Task Analysis of Laparoscopic and Robotic Procedures

Task Analysis of Laparoscopic Sigmoid Colon Resection:
General Surgery / Aug 19th, 2019 2:05 pm     A+ | a-

Task Analysis of Laparoscopic Left Colectomy / Sigmoid Resection:

Dr. Nuaman Ahmed Danawar
General Surgeon
F.MAS & D.MAS course August 2019


General Procedural Task Steps:

A. Exposure

1. operating room setup (position of surgeons, scrub nurse, drapes, etc.)
2. Patient positioning
3. Laparoscopic access (open, Veress needle or other techniques, and insertion of ports).
4. Exposure of operating field (moving of omentum, small bowel, etc.)
B. Dissection of the vascular pedicle
5. Dissection of the vascular pedicle (incision of the peritoneum, creation of window below and above, and dissection with
stapler, clips, ultrasound dissection tool or other techniques)
6. Retrocolic dissection of mesentery (right side toward hepatic flexure, left side toward splenic flexure)
7. Identification of landmark (right side: duodenum, left side: left ureter) C. Mobilization
8. Dissection of flexure (right side: hepatic, left side: splenic)
9. Mesorectal dissection (including total mesorectal excision (TME), only for rectal resections) 10. Dissection of
the bowel (transection, using stapler another similar device)
D. Anastomosis
11. Extraction of the specimen (creation of incision, bringing out the specimen, completion of resection)
12. Anastomosis (intra or extra-corporeal)

Detail Executional Task Steps:

