cut between the clips and the knot.
The cystic artery is identified and clipped using the end clips by applying 2 clips proximally and one clip distally. The artery cut using scissors.
Using the Harmonic, the gallbladder is dissected from its bed in the liver surface by cutting the anterior and posterior peritoneum.
Dissection continued till the fundus of the gallbladder, till it is detached from the liver.

The gallbladder bed is inspected for any bleeding and should be controlled by using fulguration by monopolar (using hook).
Using endobag, the gallbladder is retrieved through the epigastric port.
Ports removal and closure:
Under direct vision, 5 mm ports and epigastric port are removed.
Gas insufflation is stopped, the abdomen is deflated, The umbilicus port is removed, facia is closed using Vicryl 0.
All Skin incisions are closed using Rapide Vicryl or staplers.

Elaborated Steps:

Position the patient in the supine position with both arms tucked.

Administer general anesthesia.

Place a Foley catheter to empty the bladder.

Preoperative antibiotics are administered.

Insufflate the abdomen using CO2.

The laparoscope is inserted through a 10mm port at the umbilicus.

Place 2-3 additional trocars as required.

Identify the gallbladder, liver, common bile duct, cystic duct, and cystic artery.

Use the hook cautery to dissect the cystic artery.

Clip and divide the cystic artery.

Dissect the cystic duct.

Clip and divide the cystic duct.

Use the hook cautery or harmonic scalpel to dissect the gallbladder from the liver bed.

Use a grasper to retract the gallbladder.

Use the hook cautery or harmonic scalpel to dissect the gallbladder from the liver bed.

Use a grasper to retract the gallbladder.

Continue dissection until the gallbladder is free from the liver bed.

Use a retrieval bag to extract the gallbladder.

Inspect the cystic duct and cystic artery for hemostasis.

Remove the trocars.

Deflate the abdomen.

Close the incisions with sutures or staples.

Apply sterile dressing to the incisions.

The patient is awakened from anesthesia.

Extubate the endotracheal tube.

Move the patient to the post-anesthesia care unit.

Administer analgesics for pain management.

Monitor vital signs and urine output.

Check the dressing for bleeding or drainage.

Observe the patient for any signs of infection or complications.

Advise the patient to avoid strenuous activity for 2-4 weeks.

Advise the patient to avoid heavy lifting for 2-4 weeks.

Schedule a follow-up appointment.

Evaluate the patient's postoperative course.

Monitor for any complications, such as bleeding or infection.

Evaluate the patient's recovery of bowel and bladder function.

Adjust medication as needed.

Evaluate the healing of the incisions.

Provide the patient with a detailed report of the procedure and postoperative care.

Advise the patient on any potential complications or side effects of the procedure.

Provide the patient with instructions on follow-up appointments and monitoring.

Advise the patient on when to resume normal activities, such as driving, work, and exercise.

The patient follows up with the surgeon at regular intervals.

The surgeon evaluates the patient's healing and progress at each follow-up appointment.

The surgeon orders any necessary imaging or laboratory tests to evaluate progress.

The surgeon adjusts medications or treatment as needed.

The surgeon monitors the patient for any signs of complications or side effects.

The surgeon communicates with the patient's primary care physician to ensure continuity of care.

The surgeon provides the patient with information on any further treatment or follow-up care.

The patient continues to follow the surgeon's instructions and attend regular follow-up appointments.

Task Analysis Laparoscopic Tubal Ligation by Mishra’s Knot

Sun, 29 Dec 2019 16:26:17 +0000

Dr. Andi Setiawan Tahang Sp.OG, M.Kes, F.MAS, FICRS
Gynecology, December 23rd, 2019

Equipment needed:

1. Laparoscopic drapes, insufflators, light source, HD camera with a 30-degree telescope (10 mm), seven parameter monitor, LCD monitor.
2. Veres needle 12 cm with 10 ml NS syringe, and 10 ml xylocaine 2 % for subcutaneous injection before doing skin incision.
3. Two 10 mm and one 5 mm port.
4. 11, number scalpel.
5. The length of suture used in the extracorporeal knot for the free structure is 75 cm by no.1 vicryl.
6. Bhandarkar Knot Pusher.
7. Ligasure.
8. An Atraumatic grasper.

