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
- 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.
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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How to Perform and Implement Task Analysis of Laparoscopic and Robotic Procedures
Task analysis is a critical component of any complex surgical procedure, including laparoscopic and robotic surgeries. It involves breaking down the procedure into its constituent tasks, identifying the steps, skills, and cognitive processes required. Task analysis not only enhances the understanding of these intricate surgeries but also serves as a foundation for training, skill assessment, and continuous improvement in healthcare. In this essay, we will delve into how to conduct and implement task analysis for laparoscopic and robotic procedures.
Understanding the Significance of Task Analysis
Before we explore the procedure for task analysis, it's essential to recognize why it is of paramount importance in the realm of surgery, particularly for laparoscopic and robotic procedures.
1. Enhanced Learning and Training: Task analysis helps in developing structured training programs. It breaks down complex procedures into manageable components, making it easier for trainees to learn and practice each step methodically.
2. Skill Assessment: By understanding the tasks and sub-tasks involved, it becomes possible to assess the competence of surgeons and surgical teams. This is crucial for ensuring patient safety and quality care.
3. Workflow Optimization: Task analysis can reveal inefficiencies in surgical workflows. Identifying these bottlenecks allows for process improvements, potentially reducing surgical times and enhancing outcomes.
4. Error Reduction: Recognizing potential points of error is vital for preventing surgical complications. Task analysis can highlight critical steps where errors are more likely to occur, leading to proactive measures to mitigate risks.
Procedure for Task Analysis of Laparoscopic and Robotic Procedures:
Task analysis for laparoscopic and robotic procedures involves several steps:
Step 1: Define the Surgical Procedure
Begin by clearly defining the surgical procedure you wish to analyze. Whether it's a laparoscopic cholecystectomy or a robotic prostatectomy, having a specific procedure in mind is essential.
Step 2: Gather Expert Input
Engage experts in the field, including experienced surgeons, nurses, and other surgical team members. Their input is invaluable in identifying and detailing the tasks involved.
Step 3: Identify the Tasks and Sub-Tasks
Break down the surgical procedure into tasks and sub-tasks. For instance, in a laparoscopic cholecystectomy, tasks could include trocar placement, camera insertion, gallbladder dissection, and suturing. Sub-tasks under "trocar placement" might involve choosing trocar sizes, making incisions, and inserting trocars.
Step 4: Sequence the Tasks
Establish the chronological order of tasks. Determine which tasks are dependent on others and identify any parallel processes. Sequencing tasks is essential for understanding the flow of the procedure.
Step 5: Define Task Goals and Objectives
For each task and sub-task, define the goals and objectives. What should be achieved in each step? For instance, in gallbladder dissection, the goal might be to safely detach the gallbladder from the liver while preserving nearby structures.
Step 6: Skill and Equipment Requirements
Specify the skills and equipment required for each task. Consider the level of expertise needed, such as basic laparoscopic skills or advanced robotic manipulation. Document the instruments and technology involved.
Step 7: Cognitive Processes
Identify the cognitive processes involved, such as decision-making, spatial orientation, and problem-solving. Understanding the mental aspects of surgery is critical for training and error prevention.
Step 8: Consider Variations and Complications
Acknowledge potential variations in the procedure and anticipate complications. How would the surgical team adapt if unexpected issues arise? Task analysis should encompass both the standard procedure and potential deviations.
Step 9: Develop Training and Assessment Tools
Use the task analysis results to create structured training modules. These modules should align with the identified tasks, objectives, and skill requirements. Additionally, design assessment tools to evaluate the competence of trainees and surgical teams.
Step 10: Continuous Improvement
Task analysis is not a one-time endeavor. Regularly revisit the analysis to incorporate new techniques, technology, and best practices. Continuous improvement is vital for staying at the forefront of surgical care.
Implementing Task Analysis Results:
Once task analysis is complete, it's crucial to implement the findings effectively:
1. Training Programs: Develop and deliver training programs based on the task analysis. These programs should encompass both simulation-based training and real-life surgical experience.
2. Skill Assessment: Use the assessment tools developed during task analysis to evaluate the skills of surgical teams. This can be done through structured evaluations and objective metrics.
3. Quality Improvement: Task analysis can reveal areas for process improvement. Work with the surgical team to implement changes that enhance efficiency and patient outcomes.
4. Error Prevention: Utilize the identified points of error to develop strategies for error prevention. This might involve checklists, preoperative briefings, and enhanced communication protocols.
5. Research and Innovation: Task analysis can also guide research efforts, leading to the development of new techniques and technologies that improve surgical procedures.
In conclusion, task analysis is an indispensable tool in understanding, teaching, and advancing complex surgical procedures such as laparoscopic and robotic surgeries. By meticulously dissecting each task and sub-task, identifying skill requirements, and considering cognitive processes, healthcare professionals can enhance patient safety, optimize surgical workflows, and continually improve the quality of surgical care. Task analysis is not merely an analytical exercise; it is a pathway to excellence in surgical practice.
