Task Analysis of Laparoscopic Procedures

TASK ANALYSIS OF TAPP FOR RIGHT INGUINAL HERNIA
General Surgery / Oct 6th, 2017 7:06 am     A+ | a-
Dr. Ramesh Basnet
Nepal


A)Patient Position:

1. The patient is placed in the trendlenberg position so as to make bowel fall away from the operative site

B) Instruments and Surgeon’s Position:
1. The height of table should be 0.49 times surgeon height.
2. The monitor should be at a distance of 5 times its diagonal length from Surgeon.
3. The surgeon should stand on left side.
4.The Surgeon, the hernia site and the monitor should be along the same axis.

Port positioning:
1) The Optical Port should be placed at infraumblical crease.
2) The other two port is placed according to baseball diamond concept ,ie.  one on rt side and other on left side.

Access to peritoneal cavity
1. Make an incision 2 mm with 11 no blade at inferior crease of umbilicus.
2. Lift the abdominal wall and insert the Veress needle directing towards anus through the incision at a 450 angle to the        spine and perpendicular to the lifted abdominal wall.
3. Make confirmation of introperitoneal entry by double click sound, Hanging drop test and Plunger test

After confirmation:

1.Connect the CO2 either to the Veress needle  & begin inflating the intra-peritoneal space till the intra-abdominal pressure reaches the preset pressure of 12-15mmHg,
2.Take the veress needle out of the abdomen
3. Enlarge the infraumblical incision up to 11mm.
4.Put the canula inside the trocar
5. Slowly screw the cannula with the trocar into the peritoneal cavity in perpendicular direction.
6.  The camera is white-balanced and then focused.
7. The telescope is then advanced through the umbilical port into the abdominal cavity under direct vision.
8. Perform diagnostic laparscopy and locate the site of pathology
9.  Make two 5mm operating ports on either side of optical umbilical port under direct vision on the concept of baseball diamond theory.

Procedural Steps:

1. Start the peritoneal dissection at 2 O’clock position at a distance of 6 cm from the outer margin of the hernia defect.
2. Hold the peritoneum by Maryland and lift it and cut the peritoneum with scissor at a point mentioned above
3. Allow the CO2 to enter inside which will create the plane of dissection
4. Then lift the leaf of peritoneum & start dissecting the peritoneum using scissor till you reach the medial umbilical ligament.
5. While dissecting the peritoneum, push the fat and fibrous strands towards the anterior abdominal wall.
6. Make medial Pocket: Push the bladder down and push the fibrous tissue towards anterior abdominal wall till u see the coopers ligament
7. Make lateral pocket:
  • Push the fibrous tissues towards abdominal wall and push the posterior leaf downwards     
  • Complete dissection over triangle of doom and pain
8. Start dissection of sac
  • Hold the sac with Maryland
  • Do blunt dissection by pulling the sac towards you and pushing the vas deferens, spermatic vessels away  till the sac separates from spermatic cord.
Mesh Placement: 

1. Take Prolene mesh – 10*15 cm and make a roll of mesh outside the abdomen.
2.  Hold the mesh with a needle holder and put it inside the reducer
3. Introduce the mesh assembly through the 10 mm optical port.
4.  Put the telescope in and unroll the mesh under vision.

Fixation of Mesh:
With Tackers
1. Fix the medial corner of the mesh to the cooper’s ligament using either tackers.
2. Apply one tacker on mesh over rectus abdominis in anterior abdominal wall
3. Apply one tacker on mesh over transverse fascia in anterior abdominal wall
With Suture
1. Hold the need holder with right hand and rotate it anticlockwise and take bite over cooper ligament and mesh and fix with intracorporeal surgeon knot
2. Take bite on rectus abdominis muscle and on mesh and fix with intrcorporeal surgeon knot.
3. Take a bite on transverse fascia and on mesh and fix with itracorporeal surgeon knot.
 
Peirtoneal closure:
With Tackers
       1. Do double breasting of lower leaf over the upper leaf of perintoenum and apply tackers.
With Suture 
       1. Start Suturing from lateral to medial with continous inracorporeal suture with vicryl 2.

Port side closure:
1. The port entry sites are examined for bleeding.
2. Close the optical port using veress needle under vision with 5 mm telescope from 5 mm canula.
3. Pneumoperitoneum is relieved.
4. The Cannula is removed with telescope within so as to make nothing comes along with it and.
5. Tighten the knot after removal of canula.
6. Other two port site are closed.
7. Skin around the port site  is cleaned with the antiseptic solution.
8. Dry sterile dressings are applied on the port sites.





 
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