Task Analysis of Laparoscopic Procedures

Task Analysis of Laparoscopic Cholecystectomy
General Surgery / Aug 27th, 2017 4:42 pm     A+ | a-
DR. M.RAJESH GANDHI
CHETTINAD MEDICAL COLLEGE AND HOSPITAL
KELAMBAKAM, CHENNAI
 
TASK ANALYSIS OF LAPAROSCOPIC CHOLECYSTECTOMY

Anesthesia:

1.      Laparoscopic cholecystectomy must be performed under general anesthesia
2.      checking the all devices
3.      Before starting operation surgeon must be sure all devices (insufflator, camera, light source, monitor, telescope and energy devices set up) are working.
4.      Surgeons position
5.      Operation table height must be 0.49 X surgeons height
6.      Surgeon stands left side of the table
7.      Camera assistant stands left side of the surgeon
8.      Other assistant stands opposite side for traction of fundus
9.      Surgeon, target organ and monitor should be in coaxial alignment
10.   Monitor should be placed 5 times far from the surgeon of its diagonal diameter and height should be 20 cm lower than surgeon’s eyes.
 
Preparation :

1.The skin is initially prepared with betadine solution from just below   the nipple line to the inguinal ligaments and laterally to the anterior superior iliac spine. The operative field is then draped with sterile drapes.

Insufflation:

1.      One of the most important step of all laparoscopic procedures is correct and enough insufflation the abdomen with CO2.
2.      Evert umbilicus with two Alley’s  forceps  both side
3.      Make an 3 mm skin incision with no :11 blade over the lower inferior crease of umbilicus.
4.      Hold up the abdominal wall 
5.      Hold the Veress needle( 4cm + thickmess) as a dart and put on the incision
6.      Veress needle must be perpendicular  to abdominal wall
7.      Tip of the veress needle should be inserted towards rectum
8.      Push the Veress needle and pass two layers of abdominal wall( realizes 2 prick)
9.       3  confirmatory tests to be done ;a) flushing  and  aspiration b) hanging drop c) plunging . when all these confirmatory tests shows positive it indicates entered into pneumoperitoneum.
10.   Connect the CO2 tube.
11.   Enlarge the incision( 1cm) to become smiley incision for optical port
12.   Insert 10 mm trocar with screwing movements slowly
13.   Connect the gas tube to the trocar
14.   Be sure your camera’s white balance is OK 
15.   Insert the camera through the 10mm trocar
16.   30 degree camera is recommended
17.   After entering the abdominal cavity inspect all abdomen possible bleeding, injury, adhesions or other pathologies which are undefined before.

INSERTION OF WORKING PORTS( BASED ON BASE – BALL DIAMOND)

1.      A 1 cm incision approximately in the junction of upper third minimizing 2/3rd of the line between your xiphisternum and umbilicus.
2.      A 5 mm incision within the right mid-axillary line about5 - 8 cm below the rib margin.
3.      A 5 mm incision in the right mid-clavicular line about 2 cm. below the costal margin.
EXPOSURE AND DISSECTION
1.      The lateral port  is applied to the fundus and used to hold it cephalad over the dome of the liver.
2.      If  gallbladder distended extremely it must be drained with a needle.Hold the Hartman’s pouch with the medial grasper and make a traction to caudolateral.
3.      With this maneuver straighten the cystic duct (ie, retracts it at 90° from the common bile duct [CBD]) and helps protect the CBD injury. 
4.       Any adhesions are between the gallbladder and the omentum or duodenum must be dissected with energy devices.( momopolar, bipolar, harmonic).
5.      On the area of the hilum of the gallbladder it must be avoided over-dissection.
6.      All movement are must be controlled and towards down to up.
7.      After dissecting adhesions by retracting the infundibulum to the left side anterior peritoneum of gallbladder must be dissected at the level of Hartman’s pouch.
8.      Then by retracting the infundibulum to the right side dissect the posterior peritoneum.
9.      After opening both side of peritoneum there will be a window behind the infundibulum.
10.   In this bundle there is cystic duct and artery.
11.   Exposure them with meticulous dissection.
12.   After having enough space put 3 clips to the cystic duct or ligate it with extracorporeal suture
13.   Then apply 2 clips to the artery.
14.   Cut both of them with scissor or with energy device such as harmonic
15.   Hold the infundibulum again.
16.   With monopolar hook or harmonic device start the dissection to gallbladder from hepatic surface.
17.   Subsequently cut  both side of peritoneum .
18.   Make some traction to upper side.
19.   In this step be careful about some aberrant bile duct or artery.
20.   Dissect the gallbladder towards the fundus.
21.   Small oozing is controlled by fulguration.
22.   Try to avoid perforation of bladder.
23.   Before the cutting last attachment of fundus  look for bleeding of liver and clip area.
24.   If there is some clots irrigate and aspirate for better view.

Mobilization and removal of gallbladder
  • With 5-mm graspers are applied to the gallbladder and used to hold it over the right upper quadrant. . 
  • Bed of bladder and sub and suprahepatic spaces are irrigated and suctioned to ensure adequate hemostasis and removal of any debris or bile that may have spilled.
  • Gall bladder is retrieved by using endobag through epigastric port .
 
Port removal and closure

1.       The epigastric port   and the two 5-mm ports are removed under direct vision.
2.       The fascia is closed at the umbilical port.
3.       All of the skin incisions are closed with skin staples .
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