Task Analysis For Endometriotic Cystectomy In An Infertile Female
Dr.G.Latha M.D.,M.ch(Rep med & surgery),
November 2016 batch.
1. Patient to be anaesthetized.
2. Patient to be placed in lithotomy position with 15o head down.
3. Abdomen and perineum to be painted and draped
4. Surgeon has to be on the patient’s left side, assistant on right side and 2nd assistant if needed in between patients legs for uterine manipulation
5. Monitor to be placed 15o below the visual axis of surgeon on the opposite side.
6. All the equipments placed on the opposite side of surgeon
7. Camera, light source, insufflator and electro surgical unit to be plugged in to their respective equipments and all cables tied
over upper drape using a guaze and towel clip.
8. Telescope with camera attached to the light source.
9. Laparoscopic mode to be “on “on the camera cable attachment instrument
10. White balancing and focussing of camera done by placing camera at a focal length of 10cm from gauze piece.
11. Over inferior crease of umbilicus, place 2 Allis tissue holding forceps on either side and give 2mm stab incision with No.11 blade.
12. Dilate rectus muscle until rectus sheath with mosquito forceps.
13. Measure thickness of anterior abdominal wall and add 4cm.
14. Take a veressneedle of 12cm
15. Spring action and patency of veressneedle has to be checked.
16. Hold verres needle like a dart at the measurement taken by adding 4cm to anterior abdominal wall.
17. Lift the lower abdominal wall with left hand and hold Veressin right hand.
18. Veressshould be held perpendicular to the lower abdomen and 45o to upper abdomen.
19. Direct Veresstowards anus.
20. 2 clicks to be heard to say that it has passed intraperitoneally. 1st click is heard as it passess via rectus sheath and 2nd click when it enters via general peritoneum.
21. Confirmation that Veressneedle is intra peritoneal is by hanging drop test and aspiration test.
22. Insufflator tubing to be connected to Veresswhich contains CO2 and creates pneumoperitoneum
23. Preset pressure is set at 12mm Hg and flow rate at 1 litre/ mt.
24. As soon as CO2 flow starts, look over insufflator for quadromanometricmeasurements mainly actual pressure and total volume of gas used.
25. These 2 parameters should raise parallely.
26. Check for liver dullness at 200 cc flow of CO2
27. To reach an actual pressure of 12mm Hg, minimal volume of gas should be 1.5 litres.
28. Once the actual pressure of 12mm Hg attained,Veressneedle to be removed.
29. Incision over inferior crease extended to 10-11 mm as smiling incision.
30. With the help of assistant, lift the lower abdominal wall.
31. Hold 10mm port over the thenar eminence like a pistol
32. Place it perpendicular to abdomen and by screwing movements, pass it intraperitoneallydirected towards the anus.
33. It is confirmed to be intraperitoneal by hearing a click, whoosing sound and also loss of resistance.
34. Now pass a 10mm telescope via the Cannula with light source attached
35. Visualize and confirm that cannula is intraperitoneal.
36. Visual inspection of entire abdomen in clock wise manner to be done.
37. Check for the side and size of endometriotic cyst.
38. Based on base ball diamond concept, 2 ipsilateral 5mm secondary ports made. 1stport is 7.5cm from primary port and 2ndport, 7.5cm from 1stport along the 18 cm arc.
39. These secondary portsare made under transillumination to avoid inferior epigastrc vessel injury.
40. These ports have to be placed such that manipulation angle is 60degrees,elevation angle is 30 degrees and azimuth angle from 30 degrees to a maximum of 60 degrees as they are ipsilateral ports.
41. Laparoscopicchromopertubationdone to check for patency of fallopian tubes.
42. Check for any adhesions.
43. If present, adhesions to be released with harmonic and near bowel and bladder, by scissors.
44. Pass Maryland grasper via left hand through lower left accessoryport and hold the endometrioticcyst.
45. Pass harmonic using right hand via upper left secondary port.
46. Give a small incision using harmonic over the endometriotic cyst.
47. Suck the chocolate coloured fluid from the endometriotic cyst.
48. Remove the harmonic and pass another Maryland or Robidissector.
49. Hold the incisedovarian tissue wall &cyst wall edges with 2maryland’sdissectors.
50. Stripping of cyst wall from ovarian tissue wall to be done.
51. Remove the entire cyst leaving ovary without destroying ovarian tissue so as to not to reduce ovarian reserve.
52. Suction to be passed and check for any bleeders.
53. Fulguration of endometriotic spots to be done.
54. Cystectomy specimen brought outvia 10mm port by passing 5mm telescope through 5mm secondary port incision on left side
55. Replaced by 10 mm telescope once the cystectomy specimen removed.
56. Thorough suction irrigation has to be done with normal saline
57. Check for perfect haemostasis.
58. Around 1.5 litres of normal saline left inside the abdomen to prevent adhesions.
59. Abdomen deflated
60. Left secondary ports removed under vision
61. Now the primary port has to be removed by shaking movements so that omentum doesn’t entangle.
62. 10 mm port site closed using Veress needle.
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