Procedure

1. The procedure can be performed under GA or LA.
2. Put the patient in a supine position with 15 degrees head down.
3. Quadrimanometric device ready, the preset pressure should not be more than 12 mm, and the gas flow rate 1L/min.
4. Position of the surgical team: Surgeon on the left side of the patient and coaxial alignment with the target organ (the tubes) and the monitor at a distant about 5*diameter of the monitor and the table height 0,49* surgeon height.
5. Disinfect the abdomen from the nipple till the pubic symphysis line and to the level of anterior iliac spines laterally.
6. Xylocaine 10 ml is subcutaneously infiltrated around the umbilicus.
7. By the use of an 11 mm blade, 2 mm incision at the lower umbilical skin crease.
8. Verres needle is checked for valve action and patency by n/s irrigation.
9. Hold it like a dart and skin thickness is elicited by holding it at the level of the umbilicus and add to it 4 cm for needle tenting, the needle should be perpendicular to the abdominal wall and directed toward anus, left hand should hold the lower abdominal to make it 45 degrees toward the patient body.
10. Two clicks are heard at this time, during the rectus and peritoneum entry, then check by suction-irrigation test, hanging drop test.
11. The insufflator is switched on and connected to the veress needle.
12. Check the flow rate and the actual pressure at this time, the flow rate, not more than 1,5 L/min, the actual pressure increasing gradually, and not exceeding preset pressure.
13. When the actual pressure becomes equal to the preset pressure, take out the needle and do a 10 mm smiling incision in the lower umbilical crease.
14. Insert artery holding forceps to the incision to dilate the vitellointestinal duct and separate the recti muscle (Scandanavian technique).
15. Insert a 10 mm umbilical port and connect the insufflator and close the valve for continuous pneumoperitoneum.
16. Insert a 10 mm 30 degree telescope and take a panoramic view.
17. 10 mm port is inserted under direct vision in the left iliac fossa 7,5 cm lateral to the umbilicus and 5 mm port is inserted under direct vision in the right iliac fossa 7,5 cm lateral to the umbilicus according to Baseball Diamond Theory.
18. Prepare of the length of suture in the extracorporeal knot for the free structure is 75 cm by vicryl no.1
19. Take the Bhandarkar knot pusher in the left hand and pass 2 cm suture through. The eye in the tail end of the Bhandarkar knot pusher by the right hand.
20. The knot pusher is now reversely feed in the 3 mm reducer. Reverse feeding is important.
21. Once the reducer is fed, the thread is pulled out from the eye of the tail of the knot pusher. The job of the eye in the tail is just to pass the suture safely from the reducer.
22. Now the other end of the suture is passed through the eye of the head end using the right hand.
23. Ask the assistant for finger and make the configuration of Mishra’s knot is 1-1-1-1-1-1-1. One hitch one wind one lock, 2nd wind second lock and 3rd wind, and the final lock.
24. Make the diameter of loop 6 cm by sliding the loop by right hands finger and thumb.
25. After that, hide the knot and its loop under the reducer.
26. Now the knot pusher and the reducer are introduced through the 10 mm port. If it is introduced through the 10 mm, port additional 5 mm reducer should be introduced.
27. An Atraumatic grasper should also be introduced from the contralateral port (5 mm port in the right hand).
28. The loop of the knot should go near to the Right or Left Fallopian Tube.
29. The Atraumatic grasper should have to enter or introduced in the loop and catch the left fallopian tube.
30. Now the knot pusher should go to feed the loop behind the left fallopian tube. The same way as our hands goes behind when we put garland on someone’s neck.
31. The knot now can be slide to the left fallopian tube. By establishing the knot pusher with the left hand and pulling the suture with the right hand.
32. After tightening the knot consecutively three times, the knot pusher after that coagulation and cutting by Ligasure (Bipolar).
33. 5mm reducer is pulled, and hook scissors is introduced from the same port, and the suture is cut, leaving 1 cm tail.
34. The same is repeated on the right fallopian tube. Remove the applicator.
35. Take a 5 mm telescope after white balancing and fixation before insertion through the 5 mm port.
36. Prepare the veress needle and make a loop of thread (proline) to use it for the closure of the 10 mm port to prevent future hernia.
37. Close the umbilical 10 mm port and 10 mm second port in the left hand under direct vision by no.1 vicryl.
38. Deflate the abdomen gradually making jerky movement by the 5 mm telescope to avoid intestinal entrapment to the port.
39. Put a surgical dressing on the port sites.

