Task Analysis of Laparoscopic and Robotic Procedures

Laparoscopic Repair Of Inguinal Hernia
General Surgery / Nov 26th, 2016 10:07 pm     A+ | a-
Laparoscopic Repair ofInguinal Hernia: A Task Analysis
Dr. Pramey P. Dhage
General Surgery
World Laparoscopy Hospital
FMAS & DMAS, November 2016

 

Short Review of Inguinal Hernia

An inguinal hernia is a protrusion of abdominal-cavity contents through the inguinal canal. About 66% of the affected people are symptomatic. This may include pain or discomfort especially with coughing, exercise, or bowel movements. Often it gets worse throughout the day and improves when lying down. A bulging area may occur that becomes larger when bearing down. Inguinal hernias occur more often on the right than left side. The main concern is strangulation, where the blood supply to part of the intestine is hampered. This usually produces severe pain and tenderness at that area.

Risk factors : Smoking, chronic obstructive pulmonary disease, obesity, pregnancy, peritoneal dialysis, collagen vascular disease, and previous open appendectomy, among others. Hernias are partly genetic and occur more often in certain families. It is unclear if inguinal hernias are associated with heavy lifting. Repair may be done by open surgery or by laparoscopic surgery. Laparoscopic surgery generally has less pain following the procedure.

Approach Considerations

The basic surgical principles of laparoscopic repair include the following:
1. No tension technique
2. Appropriate trocar placement and 
3. The use of appropriate size mesh.
4. The number of trocars used and their placement are related to the site of hernia.

Preoperative Preparation

The patient must be free of skin infections and the respiratory function must be evaluated and optimized before the operation. If the hernia contains parts of the gastrointestinal tract such as bowel, appropriate imaging should be performed in order to avoid any intraoperative complications. The patient may be given a bowel preparation prior to surgery.

Anesthesia

General Anesthesia with endotracheal tube is required or even high spinal is also preferred now a days. 

Operative Preparation:

Peri-operative antibiotics should be given according to the most recent national guidelines. The stomach must be decompressed with anaso-gastric tube, a Foley catheter must be placed and stockings are applied. The skin is prepared in a routine manner using antiseptics solutions.

Patient Position:

The patient is placed in the trendlenberg position so as to make bowel fall away from the operative site i.e. pelvic region. Optional left or right tilt can be given if required.

Instruments and Surgeon’s Position:

All devices and instruments needed for the operation must be checked for proper function & insulation. The surgeon’s position must follow the principles of ergonomics in laparoscopic surgery i.e. suitable table height of 0.49*surgeon’s height, placement of monitor at a distance of 5 times its diagonal length and at a height not less than approximately 20cm from his/her visual axis & Surgeon –hernia site- monitor all should be along one axis.

Port positioning:
 
The 10mm optical port for the telescope and the 5mm lateral portsfor operating instruments are placed in position as per the “Baseball-Diamond” principle of port placement put forth by Dr. R. K. Mishra for best egronomical comfort & good exposure, traction, counter traction and good working angles between the instruments. The operating ports need to be placed at a distance not less than 5cm with each other. 

Access to peritoneal cavity

a. For the closed technique:

• Make an incision on the skin, no more than 3mm using a scalpel blade No. 11 at inferior crease of umbilicus.
• Lift the abdominal wall and insert the Veress needle through the incision at a 45o angle to the spine and perpendicular to the lifted abdominal wall. (This will help to point the veress needle towards the sacral promomtary in turns sacral hollow curve such a way that none of the visceral organ gets injured.)
• After you hear the “two click” sounds, confirmation of intra-peritoneal entry is done by irrigation,aspiration and hanging drop tests.

b. For the open technique:


• Make a smiling incision on the inferior crease of umbilicus of 11mm.
• Using Scandivian technique, to gain safe entry to the intra-peritoneal space.
• Insert the cannula using the blunt trocar into the peritoneal cavity
• Secure the port with lateral stay sutures 

When access to peritoneal cavity is achieved:

• Connect the CO2 either to the Veress needle (for closed technique) or the port (for open technique)
• Begin inflating the intra-peritoneal space according to the principles of insufflation.
• Observe the rise of the intra-abdominal pressure and the total volume of gas as the abdomen and hernia gets distended.
• For the closed technique, after the intra-abdominal pressure reaches the preset pressure of 12-15mmHg,
• Take theveress needle out of the abdomen
• Enlarge the incision up to 11mm and
• Slowly screw the cannula with the trocar into the peritoneal cavity in perpendicular direction. (Insufflation will avoid the possible visceral injury due toperpendicular entry.) 
• The camera is white-balanced and focused. The telescope is then advanced down through the umbilical port into the abdominal cavity under direct vision.
• All four quadrants of the abdomen are examined for any possible accidental pathological findings, if present.
• Then locate the site of action. It is the inguinal region either right or left or both depending upon the defect site/sites.
• Considering the Baseball Diamond concept, put two 5mm operating ports on either side of optical umbilical port under direct vision from inside eliminating the injury to the inferior epigastric vessels by tras-illumination.
• Once, all ports are in position, the hernia and its contents are evaluated.
• Additional unrecognized hernia defects may be found.

