Task Analysis of Laparoscopic Procedures

Task Analysis of Laparoscopic Splenectomy
General Surgery / Sep 1st, 2017 2:03 am     A+ | a-
Dr.Tejasvi Kumar.C
Assistant Professor/Lecturer
KIMS, Bangalore
 
Task Analysis of Laparoscopic Splenectomy
 
Indications
  • Idiopathic Thrombocyotopenic Purport
  • Autoimmune Haemolytic Anemia
  • Microspherocytosis
  • Benign tumours and cysts
  • AIDS-related thrombocytopenia
 
Contra-Indications
  • Massive Splenomegaly
  • Portal Hypertension
 Preoperative Preparation 
  • Vaccines - Pneumococcal , Haemophilus influenza, Neisseria meningitidis ideally two weeks prior to surgery or post operatively. 
  • Blood and platelet transfusion if needed and arrange blood.
 
Anaesthesia 
  • General anaesthesia with endotracheal intubation is required.
  • Two large IV catheters.
  • Foleys catheter and Nasogastric tube. 
 
Patient Position  
  • Patient placed in right lateral position and left arm crossing chest and lying on right arm.
  • Left hip and chest are elevated with pillows, leaving the flank area open and the left knee flexed, with a padding o blankets between the legs. 
  • The patients secured across the chest and hips to the table with wide adhesive tape,as the operating room table will be tilted.
Operation room check list
  • Monopolar cautery check done along with patient end plate and Hormonic scalpel checks done. 
  •  Coaxial alignment of surgeon, target and monitor checked. 
  • Camera connected, white balancing and focusing done. 
  • Co2 cylinder checked for sufficient insuflation. 
  •  Working status of all the lap instruments along with insulation check is     properly made. 
 
Operative Preparation

The skin is prepared from the lower chest to pubis.

Port placement
  • A 10 mm camera port is inserted at the level of the umbilicus over the left mid clavicular line. 
  • A 2mm stab incision is placed and verses needle is inserted perpendicular to abdominal wall. 
  • Intrabdominal position if verses is confirmed by the suction, irrigation, hanging drop and plunger test. 
  • Pneumoperitoneum is created by setting the insufflator at 14 mm hg. 
  • Camera inserted and abdomen inspected noting the size of the spleen for working port placement. 
  • Two additional 5mm ports are inserted on either side of camera port at 7.5 cms according to base ball diamond concept. 
  • Additional epigastric port can be inserted for liver retraction in case of hepatomegaly.
 
Details of procedure
 
Dissecting free from ligaments
Splenectomy Laparoscopic

 
  • After inspection of the abdomen the splenocolic ligament is visualised along with greater omentum. 
  • Splenic end of the ligament is identified and elevated with traction identifying a plane above the splenic flexure and entered using harmonic scalpel. 
  • Dissection continued medial to spleen to reach the gastrosplenic ligament containing short gastric vessels. 
  • By giving traction over the greater curvature of stomach lesser sac is entered using blunt dissection and short gastric vessels are divided 1 cm away from the gastric wall. 
  • The pancreas,splenic artery and vein running at the base of lesser sac are visualized. 
  • Short gastric are divided upto gastro oesophageal junction.
  • Spleen is elevated medially and the splenorenal ligament is divided and continued till the top of spleen is free. 
 
 
 
Laparoscopic Spleenectomy
 
 
Dissection of splenic pedicle
  • Dissection of the medial part of spleen continued to reach the splenic pedicle. 
  • The area chosen should be distal to the tail of the pancreas but proximal to the trifurcation of the splenic vessels.
  • A 12 mm port is required for Endo GIA Vascular stapler for the splenic pedicle.
  • Dissection is performed until vessels an be safely encompassed within the  jaws of the Vascular stapler.
  • Care is taken to include the pedicle having splenic artery and vein in the arms of the stapler and fired . 
  • Alternatively artery and vein can be dissected and fired with stapler separately. 
  • Reinforced plastic bag is introduced and the organ is carefully placed into the bag. 
  • Bag is closed and partially withdrawn through the abdominal wall until the open rim of the bag is under control outside the abdomen. 
  • Bag is cut free from the carrier using drawstring in the end of instrument handle. 
  • Spleen is morcellated and extracted 
  • Post extraction the right upper quadrant lavaged with suction irrigator and a careful inspection is made of all cut surfaces and vessels. 
  • Tail of the pancreas is examined for possible injury. 
  • A silastic catheter drain is placed. 
  • All ports are closed under vision.
 Laparoscopic Splenectomy
Post operative care  
  • The NG tube is removed post operatively.
  • Foleys catheter is discontinued when the patient is alert enough to void.
  • Clear liquids can be started within a day and diet is advanced as tolerated.
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