Elaborated Steps of other technique

Position the patient in the supine position with both arms tucked.

Administer general anesthesia.

Place a Foley catheter to empty the bladder.

Preoperative antibiotics are administered.

Insufflate the abdomen using CO2.

The laparoscope is inserted through a 10mm port at the umbilicus.

Place 1-2 additional trocars as required.

Identify the fallopian tubes.

Apply Mishra's Knot or

Use the bipolar cautery or monopolar cautery to coagulate the isthmic portion of the tubes.

Apply a second layer of cautery to ensure complete occlusion of the tubes.

Remove the laparoscope.

Remove the trocars.

Deflate the abdomen.

Close the incisions with sutures or staples.

Apply sterile dressing to the incisions.

The patient is awakened from anesthesia.

Extubate the endotracheal tube.

Move the patient to the post-anesthesia care unit.

Administer analgesics for pain management.

Monitor vital signs and urine output.

Check the dressing for bleeding or drainage.

Observe the patient for any signs of infection or complications.

Advise the patient to avoid strenuous activity for 2-4 weeks.

Advise the patient to avoid intercourse for 2-4 weeks.

Schedule a follow-up appointment.

Evaluate the patient's postoperative course.

Monitor for any complications, such as bleeding or infection.

Evaluate the patient's recovery of bowel and bladder function.

Adjust medication as needed.

Evaluate the healing of the incisions.

Provide the patient with a detailed report of the procedure and postoperative care.

Advise the patient on any potential complications or side effects of the procedure.

Provide the patient with instructions on follow-up appointments and monitoring.

Advise the patient on when to resume normal activities, such as driving, work, and exercise.

The patient follows up with the surgeon at regular intervals.

The surgeon evaluates the patient's healing and progress at each follow-up appointment.

The surgeon orders any necessary imaging or laboratory tests to evaluate progress.

The surgeon adjusts medications or treatment as needed.

The surgeon monitors the patient for any signs of complications or side effects.

The surgeon communicates with the patient's primary care physician to ensure continuity of care.

The surgeon provides the patient with information on any further treatment or follow-up care.

The patient continues to follow the surgeon's instructions and attend regular follow-up appointments.

Task Analysis of Laparoscopic Cervical Cerclage Stitch

Sun, 29 Dec 2019 16:19:36 +0000

Dr Aishwarya Balakumar MD OBGYN DIP IN USG
SRKV HOSPITAL
CHENNAI TAMILNADU

INTRODUCTION

Cervical shortening has been associated with recurrent second-trimester pregnancy loss as well as increased risk of spontaneous preterm birth.
The association between cervical dysfunction and pregnancy loss was first described by Riverius in 1658, and thoroughly effective interventions to this problem have proven somewhat elusive even though vaginal cerclage initially by Lash, Shirodkar, and MacDonald in the 1950s has achieved some success over the years. However, the evidence supports transabdominal cerclage first described by Benson and Durfee in 1965 as a more effective intervention, especially in a non-pregnant woman. Emerging evidence now shows that laparoscopy has better obstetric outcomes than laparotomy when used to place the stitch.

INDICATIONS

Recurrent second-trimester pregnancy losses due to cervical factor
Recurrent spontaneous preterm births
Failed Vaginal Cerclage.

ADVANTAGES:

Very useful in cases of previously failed vaginal cerclage

DISADVANTAGES

1. More expensive

2. Elective cesarean delivery is mandatory.

TIMING

1. Pre pregnant state

2. Between 11 to 13 weeks of gestation

TASK ANALYSIS

1. Pre-operative Evaluation

2. Equipment checks

3. Port placement

4. Intraoperative steps

PRE-OPERATIVE EVALUATION

1. Relevant history and physical examination should be done as well as a routine checklist for major surgery applied to rule out any potential co-morbidities.

