Task Analysis of Laparoscopic Procedures

Task Analysis For Laparoscopic Cholecystectomy
General Surgery / Oct 4th, 2017 8:56 am     A+ | a-
Cholecystectomy is one of the most commonly performed abdominal surgical procedures, and in developed countries many are performed laparoscopically. As an example, 90 percent of cholecystectomies are performed laparoscopically. Laparoscopic cholecystectomy is considered the "gold standard" for the surgical treatment of gallstone disease. This procedure results in less postoperative pain, better cosmesis, shorter hospital stays and disability from work than open cholecystectomy
              
 PROCEDURE STEPS:
  1. Patient put under general anaesthesia .
  2. Patient preparation and positioning.
  3. Surgeon , patient and monitor should be at coaxial alignment.
  4. Establishment of the access by Veress needle.
  5. Gas insufflation with CO2.
  6. Ports insertion.
  7. Surgical steps.
  8. Specimen retrieval.
  9. Ports closure .
  10. Deflation  of the abdomen.
  11. Skin closure.
  12. Patient  extubation.
EXECUTIONAL  STEPS :
  • General Anaesthesia :
  1. Patient should be under GA.
  2. Position the patient in supine position.
  3.  Availability of the following  instruments should be checked :
    1. Access instruments : Blade 11,  Veress needle, two 10 mm ports, two 5 mm ports.
    2. Optical instruments: 10 mm telescope, camera, light cable.
    3. Operating instruments : Maryland, Traumatic grasper, semi traumatic grasper, endoclips, Curved endoscissor, Vicryl suture, endobag.
    4. Energy  instruments : Harmonic , hook connected with monopolar.
  4. Check the function of the monitor, insufflator ,light source, amount of gas cylinder, harmonic setting frequency between 3-5, and check the monopolar function for cutting and coagulation.
  • Patient and surgeon Positioning :
  1. Table height should be adjusted to the surgeon height (0.49 X surgeon height).
  2. Patient should be prepped form the nipples to the mid-thighs. Patient draping and cable arrangement.
  3. The surgeon should stand at the left side of the patient, The monitor at the right side of the patient,1st assistant  should be at left side of the surgeon and the 2nd assistant at the right side of the patient.
  4. The monitor, target organ and surgeon should be aligned in coaxial alignment.
  5. The monitor should be at 15 degree below the surgeon eyes and 5 times of its diagonal diameter away from the surgeon.
  • Access and Insufflation:
  1. Umbilicus to be hold With Allys Forceps, then  using  blade 11, 3 mm incision to be made  at the inferior crease of the umbilicus.
  2. Size 10 Veress needle insertion : start with checking the veress needle  function and patency  by flushing it with NS  and hearing 2 clicks of the valve .
  3.  The length of the needle which should be inserted should be 4cm + abdominal wall thickness .Veress Needle  should be hold as dart at 45 degree , left the abdominal wall in a way that veress needle should be perpendicular to it and pointed toward the anus. Will feel  2 areas of resistance , should be intrabdominal after the you passed the 2nd area .
  4. Check the position of the Veress needle by 3 ways:
    1. Flush the needle with NS which should go easily .
    2. Aspirate , nothing should come .
    3. Hanging drop test:  drops of NS are placed at the cannula of the needle , should sink  when  lower abdominal wall is lifted.
        5. Qudrimanometric 40 litres Insufflator to be on, the following setting should be applied:
                  a. Set pressure 12 and flow 1 L / min.
        6. The gas tube  should be flushed with CO2 before attaching it the veress needle.
        7. The gas tube to be attached to the veress needle and start insufflation , making sure that the abdomen is tympanic and                   distended equally in all quadrants. Insufflators parameters should be observed carefully during insufflation .
        8. Once the actual pressure reach to the set pressure of 12 mmHg , Veress needle will be removed.
        9. At the same umbilical  inferior crease , Using 10 mm cannula , the area is marked for the incision, then the incision                            increased to 10 mm, smiley incision  .
       10. The vetelinointestinal tract is opened and dilated with artery forceps .
       11. 10mm port is inserted through the tract and attached to the gas tube.
       12. 30 degree Camera to be adjusted in terms of white balance , and focus .
       13. Camera to be inserted and check for any bleeding, adhesion or bowel injury.
  • Working ports insertion :
  1. Based on baseball diamond concept working ports sites are determined and inserted under direct visualization as follows:
    1. 10 mm port at the epigastric area at the line between xiphisternum and umbilicus. This port should be inserted left to the falcifurm ligament but piercing the membranous part  and should come out right to it.
    2. 5 mm port at right  mid clavicular line, around 2 cm below costal margin.
    3. 5 mm port at the right mid axillary line, around 5-8 cm below the costal margin.
  • Surgical steps :
  1. Position the patient in left lateral, head up.
  2. Through the lateral 5mm port, Using the traumatic grasper, the fundus of the gallbladders should be retracted upward and toward right shoulder of the patient.
  3. The gall bladder is retracted anteriomedialy, With help of the grasper the Hartmans pouch exposed, all adhesions are released with blunt dissection or Harmonic use.
  4. The Gallbladder infundibulum  is retracted toward the left shoulder so the anterior  peritoneum is exposed.
  5. Making sure that we are above the Rouviere’s Sulcus, dissection to be started at the anterior peritoneum  at the Hartmans pouch level using the harmonic.
  6. Then the  infundibulum is retracted to the right side, anterior lateral posterior peritoneum is exposed and  dissected.
  7. By this time a window is created below the infundibulum connecting the anterior and posterior openings.
  8. The critical view of safety (cystic duct, CHD and  edge of the liver) is viewed, Cystic duct is identified, dissected and isolated from the artery. Always avoid over traction , to prevent CBD injury.
  9. Using Vicryl suture with Mishras knot, cystic duct is ligated near the CBD . Moreover , clips are applied at the distal end of the duct. Using the scissor, the cystic duct is cut between the clips and the knot.
  10. Cystic artery is identified and clipped using the endoclips by applying 2 clips proximally  and 1 clip distally.  The artery cut using scissor.
  11. Using the Harmonic, the gallbladder is dissected from the its bed in the liver surface by cutting the anterior and posterior peritoneum.
  12. Dissection continued till the fundus of the gallbladder, till it is detached from the liver.
  13. The gallbladder bed is inspected for any bleeding and should be controlled by using fulguration by monopolar (using hook) .
  14. Using  endobag, the gallbladder is retrieved through the epigastric port.
  • Ports removal and closure:
  1. Under direct vision, 5 mm ports and epigastric port are removed.
  2. Gas insufflation is stopped, abdomen is deflated, The umbilicus port  is removed, facia is closed using Vicryl 0.
  3. All Skin incisions are closed using Vicryl or staplers.
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