Surgical Procedure

• Adhesiolysis, if required is done and contents of the hernia sac are reduced. Make wise use of energy sources if required.
• Now start the peritoneal dissection laterally from a distance of 6 cm at 2 O’clock position for right inguinal hernia & at 10 O’clock position for left inguinal hernia.
• Hold the peritoneum by Maryland or atraumatic grasper, lift it, take a cut with scissor at desired point.
• Then lift the leaf of peritoneum & start bluntly dissecting the peritoneum using scissor.
• Do only peritoneal dissections lateral tomedial.
• Dissect till you reach above the defect.
• Don’t dissect sac at this point.
• Then start from median umbilical ligament go laterally.
• While dissecting the peritoneum, push the fat towards the anterior abdominal wall so that the vital structures present in the pre-peritoneal fat may fall away from the peritoneum assuring their safety.
• Also the only peritoneal dissection leads to less bleed.
• Once done with the lateral & medial dissections, start dissection of sac with upward & backward traction of sac.
• Special precautions should be taken while dissecting over triangle of doom, triangle of pain & trapezoid of disaster. 
• While dissecting the sac, good differentiation should be sought between sac & pseudo-sac. Pseudo-sac is the transvesalisfasia which may be tractioned upwards leading to pulling up of testis.
• If this happens, assistant should be asked to keep a hold of testis in scrotum & then carefully dissect the sac from pseudo-sac.
• Use of energy sources in the area of triangle of doom should be very carefully monitored.
• Medial dissection should be done upto the visualization of Cooper’s ligament.

Mesh Placement: 

• Prolene mesh – 10*15 cm.
• Make sure for sufficient area is dissected to place the mesh of appropriate size.
• This mesh covers all the hernia sites i.e. Deep inguinal ring, Hasselbach’s triangle, Obturator canal & Femoral ring
• Now make a roll of mesh outside the abdomen. 
• Hold the mesh with a needle holder with a 10 to 5mm reducer previously loaded over the shaft.
• Pull the mesh within the reducer.
• Then introduce the mesh assembly through the 10 mm optical port.
• Now put the telescope in and unroll the mesh under vision.
• First fix the medial corner of the mesh to the cooper’s ligament using either non-absorbable suture material or tackers. 
• Now the mesh is well placed in position.
• If required, mesh can be fixed at the periphery at multiple sites avoiding the delicate areas of triangle
• Of doom, triangle of pain & trapezoid of disaster.
• So it is always better to fix only on the aanterior abdominal wall & inguinal ligament.
• There is also another school of thoughts which say “NO FIXATION IS BETTER FIXATION”.
• Once the mesh is placed, then the over lying dissected peritoneum is resutured using vicryl or fixed with tackers.
• Before moving out the telescope the port entry sites are examined for bleeding.
• Optical port is sutured by placing suture within & out under vision using veress needle or a trans-fascial needle.
• Pneumoperitoneum is relieved.
• Cannula is removed with telescope within so as to make it sure that neither the bowel nor the omentum had entered the port wound.
• Knot is tightened after removal of cannula.
• Skin is sutured using ethiprime 3-0 at all port sites.
• Skin around the sutured wound is cleaned with the antiseptic solution.
• Dry sterile dressings are applied to the entry sites.
 
Postoperative Care

• Remove the nasogastric tube when the patient gains consciousness.
• Remove the Foley’s catheter when the patient is able to void urine of his own.
• Administer appropriate antibiotic, analgesic, PPI, anti-emetics & I.V. fluids as required.
• Advance to oral diet as tolerated by the patient, starting with fluids within 1 day

Complications:

• There are no possible complications if every precaution stated above is very well taken care of.
• Postoperatively, some patients develop prolonged ileus which is usually managed conservatively. 
• Surgical-site infections are rare but if developed, they might require the removal of the mesh.
• Serum accumulation in the previous hernia sac is common. Aspiration is not advocated as it may lead to implantation of nidus for infection. It may resolve of its own in few days.
• Some patients may complain of pain at the fixation sites that may too resolve in few days.
• Discomfort of mesh may be sometimes felt which goes off on its own as the fibrosis occurs.

Bibliography - Internet Sources

1. Task Analysis of Laparoscopic procedures, from World Laparoscopy Hospital Website
2. Guidelines for laparoscopic inguinal hernia repair, SAGES. from:
 https://www.sages.org/publications/guidelines/guidelines-for-laparoscopic-inguinal-hernia-repair/
3. Laparoscopic Inguinal Hernia Repair, WebSurg. Mar 2014; 14(03) Retrieved from:
http://www.websurg.com/Laparoscopic_inguinal_hernia_repair_(LVHR)-vd01en4221.htm 
4. Laparoscopic Inguinal Hernia Repair Technique, Medscape. Retrieved from: http://emedicine.medscape.com/article/1892407-overview
5. Robert M. Zollinger& E. Christopher Ellison (2011), Zollinger’s Atlas of Surgical Operations
6. Richard L. Whelan, James W. Freshman & Dennis L. Fowler (2006), The SAGES Manual: Perioperative Care In Minimally Invasive Surgery

3 COMMENTS
Mohit Tyagi
#1
Nov 27th, 2016 2:25 am
Inguinal hernia repair is surgery to repair a hernia in the abdominal wall of your groin. A hernia is tissue that bulges out of a weak spot in the abdominal wall. Nicely written in these Task by Dr. Pramey P. Dhage.
S.K.Rana
#2
Nov 29th, 2016 2:25 am
Thanks Dr. Pramey P. Dhage for this task
R.K Rawat
#3
Nov 30th, 2016 11:13 pm
Thank you,
It gave me a detailed information on Laparoscopic Repair Of Inguinal Hernia which i am about to get operated for.
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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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