Investigations such as Full blood count, Blood Urea Electrolytes, ECG, Chest X-ray, ECHO and Coagulation profile done
Mandatory anesthetic review
Informed consent
Bowel preparation (done the previous night)
All equipment tested before surgery.
Antibiotics are given at induction of anesthesia.

EQUIPMENT/HARDWARE

Telescope 10mm, 30 degree
Electrosurgical Unit (Monopolar) or Harmonic Scalpel
Atraumatic Grasper, Scissors, Maryland Dissector, Needle holder
Sutures: Mersilene tape 5mm, Vicryl # 0, #3/0.

TEAM MEMBERS

Obstetrician-gynecologist with competencies in minimal access surgery.
2 Assistants
Anesthesiologist
Scrub Nurse

SURGICAL TEAM POSITIONING

Surgeon: Left side of the patient’s abdomen

1st Assistant: Controls camera, stands slightly behind and to the right of the surgeon.

2nd Assistant: Controls the uterine manipulator stands in between the slightly abducted legs of the patient.

Anesthesiologist: At the head of the patient

Scrub Nurse: slightly behind and to the left of the surgeon

PATIENT POSITIONING: Initially supine, and then steep Trendelenburg with lithotomy position to help bowel fall away from the pelvis

Anesthesia: General

PORT POSITIONING: Using a baseball diamond concept, 3 Ports are used; one 10mm optical port and two 5mm ports, each 7.5cm from the optical port in contralateral setup.

ABDOMINAL ENTRY (Closed Access Technique)

A stab incision is made at the inferior crease of the umbilicus, and the Veress needle held like a dart is advanced through the anterior abdominal wall, which is lifted at an angle of 90 degrees till two clicks are felt. The correct placement of the Veress needle is confirmed with saline and the hanging drop test, and then insufflation with medical grade CO2 is started at an initial flow rate of 1L/min and preset pressure of 15mmHg. Once the preset pressure is achieved, the Veress needle is removed, and the stab incision enlarged by the Scandinavian technique to 11mm to allow placement of the 10mm port.

PRIMARY PORT PLACEMENT

The primary port is introduced by the surgeon holding the 10mm trocar and cannula like a pistol and advancing it slowly with continuous screwing movements initially perpendicular to the abdominal wall and the later directed towards the anus till a give is felt. The correct trocar placement is confirmed by briefly pressing the valve on the cannula to hear the hissing sound of escaping the gas. Once this is confirmed, the trocar is removed and the gas pipe of the insufflator connected to the 10mm port, and the preset pressure adjusted to 12 mmHg, which would be the working pressure.

The continuous monitoring of the carbon dioxide pressure is done by the Quadro manometric microprocessor-controlled insufflator device.

A 10mm 30-degree telescope with the focus and white balancing already adjusted are then introduced into the abdomen via the 10mm port. A panoramic view and initial inspection of the abdomen is done starting with the point of primary port entry and adjacent area then to the right paracolic gutter, appendix, large bowel, stomach, omentum, transverse colon then to the pelvis, the uterus, ovaries, tubes, bladder, round ligament, median, medial and lateral umbilical ligaments, triangles of pain, doom and trapezoid of disaster are all inspected, any pathology seen should be noted and recorded. The uterine manipulator is then fixed, especially if not pregnant (Nathanson’s Liver retractor may help if pregnant) and the mobility of the uterus is then demonstrated by full range manipulation by the assistant, and any areas of adhesion or limited mobility is noted if there is a history of previous surgery or infections.

ACCESSORY PORTS PLACEMENT

After inspection, two 5mm accessory ports are placed through the anterior abdominal wall in contralateral configuration through the stab incision made at the transilluminated points on the abdomen to avoid the inferior epigastric vessels, which should be medial to the ports.These two ports are then advanced under direct vision and directed towards the pelvis.

