Task Analysis of Laparoscopic Procedures

Task Analysis For Ruptured Right Sided Ectopic Pregnancy
Gynecology / Oct 3rd, 2017 5:22 am     A+ | a-
Dr. Elizabeth W. Kimotho
M.B.Ch.B, M.Med OBGYN,
The Nairobi Hospital, Kenya.

Introduction:-

Ruptured ectopic pregnancy is a common gynaecological emergency which requires prompt and precise intervention in order to save the woman’s life.  Intervention required is salpingectomy to achieve haemostasis and at the same time a diagnostic laparoscopy to inspect the other fallopian tube and both ovaries.

Contraindication:-

Shock is a common presentation in ruptured ectopic.  In class 1 and 2 shock, laparoscopy is the Gold standard.  However in Class 3 and 4, laparotomy is preferred as the patient is haemodynamically unstable and cardiovascular system is compromised due to hypovolimia.

Pre operative laboratory tests:-
  • Full blood count
  • Urea, electrolytes and creatinine
  • Blood Group and crossmatch.
Team members:-
  • Gynaecologist (surgeon)
  • Anaesthesiologist
  • Nurse assistant
  • Scrub nurse
  • Runner nurse
  • Theatre technician.
Equipment:- 
  1. Tower – 2 monitors, light source, suction irrigation, electro-surgery power source, insufflator, camera and video recorder.
  2. Cables – light cable, suction irrigation, bipolar, camera and gas.
  3. Access equipment – veress needle, 3 cannula and trocar (two 10mm and one 5mm) , telescope (10mm, 30degree), camera , scalpel blade number 11, 10cc syringe with normal saline, 2 alice forceps and an artery,
  4. Operation equipment – Maryland forceps, probe, semi traumatic grasper with rachet handle, 10mm suction and irrigation, electro surgical equipment (bipolar forceps or harmonic or ligasure), endo loop or suture for extra corporeal knot (75cm length) and endo bag (size A).
Patient position:-

Semi lithotomy position with 20degree head down during entry into peritoneum.  Thereafter, further head down 30 degrees to move haemoperitoneum out of the pelvic cavity and allow for better visibility.

Surgical Team position:-

Surgeon on the left side of patient (opposite side to the pathology), Assistant on the right side, scrub nurse on the left side next to surgeon, Anaesthesiologist near head of patient.

Equipment position:-

Surgeons monitor should be on the right side of patient.  Co axial alignment of the surgeon, operation site and screen is very important for ergonomics in laparoscopy.  Second screen for assistant should be on the left side.  Tower should be at a position clearly visible to the surgeon.  Anaesthetic machine will be located close to the head of the patient.

