Task Analysis of Laparoscopic Procedures

Diagnostic Laparoscopy for Infirtility
Gynecology / Nov 18th, 2016 5:13 am     A+ | a-
Dr Jyothi Mahesh
MBBS,DGO,MS(OBG)
Consultant Obstetrician & Gynaecologist
Mahesh surgical & maternity centre
Tumkur, KARNATAKA-572103

 

TASK ANALYSIS FOR DIAGNOSTIC LAPAROSCOPY FOR INFERTILITY


1. Surgical team: Surgeon, Anaesthetist, Assistant, Scrub nurse

2. Equipment needed:
       a. Laparoscopic drapes, insufflator, Light source, HD camera with 30 degree telescope(10mm),
          Seven parameter monitor, LCD monitor
       b. Veress needle
       c. Ports: One 10mm reusable port , one 5mm port
       d. Basic laparoscopic instruments - Atraumatic grasper, punch biopsy forceps, suction – 
           irrigation cannula with apparatus.
       e. Speculum, vulsellum, uterine manipulator. Rubin’s cannula, methylene blue dye, 10ml
           syringe
       f. Vicryl 2-0 , size no.11 blade, BPL handle,10mm syringe with saline, 10ml
           syringe with 2%xylocaine , needle holder, straight scissor, 2 alley’s.

3. Method of anaesthesia: General Anaesthesia

4. Setting of the equipment
       a. Pre-set pressures of the insufflator to 12 – 15mmHg 
       b. White balancing with white gauze and focusing at about 10cm range

5. Position of patient:
       Modified lithotomy with head end low by 15 degree.

6. Position of the surgical team and equipment:
       a. Surgeon on the left side of patient, in line with target and monitor, 5 times diagonal length of 
          the screen(co- axial)
       b. Assistant on the right of the surgeon
       c. Assisting nurse in-between legs of patient
       d. Anaesthetist on the cephalad position

7. Attainment of pneumoperitoneum and introduction of ports
       a. Surgeon makes a stab wound with size11 blade at the inferior crease of umbilicus
       b. Surgeon check the spring of veress needle as well as patency with saline in 10mm syringe
       c. Surgeon grab entire thickness of the infra-umbilical midline wall of abdomen & measure
       thickness of abdominal wall. He holds veress needle like a dart at a distance  equal to 4cm plus
       abdominal wall thickness, from tip.
       d. Insert Veress needle pointing towards anus, perpendicular to entry point and 45 degrees to the 
       body of patient.
       e. Surgeon advances the veress needle and feels 2 clicks (one on rectus sheath and one on 
       peritoneum
       f. Surgeon carry out the injection/aspiration test and saline drop test with a 10mm syringe with
       saline, to confirm intraperitoneal positioning of veress needle
      g. Switch on the insufflator and connect the tube to veress needle with flow rate of 1L/min.Monitor
       that the insufflator is confirming correct positioning of veress needle.
       h. Once pressure reached pre-set pressure, Surgeon uses size 11 blade to make a smiley skin
       incision in the infra umbilical crease, to fit a 10mm port. This can be pre-checked by placing a
      10mm port for estimation of incision.
      i. With artery forceps open obliterated vitellointestine duct till rectus sheath & insert 10mm port 
      holding it like a Gun with tip of index finger at half way distance from piercing end, middle
      finger wrapping gas port & then thenar eminence pressing trochar against cannula.
      j. With clockwise & anticlockwise screwing movement enter abdominal cavity perpendicularly &
      hear for single click. Take out cannula & hear for hissing sound of gas which confirm
      intraperitoneal placement.
      k. Surgeon inserts the telescope and confirms intraperitoneal position.
      j. Surgeon inserts the 5mm ports under direct vision in left iliac fossa avoiding vessels.
      k. Inserts atraumatic grasper through 5mm port.

 8. Inspection
Inspects the entire abdomen in steep trendelenberg position in clockwise direction i.e., first structures just below umbilicus& then caecum, appendix,ascending colon, paracolic gutter, hepatic flexure. Then in reverse trendelenberg position inspects right lobe of liver, gall bladder, withdraw telescope little to cross falsiform ligament& then look transverse colon, left lobe of liver, stomach, spleen, splenic flexure,descending colon, sigmoid colon,walk over small intestine. Inspects pelvis-3 false ligaments, 3true ligaments, 3 dangerous areas,uterus, fallopian tubes, ovaries, bladder, POD.

9. Assistant at pelvic end injects methylene blue dye through rubin’s cannula. Surgeon looks for free flow of dye through bilateral fimbrial ends .

10. If any pathology is found, take tissue for biopsy or fluid for cytology. Also take video or photo of pathology found. If consent for operative procedure was taken prior, can proceed. Otherwise don’t proceed.

11. 5mm port is removed under direct vision
  
12. The 10mm port is removed together with telescope

13. The 10mm umbilical port facia is closed with vicryl 2-0

14. The 5mm ports, only skin is closed with vicryl 2-0

15. The 10mm port is closed with subcutaneous vicryl 2-0.



 
2 COMMENTS
Dr. ARUN
#1
Nov 19th, 2016 8:57 am
Nicely written thanks for this task analysis....
S.K. RAMAN
#2
Nov 23rd, 2016 2:56 am
Diagnostic Laparoscopy is a surgical procedure that involves insertion of a narrow telescope-like instrument through a small incision in the belly button. So thanks for help throw this task ...(Dr Jyothi Mahesh)
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