ELECTROSURGICAL DISSECTION

Once all ports have been placed, the appropriate instruments are now introduced in this case the atraumatic grasper in the left hand and harmonic scalpel or alternatively the monopolar scissors in the right hand. With the uterus in retroverted position by the manipulator, the anterior UV fold of the peritoneum is held with the grasper in the midline and opened with the harmonic and dissected to about 3-4 cm on either side, left and right. The bladder is carefully dissected from the cervix and pushed away. The uterus is the pushed to anteverted position and about 2cm just above the arc of the uterosacral ligament posteriorly, this an avascular area through the broad ligament at the level of and lateral to the internal os and also medial to the uterine artery, two points; one on the left and one on the right are coagulated to create an opening to pass the needle of the Mersilene tape. The tape with needles in end ski configuration is now introduced through the 5mm port and passed first from anterior to posterior on the left side and then posterior to anterior on the right side through the coagulated area with needle of the tape held perpendicular to the needle holder.
While this is being done on the left side and right sides, make sure to avoid injury to the bladder and uterine vessels. The needles on the Mersilene tape ends are cut and removed through the 5mm Port, a surgeon’s knot is then made anteriorly, and the excess Mersilene tape trimmed off. The free ends of the Mersilene tape are then fixed to the anterior cervical fascia to secure it using Vicryl #1; then the peritoneum is the closed off from left to right using the same Vicryl suture with Dundee Jamming knot in a continuous manner with Aberdeen termination.[peritoneum approximation step is optional we can keep the UV fold free.

COMPLETION

The abdomen is then inspected for any significant bleeding to rule out any injury, and if found to be satisfactory, then the CO2 gas is switched off, accessory ports removed under direct vision, telescope removed, and the valves of the primary port opened to decompress the abdomen. The telescope is then reintroduced through the primary port, and then both primary port and telescope removed together.

PORT CLOSURE

Only ports greater than 10mm are closed fully, the skin was closed with Vicryl 3/0, and a sterile dressing applied.

POSTOPERATIVE PERIOD

The patient is monitored in the recovery room with ¼ hourly vital signs
Analgesics and Antiemetics are given
If the patient is pregnant, she is started on vaginal progestogen and oral simultaneously until 34 weeks.
Observe for 24 hours, then discharge home
Re counseling on potential complications such as suture disruption, and chorioamnionitis
To continue antenatal care and counsel on elective cesarean delivery at term.

Elaborated Steps:

Position the patient in the lithotomy position.

Administer general anesthesia.

Insert a Foley catheter to empty the bladder.

Preoperative antibiotics are administered.

Insert a uterine manipulator to improve visualization.

Insufflate the abdomen using CO2.

The laparoscope is inserted through a 10mm port at the umbilicus.

Place 2-3 additional trocars as required.

Identify the cervix.

Dissect the bladder off the anterior aspect of the cervix.

Use a monopolar or bipolar electrosurgical device to create a tunnel on the cervix.

Insert a 4-0 or 5-0 monofilament suture through the tunnel.

Tie the suture to form a loop around the cervix.

Tighten the suture to achieve the desired level of cervical competence.

Cut the suture ends and bury them in the cervical tissue.

Inspect the cervix and surrounding structures for any signs of bleeding.

Remove the laparoscope.

Remove the trocars.

Deflate the abdomen.

Close the incisions with sutures or staples.

Apply sterile dressing to the incisions.

The patient is awakened from anesthesia.

Extubate the endotracheal tube.

Move the patient to the post-anesthesia care unit.

Administer analgesics for pain management.

Monitor vital signs and urine output.

Check the dressing for bleeding or drainage.

Observe the patient for any signs of infection or complications.

Advise the patient to avoid strenuous activity for 2-4 weeks.

Advise the patient to avoid intercourse for 2-4 weeks.

Schedule a follow-up appointment.

Evaluate the patient's postoperative course.

Monitor for any complications, such as bleeding or infection.

Evaluate the patient's recovery of bowel and bladder function.

Adjust medication as needed.

Evaluate the healing of the incisions.

Provide the patient with a detailed report of the procedure and postoperative care.

