Task Analysis of Laparoscopic and Robotic Procedures

Task Analysis for a Laparoscopic Transperitoneal Radical Nephrectomy
Urology / Jan 27th, 2018 6:10 am     A+ | a-


1. Initially position the patient in supine for the anesthesia steps.                                          
2. Placement of orogastric tube and 18 Fr Foley catheter                                           
3. Position the patient in a modified lateral decubitus position with the umbilicus placed over the break in the operating table.
4. Flexed the table as needed or put a ballon under the patient at the level of the umbilicus
5. Support the buttocks and the dorsum with padding and all the potential pressure points 
6. The surgeon is positioned on the abdominal side of the patient, and the first assistant is placed caudally to the surgeon.
7. The laparoscopic cart is positioned at the back of the patient’s chest with the operative team facing the video monitor.
8. The instruments table is positioned behind the operative team.
9. A cutaneous incision is made two finger breadths below the costal margin arch, at the level of the lateral border of the rectus muscle.                                                   
10. The Veress needle is introduced through the incision                                       
11. Establish the pneumoperitoneum                                                              
12. Remove the Veress needle 
13. Introduce an 11-mm trocar through the same incision, perpendicularly to the abdominal wall.                                              
14. Introduce the optics through the trocar
15. Inspect the abdomen for any injury due to insertion of the Veress needle or the trocar, and to identify adhesions in areas where the secondary ports will be placed.                                               
16. Second Port colocation (5 mm) according to the baseball diamond concept 
17. Third Port (11 mm)                                      
18. Fourth Port (5 mm) If liver retraction is necessary during a right-side nephrectomy. 
19. Colon Mobilization: For a left-side nephrectomy, the plane between the descending colon and the underlying Gerota’s fascia is developed to allow the colon to fall medially This plane of dissection is carried out cranially. The splenorenal and lienocolic ligaments are incised, allowing the spleen and the tail of the pancreas to be separated from the upper pole of the kidney.
20. For a right-side nephrectomy, the liver is cranially retracted using a grasper that is fixed to the abdominal wall. The ascending colon is mobilized and dissected from the underlying Gerota’s fascia. Mobilization of the colon continues caudally to the common iliac vessels.
21. Following the medial mobilization of the colon and mesocolon
22. Visualize the gonadal vessels 
23. Inside the Gerota’s fatty tissue at the level of the lower pole of the kidney to locate the psoas muscle The psoas is followed to expose the ureter just lateral and deep to the gonadal vessels.
24. Dissect the ureter and freed it until the crossing of the iliac vessels. Both structures are lifted and, by visualization of the psoas muscle, followed cranially to the lower pole and hilum of the kidney
25. Release the attachments between the psoas muscle and Gerota’s fascia by sharp and blunt dissection,
26. Coagulate the small vessels to the ureter and branches of the gonadal vein with the bipolar grasper.
27. On the left, tracking the course of the left gonadal vein into the renal vein and firm elevation of the lower pole of the kidney on both sides assists in the identification and blunt dissection of the renal hilum.
28. The renal vessels should be individually dissected
29. The renal vein is dissected, taking care of the lumbar veins that drain posterior to the vessel. 
30. The left adrenal vein is preserved if the ipsilateral adrenal gland is not removed.
31. The renal artery is exposed posterior to the renal vein and dissected
32. Hem-o-lok. polymer clips are applied to the artery 
33. Use three clips on the renal vein
34. Transect the vessels 
35. The dissection continues posteriorly and superiorly to the upper pole. The attachments of the kidney to the posterior and lateral abdominal wall are released by blunt and sharp dissection.
36. The ureter is double-clipped with Hem-olock clips and transected to allow the kidney to be fully mobilized.
37. Performe a lower ilioinguinal muscle-splitting incision
38. Introduce a large laparoscopic bag through the small opening of the ilioinguinal incision. The kidney is placed intact inside the bag and the specimen is removed.
39. The abdominal wall is closed using running Vicryl 2-0 for the peritoneum and muscle
40. When the abdominal wall is closed, pneumoperitoneum is re-established and the optic introduced for revision of the hemostasis. 
41. Insert a silicone Penrose drain 
42. Close the skin incisions with subcuticular Monocryl 3-0. 
Dr Nitish Kumar Yadav
May 24th, 2020 6:18 am
wonderful Task Analysis for a Laparoscopic Transperitoneal Radical Nephrectomy. Thank you for posting such a useful step of surgery's very informative and educative. Thanks for Sharing.
Dr. Rajashekar Reddy
May 24th, 2020 6:27 am
Thank yous so much sir! Posting such a great article of Laparoscopic Transperitoneal Radical Nephrectomy it's really help me a alot in my surgery. Your videos are the reason I started laparoscopy surgery. I am reading your all task analysis for better understanding. I want join for M.MAS course. Thanks for posting great Task Analysis.
Dr. Bomani Bordoloi
May 24th, 2020 6:31 am
Thanks for posting this !!Task Analysis for a Laparoscopic Transperitoneal Radical Nephrectomy !! Dr. Mishra is so helpful and he make it so much easier to understand than the textbook! Keep it up!!
Thanks for posting.
Dr. Hassan Al Hakimi
May 24th, 2020 6:39 am
Thank you so much for the Article. It's really awesome Task Analysis for a Laparoscopic Transperitoneal Radical Nephrectomy very informative and educative and lot's of information.Keep it up the good work! Thanks for posting.
Dr. Bashir Mahmud Al Rabbani
May 24th, 2020 6:43 am
Awesome.. I tried to understand though textbook, well it left me exhausted, Thanks you sir now everything became clear. God bless you. You're really a great teacher. After reading this Task Analysis for a Laparoscopic Transperitoneal Radical Nephrectomy. seriously changed my practice. Thank you.
Dr. Hemlatha
Apr 29th, 2021 12:44 pm
This is very educative and informative Article with a clear description it's very useful for me. Thanks for sharing.
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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.

Task Analysis of Laparoscopic Surgery

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.

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