Dr. Ekhlas J M Al sulaimawe
Specialist gynecologist
MB CH B, DGO,SPECIALIST degree IBMA
Azhar HOSPITAL & POLYCLINIC
21 November 2016
1. Before starting the operation, everything in the check list of the OT should be checked, the patient should be prepared by not having solid food for 24 hrs before the operation and given laxative the day before operation ,consent has been taken.
2. Operation team, surgeon ,assistant, scrub nurse, anaesthetist.
3. Equipment needed
• Laparoscopic drapes, insufflators, Light source, HD camera with 30-degree telescope (10mm), seven parameter monitor, LCD monitor
• Veress needle 12 cm with 10 ml N/S syringe, and 10 ml xylocaine 2% for sub cut injection before doing skin in scion.
• One 10 mm port and one 5 mm port
• 11 number scalpel
• Fallope ring applicator preparation and the rings should be ready with the ring pusher. load the ring by ring pusher not more than 10 minute before the application.
4. Preparation of the patient;
5. GA or LA, this depends on the anesthetic decision, sometime epidural could be given, if it is available.
6. Follys catheter insertion; size 14 or more and sometime ask the patient to void before the operation: to me prefer to insert a catheter.
7. Put the patient in supine position.
8. Tilt the patient 15-degree head down.
9. Quadrimanometric device ready, the preset pressure should not be more than 12 mm and the gas flow rate is 1L/min.
10. Position of the surgical team: sugeon on the left side of the patient and in coaxial alignment with the target organ (the tubes)and the monitor at a distant about 5*diameter of the monitor & the table height 4.9*surgeon height.
11. The patient is anaesthetized and muscle relaxant is given.
12. Disinfect the abdomen from the the nipple till the pubic symphysis line and to the level of anterior iliac spines laterally.
13. Xylocine 10 mm is subcutaneously infiltrated around the umbilicus .
18. By the use of 11 mm blade, 2 mm incision at the lower umbilical skin crease
19. Verres needle is checked for valve action and patency by n/s irrigation.
20. Hold it like a dart and skin thickness is elicited by holding it at the level of umbilicus and add to it 4 cm for needle tenting, needle should be perpendicular to the abdominal wall and directed toward anus, left hand should hold the lower abdominal to make it 45 degree toward patient body.
21. Two clicks is heard at this time, the rectus & peritoneum entry, then check by irrigation, suction test, hanging drop test.
22. The insufflator is switched on and connect to the veress needle and close the needle valve.
23. 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 exceed preset pressure.
23. When the actual pressure become equal to the preset pressure, take out the needle, and do 10 mm smiling incision in the lower umbilical crease.
24. Insert some mosquito forceps to the incision to dilate the vitellointestiinal duct and separate the recti muscles.
25. Insertion of 10 mm umbilical port by holding it like a pistol & the index finger pointed forward to the half of the tracar shaft to minimize injury incidence, by screwing movement directed toward anus .one click is to be header and whooshing sound and free movement of trocar indicating right position.
26. Connect the insufflator and close the valve for continuous pneumoperitoneum.
27. White balancing by dipping the telescope to iodine gauze then cleaning and fix at 10 cm distance from the white gauze.
28. Insert the10 mm 30-degree telescope and take a panoramic view and check the port pathway and abdomen that there's no injury had occurred.
29. 5 mm port is inserted under direct vision in the left iliac fossa 7.5 mm lateral to the umbilicus according to baseball theory at the 18 arc.
30. Do diagnostic laparoscopy for the abdomen and pelvis in a clock wise fashion in, trendelenberg position starting from the caecum, ascending colon, paracolic gutter, hepatic flexure. Then in reverse trendelenburg position inspects right lobe of liver, gall bladder. transverse colon, left lobe of liver, stomach, spleen, splenic flexure, descending colon, sigmoid colon, uterus, bladder, ovaries, tubes and Douglas pouch, if there's any pathology, we can take a biopsy but no intervention as far there's no consent was taken for therapeutic intervention.
31. The fallope ring applicator with already inserted ring note more than 10 m beforehand, is inserted through the 5 mm port under the vision of the telescope.
32. Going behind the uterus, lift it up, then a loop of tube will become clear.
33. Open the jaws of the applicator and 2 cm lateral to the uterus, take a bite, apply the ring for 5 seconds then release and check ring placement.
34. The same would be done to the other tube.
35. Take out the applicator from the abdomen.
36. Check that everything and rings placed correctly before deciding to take out the trocar.
37. Take a 5 mm telescope after white balancing and fixation before insertion through the 5mm port.
38. Prepare the veress needle and make a loop of thread (proline)to use it for closure of the 10 mm port to prevent future hernia.
39. Close the umbilical 10 mm port under direct vision by no.1 vicryl.
40. Deflate the abdomen gradually making jerky movement by the 5 mm telescope to avoid intestinal entrapment to the port
41. Put a surgical dressing on the port sites.
42. Documentation is required
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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.
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.