Advise the patient on any potential complications or side effects of the procedure.

Provide the patient with instructions on follow-up appointments and monitoring.

Advise the patient on when to resume normal activities, such as driving, work, and exercise.

The patient follows up with the surgeon at regular intervals.

The surgeon evaluates the patient's healing and progress at each follow-up appointment.

The surgeon orders any necessary imaging or laboratory tests to evaluate progress.

The surgeon adjusts medications or treatment as needed.

The surgeon monitors the patient for any signs of complications or side effects.

The surgeon communicates with the patient's primary care physician to ensure continuity of care.

The surgeon provides the patient with information on any further treatment or follow-up care.

The patient continues to follow the surgeon's instructions and attend regular follow-up appointments.

Task Analysis of TAPP For Left Inguinal Hernia

Sun, 29 Dec 2019 16:11:18 +0000

Dr. L.K. GANESH
GENERAL SURGERY
MANIPAL
KARNATAKA

A) Patient Position:
1. The patient is placed in the Trendelenburg position to make bowel fall away from the operative site

B) Instruments and Surgeon’s Position:
1. The height of the table should be 0.49 times the surgeon's height.
2. The monitor should be at a distance of 5 times its diagonal length from Surgeon.
3. The surgeon should stand on the right side.
4. The Surgeon, the hernia site, and the monitor should be along the same axis.

Port positioning:

1) The Optical Port should be placed at infra umbilical crease.
2) The other two-port is placed according to the baseball diamond concept,i.e., one on the right side and other on the left side.

Access to peritoneal cavity:

1. Make an incision 2 mm with 11 no blade at the inferior crease of umbilicus.
2. Lift the abdominal wall and insert the Veress needle directing towards anus through the incision at a 450 angle to the spine and perpendicular to the lifted abdominal wall.
3. Make confirmation of intraperitoneal entry by double click sound, Hanging drop test, and Plunger test.

After confirmation:

1. Connect the CO2 either to the Veress needle & begin inflating the intra-peritoneal space initially at one ltr/min and later at three ltr/min till the intra-abdominal pressure reaches the preset pressure of 12-15mmHg,
2. Take the veress needle out of the abdomen
3. Enlarge the infra umbilical incision up to 11mm.
4. Put the cannula inside the trocar
5. Slowly screw the cannula with the trocar into the peritoneal cavity in the perpendicular direction to the abdominal wall.
6. The camera is white-balanced and then focused.
7. The telescope is then advanced through the umbilical port into the abdominal cavity under direct vision.
8. Perform diagnostic laparoscopy/peritenoscopy and locate the site of pathology
9. Make two 5mm operating ports on either side of the optical umbilical port under direct vision on the concept of baseball diamond concept.

Procedural Steps:

1. Define the laparoscopic anatomy, Start the peritoneal dissection at 2 O’clock position at a distance of 6 cm from the outer margin of the hernia defect.
2. Hold the peritoneum by Maryland and lift it and cut the peritoneum with a scissor at a point mentioned above
3. Allow the CO2 to enter inside which will create the plane of dissection
4. Then lift the leaf of peritoneum & start dissecting the peritoneum using scissor till you reach the medial umbilical ligament.
5. While dissecting the peritoneum, push the fat and fibrous strands towards the anterior abdominal wall.
6. Make medial Pocket: Push the bladder down and push the fibrous tissue towards anterior abdominal wall till u see the coopers ligament(lighthouse).
7. Make lateral pocket:
• Push the fibrous tissues towards the abdominal wall and push the posterior leaf downwards
• Complete dissection over the triangle of doom and pain
8. Start dissection of sac
• Hold the sac with Maryland
• Do blunt dissection by pulling the sac towards you and pushing the vas deferens, spermatic vessels away till the sac separate from spermatic cord.

Mesh Placement:

1. Take Prolene mesh – 10*15 cm and make a roll of mesh outside the abdomen.
2. Hold the mesh with a needle holder and put it inside the reducer
3. Introduce the mesh assembly through the 10 mm optical port.
4. Put the telescope in and unroll the mesh under vision.