1. Perform a vertical supraumbilical incision within the site of the planned incision for specimen extraction to place
the camera port (10/12 mm) using an open Hasson technique. In certain instances where an infraumbilical
extraction may be possible (based on pathology and patientʼs body habitus), this site may be used.
2. Insert a 30° laparoscope through this trocar and establish pneumoperitoneum to 15-mm Hg with carbon
dioxide.
3. Two other trocars are required: Place one trocar in the right upper quadrant and one in the right lower quadrant
(will be used for endoscopic stapler), both lateral to the rectus muscle.
4. Additional trocars: A third trocar may be placed in the left lower quadrant to aid in the mobilization of the splenic
flexure, surgeon standing in between the legs using the right and left lower quadrant trocars). A left upper
quadrant trocar placed lat- eral to the rectus muscle may be used for additional retraction. This site also provides
an excellent vantage point for laparo- scopic visualization of the anastomosis. A fifth trocar is some- times placed
high in the right upper quadrant if needed.
5. A thorough inspection of the liver and the peritoneal cavity is required for patients with cancer to exclude any
metastatic disease.
6. Place the patient in steep Trendelenburg position with the right side of the table down.
7. Gently bring the small bowel out of the pelvis and sweep it into the right upper quadrant.
A. Lateral-to-Medial Approach
8. Grasp the sigmoid colon with an endoscopic grasper and retract it medially to expose the white line of Toldt.
9.Using either a 5-mm energy device or cautery scissors, incise the peritoneum to mobilize the sigmoid and left
colon to the level of the splenic flexure.
10. Continually grasp and manipulate the left colon/sigmoid as needed to maintain adequate superomedial tract.
This facilitates the dissection as it progresses medially to expose Gerotaʼs fascia, ureter, and sacral promontory
11. Next, reposition the patient in reverse Trendelenburg.
12. Mobilize the splenic flexure and distal transverse colon.
13. Grasp the greater omentum and lift it cephalad. Divide the gastrocolic omentum to the level of the middle colic artery.
14. Grasp the transverse colon with an endoscopic grasper and dissect the transverse colon and splenic flexure
free of the retroperitoneum inferior to the spleen.
15. After complete mobilization, intracorporeally ligate the vascular pedicle.
a. Medially isolate either the superior hemorrhoidal and the
left colic arteries or the inferior mesenteric artery.
b. Anterolateral retraction of the left colon facilitates this
identification.
c. Isolate the vessels by scoring the mesentery and creating
windows in the mesentery on each side.
d. These vessels can be divided using electrothermal bipolar
vessel sealing devices, an endoscopic stapler, or endoscopic clips. Typically, any of these devices are introduced
through the right lower quadrant trocar for an optimal angle.
e. Prior to ligation, visualize the tissue on either side of the vessel and reconfirm the location of the ureter. This is
crucial to ensure that nothing else is incorporated in the ligation. After confirming satisfactory positioning,
perform vessel ligation.
f. Continue dividing the mesentery heading cephalad and identify the inferior mesenteric vein. Isolate and divide
the vein using electrothermal bipolar vessel sealers, clips, or an endoscopic stapler.
g. Typically, only the above-named vessels are divided in this manner.
16. After isolating the smaller vessels in the sigmoid mesentery, control them with clips, electrothermal bipolar
vessel sealers, or ultrasonic shears.
17. Choose the distal extent of resection and circumferentially expose the colonic or rectal wall. This may be
performed using an energy source or a cautery-hook dissector, and at times curved dissector (such as Maryland
forceps) may be useful to develop the plane between the bowel wall and the mesocolon. Bare colon or rectal wall
should be demonstrated circumferentially.
18. Insert a 60-mm linear cutting stapler, encompass the bowel wall between the blades (making sure that
laterally nothing else is incorporated into the blades), and fire the stapler.
19. Once the left colon and sigmoid have been completely mobilized as described, grasp the proximal stapled
colon end with a locking forceps.
20. At the site of the initial trocar (camera trocar) in the infraumbilical position, make a 2- to the 4-cm vertical
incision in the skin and the fascia to allow extraction of the colon. Alternatively, a small Pfannenstiel left lower
quadrant or lower midline incision can be used.
21. Allow the pneumoperitoneum to collapse and place an Alexis® or another similar wound protector (usually, a
small to medium size is required).
22. Deliver the colon through the midline wound, and eviscerate the left colon and sigmoid on the abdominal wall.
23. Perform the proximal resection extracorporeally in conventional fashion. Place a purse-string suture and insert the circular stapling anvil into the proximal end of the bowel. Secure the purse- string suture and replace the
bowel into the abdominal cavity
24. In order to reestablish pneumoperitoneum, we recommend closing the fascia with two running absorbable
sutures (one starting superiorly and one inferiorly) and leaving the ends untied in order to allow replacement of
the Hasson trocar.
The sutures should be fastened to the trocar and should be long
enough so that they can be tied at the end of the operation.
25. Grasp the anvil with a laparoscopic anvil-grasping clamp or alligator clamp. Assess the ability of the anvil to
reach the planned anastomotic site. Further mobilization and/or vascular
division may be needed and should be performed if necessary.
26. Verify the correct orientation (i.e., no twist) for the proximal bowel.
27. Transanally insert a circular stapler and advance it to the distal
staple line. Under direct laparoscopic visual control, extend the spike of the stapler through the distal staple line.
Attach the anvil.
28. Move the laparoscope to the right lower quadrant trocar to best visualize the anvil and stapler head coming
together. Once satisfied, close, fire, and remove the stapler. Inspect the two donuts for completeness.
29. Test the anastomosis by placing an atraumatic clamp across the bowel proximal to the anastomosis. Use the
suction irrigator, fill the pelvis with saline, and immerse the anastomosis. Insufflate the rectum with air using a
bulb syringe, proctoscope, or flexible sigmoidoscope, and observe for air bubbles.
30. Irrigate the abdomen, obtain hemostasis, and close the trocar sites.
31. Remove the Hasson trocar and complete the closure of the small midline incision with the two sutures that
were placed earlier on (in Step 24). Close the fascia of all 10/12-mm trocar sites in the usual fashion.
B. Medial-to-Lateral Approach
32. This approach starts with the identification of the inferior mesenteric artery and its ligation.
33. Using an endoscopic grasper, retract the sigmoid colon supero- laterally and identify the inferior mesenteric
artery.
34. Proceed as described above (Steps 15c–g).
35. Proceed with lateral mobilization of the left colon and sigmoid
as described above (Steps 8–14), followed by Steps 16–31 to complete the procedure.
4 COMMENTS
Dr. Nutan Singh
#1
May 22nd, 2020 2:44 am
Thank you for that motivational article. It lets me feel that I can do it. Thanks for sharing your experience and knowledge.
Dr. Ratna Kumari
#2
Apr 29th, 2021 5:34 am
I really loved reading your article. I also found your posts very interesting. In fact, after reading, I had to go show it to my friend and he enjoyed it as well! Thanks for posting this educational article of Task Analysis of Laparoscopic and Robotic Procedures.


Dr. Ahmed Faud
#3
Apr 29th, 2021 5:39 am
I think this is one of the most significant information for me and I’m glad to read your article. Thank for sharing!

Dr. Mukesh Sharma
#4
Apr 29th, 2021 5:44 am
I think this is an informative post and it is very useful and knowledgeable. I really enjoyed reading this post, thank you for posting Task Analysis of Laparoscopic Sigmoid Colon Resection
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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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