Task analysis:-
  1. Clean and drape the patient under general anaesthesia.  Position patient in trendellenburg position 20 degrees.
  2. Connect the telescope, light source and camera.  White balancing and focusing of the camera is done at focal length of 10cm for 10mm telescope.
  3. Evert the umbilicus with 2 alice forceps and thoroughly clean the umbilicus.  Location of primary port entry depends on several factors;
    1. Intra umbilical in obese patients
    2. Supra umbilical in a patient with previous pelvic surgery
    3. Inferior crease of the umbilicus in other patients
  4. Using scalpel make small stab incision on only the skin, 2mm length at the determined port site.
  5. Veress needle is then introduced held like a dart at the length of 4cm + thickness of anterior abdominal wall.  Pull the full thickness of the anterior abdominal wall upwards using the thena, hypothena and all fingures of both surgeon and assistant.  This will enable the veress needle point towards the anus (90 degrees to the skin and 45 degrees to the patient axis).  Two clicks will be felt as needle penetrates the abdominal wall (1st rectus sheath and 2nd peritoneum).  To confirm correct position of the veress needle 4 tests are performed;
    1. Irrigation – push in 5cc Normal saline it should flow without resistance.
    2. Suction – sucking should have only gas bubbles
    3. Hanging drop – drop at the tip of veress should be sucked in when a negative intra-abdominal pressure is created by lifting the abdominal wall.
    4. Plunger test - removing the plunger from the syringe and creating negative intra-abdominal pressure causes the fluid in the syringe to be sucked in.
  6. Insufflator machine is now switched on to push air out of the tube.  Tube is then connected the veress needle and set flow rate of 1litre/minute.  Set pressure should be 12-15mmHg.  Watch the insufflators as the flow rate of gas and actual pressure should rise at the same rate. Watch out for uniform distension of the abdomen and loss of dullness over the liver after entry of 200ml gas.  Once actual pressure and set pressures is equal, switch off insufflator and remove the veress needle.
  7. Insertion of primary port – 10mm cannula and trocha is used for the optical port.  The skin incision is now extended with the scalpel to 11mm in the shape of a smile.  Trocha and cannula are held like a pistol with the index figure pointing to control depth of insertion, head of trocar on the thena eminence and middle figure wrapped around the gas channel.  Screwing motion at 90 degrees to the patient is used to enter the peritoneal cavity.  Confirmation of entry into the peritoneal cavity is by;
    1. Loss of resistance
    2. Sound of gas leaking from a reusable cannula and in disposable cannula there is a clicking sound as the blades retract. 
  8. Trocha is withdrawn and telescope with light cable and camera in inserted for inspection of the abdominal cavity.  Quick inspection for possible injury to viscera or abdominal wall structures is done.  Then confirmation of the pathology in the right adnexea. 
  9. Using the baseball diamond principle, two secondary ports are introduced under vision.  This is done by trans-illuminating over the area of ectopic to get surface landmark of the target.  Two arcs of 18cm and 24cm radius are drawn around the target and 2 suitable secondary port sites identified between these arcs.  Trans-illumination of the secondary port site to ensure no major vessel is in this area.  Tenting is done and cannula is inserted at 90 degrees to the patient until one click is felt (entry into the rectus sheath), the cannula is then directed towards the pelvis for the second click (entry into peritoneum cavity).  Secondary or working ports should be 10mm and 5mm.  Introduce a probe and surgeon can do a quick diagnostic laparoscopy (surgeon controls both camera and probe).
  10. Head low position is then done to take haemoperitoneum away from the site of the ectopic.  Grasper and Maryland are used to identify the right tube and confirm that it is ruptured.  In cases of tubal abortion it is possible to save the tube as long as haemostasis is achieved.  Otherwise, if tube is ruptured the salpingectomy is done (aim to conserve ipsilateral ovary). 
  11. Dissection of the mesosalpinx for free the right fallopian tube from ovary and other broad ligament structures is then done using scissors or bipolar or harmonic.  Retraction of the fallopian tube in anterior and medial direction to give adequate space for dissection and avoid injury to pelvic wall.   Caution in the dissection is important to avoid;
    1. Devascularization of the ovary - it occurs when the ovarian artery is injured in the infudibulopelvic ligament which contains the ovarian artery.    
    2. Cutting the tube too close to the uterus – it creates a uteroperitoneal fistulae and becomes a source of endometriosis.  So always cut 0.6cm away from the uterus.
  12. Various methods can be used for performing the ligation and cutting for salpingectomy :
    1. Endo loop is inserted.  Grasper goes through the loop and holds the right tube close to the uterus.  The pre-tied knot is then tightened around the tube distal to the ruptured segment of the fallopian tube.  The tube is the cut with scissors and/or electrosurgery and observed for haemostasis.
    2. Extracorporeal knot is tied with a 75cm length suture (Roaders, Meltzers or Mishras knot).  Then introduced with the Bandarkar knot pusher.  Grasper goes through the loop to grasp the fallopian tube and pull it through.  Then Bandarka knot pusher is used to place the knot distal to the ruptured segment close to the uterus.  Knot is the tightened by pushing the knot 3 times.  Then  as above, ligation and cutting of the tube is done.  Again observe for haemostasis.
    3. Electrosurgery (bipolar and scissor, harmonic or ligasure) can be used to cut and coagulate the right fallopian tube by cutting the right tube close to the uterus.  This is the preferred mode as it cuts and coagulates at the same time thus achieving better haemostaisis.
  13. Inspection of the contralateral left tube and both ovaries is done.  Their condition must be noted in view of possible future fertility for the patient.
  14. Suction and irrigation of the clots is now done. 10mm suction and irrigation is best as it does not easily block with the clots of the hemoperitoneum.  Heparinized saline can be irrigated to help break the clots.    Also manual breaking of the clots can assist with smooth flow of the suction process.  Patients head low is now reversed to enable blood from upper abdomen and paracolic gutters to come into the pelvis.
  15. Port closure is then done under vision with the veress needle for both 10mm ports.  Suture is passed but not tied.
  16. Tissue retrieval – there are various techniques that can be applied to remove the fallopian tube from the peritoneal cavity;
    1. Pull the tissue through the 10mm port with the grasper.  Align the tissue longitudinally.
    2. Use of an endo bag.  It is inserted via the 10mm port and tissue and placed inside it.  It is then closed and brought close to the 10mm port with a Grasper forcep. Cannula and grasper are removed from the abdominal wall (leading to loss of gas) and the endo bag is pulled out.  If the tissue is too bulky, it can be retrieved in pieces with an ovum forcep through the abdominal wall to debulk the endobag.
  17. Cannula for 5mm port is retrieved under vision.  10mm secondary port can now have suture tied under vision.  Gas can now be slowly released.  Lastly the Optical port with the telescope is removed, first the cannula, then telescope track out to ensure no gut or omentum is getting into the port.  Close suture for the 10mm primary port.
  18. Clean and dress the port sites.  Access the patient haemdyamic status and need for blood transfusion post operatively.  Early mobilization and feeding within 6-8hrs is recommended.  Post operative analgesics and antibiotics are also given to the patient.
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