Fixation of Mesh:

With Tackers:

1. Fix the medial corner of the mesh to the cooper’s ligament using either tackers.
2. Apply one tacker on mesh over rectus abdominis in the anterior abdominal wall
3. Apply one tacker on mesh over transverse fascia in the anterior abdominal wall
With Suture
1. Hold the need holder with the right hand and rotate it anticlockwise and take bite over cooper ligament and mesh and fix with intracorporeal surgeon knot
2. Take a bite on rectus abdominis muscle and mesh and fix with intracorporeal surgeon knot.
3. Take a bite on transverse fascia and mesh and fix with intracorporeal surgeon knot.

Peritoneal closure:

With Tackers:

1. Do double breasting of the lower leaf over the upper leaf of peritoneum and apply tackers.
With Suture
1. Start Suturing from medial to lateral with continuous intracorporeal suture with vicryl 2.

Portside closure:

1. The port entry sites are examined for bleeding.
2. Close the optical port using a veress needle under vision with 5 mm telescope from 5 mm cannula.
3. Pneumoperitoneum is deflated.
4. The Cannula is removed with a telescope within so as to make nothing comes along with it and.
5. Tighten the knot after removal of the canula.
6. The other two-port site is closed.
7. The skin around the port site is cleaned with an antiseptic solution.
8. Dry sterile dressings are applied to the port sites.

Elaboration of Steps:

Position the patient in the supine position.

Administer general anesthesia.

Insert a urinary catheter to empty the bladder.

Preoperative antibiotics are administered.

Make a 10-12mm incision at the level of the umbilicus.

Use a Veress needle to insufflate CO2 into the abdomen.

Insert a 10mm trocar through the incision.

Insert a laparoscope through the trocar and visualize the abdominal cavity.

Identify the hernia sac and reduce the hernia contents.

Identify the left inguinal region.

Make an additional 5mm incision lateral to the left rectus muscle.

Insert a 5mm trocar through the incision.

Use a laparoscopic grasper to retract the peritoneum.

Use a monopolar or bipolar electrosurgical device to incise the peritoneum along the left inguinal region.

Create a dissection plane between the peritoneum and the transversalis fascia.

Develop the preperitoneal space using a balloon dissector or other blunt instrument.

Insert a 10mm trocar through the left lower quadrant.

Use a laparoscopic grasper to retract the peritoneum.

Use a monopolar or bipolar electrosurgical device to dissect the peritoneum and develop the preperitoneal space.

Insert a self-retaining retractor to maintain the preperitoneal space.

Dissect the hernia sac and reduce any hernia contents.

Reduce the hernia sac by pulling it into the preperitoneal space.

Close the hernia defect with sutures or mesh.

Use a laparoscopic stapler to secure the mesh in place.

Ensure adequate mesh coverage and fixation.

Close the peritoneum with sutures.

Inspect the surgical site for any bleeding or hematomas.

Remove the self-retaining retractor.

Deflate the abdomen and remove the trocars.

Close the incisions with sutures or staples.

Apply sterile dressing to the incisions.

The patient is awakened from anesthesia.

Extubate the endotracheal tube.

Move the patient to the post-anesthesia care unit.

Administer analgesics for pain management.

Monitor vital signs and urine output.

Check the dressing for bleeding or drainage.

Observe the patient for any signs of infection or complications.

Advise the patient to avoid strenuous activity for 2-4 weeks.

Advise the patient to avoid lifting heavy objects for 2-4 weeks.

Schedule a follow-up appointment.

Evaluate the patient's postoperative course.

Monitor for any complications, such as bleeding or infection.

Evaluate the patient's recovery of bowel and bladder function.

Adjust medication as needed.

Evaluate the healing of the incisions.

Provide the patient with a detailed report of the procedure and postoperative care.

Advise the patient on any potential complications or side effects of the procedure.

Provide the patient with instructions on follow-up appointments and monitoring.

Advise the patient on when to resume normal activities, such as driving, work, and exercise.

The patient follows up with the surgeon at regular intervals.

The surgeon evaluates the patient's healing and progress at each follow