Task Analysis of Laparoscopic and Robotic Procedures

Task Analysis of Mishra's Knot
General Surgery / Mar 2nd, 2018 2:47 pm     A+ | a-
Dr Ex Major Deepashree Patil
(DMAS feb 2018 batch)
Army  Medical Officer (Rtd)
Assistant Professor, Dept of OBG,
RIMS ,Raichur, Karnataka

It’s aptly said “NO FUTURE WITHOUT SUTURE” which emphasises on the importance of suturing & knotting skills in laparoscopy. DR.(Prof)R.K. MISHRA is the proponent of new technique of knot named after him as “Mishra‘s  Knot” in the year 2003 ;and since then many surgeons are using this knot.
Structures : Continuous structure
Suture: Type: any type
Length: 90 cm preferrable, Needle: Endoski needle, Knot pusher: Bhandarkar’s knot pusher
Needle holder-1
Long reducer-1
Ports inserted-3 [1 Telescope & 2 side ports 5mm and 10mm]
Configuration of Mishra’s Knot
1 HITCH; (1-1)3   WIND AND half LOCK alternating for 3 times
Short/ Anterior/ Long/Posterior limb           
Wrapping  /Working limb
STEP E1 Hold the needle at swag end tip with needle holder .
STEP E2 Hold the lateral one third from tip of needle with curved artery    such  that convexity faces convex centre of the needle.
STEP E3 Bend from E1 such that it makes J shape. There should not be   curves/hemps. It should be smooth.
1. Insert  Maryland in 5mm reducer and hold suture at tail end & pull suture out of reducer & stop till 6 cm of swag end seen
2. Re –introduce Maryland and hold suture 2 cm away from swag end and hide needle with suture in reducer with 5 mm reducer, introduce Maryland and suture both together through 10mm port
3. Introduce Maryland  grasper in 5 mm port
4. Make a window by dissecting the tissue plane over the suture to be tied.
5. Introduce needle holder from Rt. Side port and align the needle from Rt. Hand needle holder.
6. Take a bite /pass suture through the window and hold with Maryland or atraumatic grasper pull suture for 2 cm. Drop the needle
7. Hold the suture with the needle holder 2cm from the swag end of needle & feed the suture of 5 cm length for 4 times such that atleast 20 cm of suture is inside abdomen.
8. The telescope to be focused towards the cannula of the needle holder to show the suture. 
9. With the Maryland, hold 2 cm from sway end, pull the suture out of the reducer and cut the needle through 10mm port. 
10. Take care not to give more  pressure so as to avoid cutting of  tissue
11. Assistant finger placed over washer  of reducer in between the 2 suture to prevent gas leak
12. Tie Mishra’s  knot as illustrated( Follow steps H1-3 ;W1-3 ;L1-3 ;S1-3 ) 
Making a Hitch
H1 with left hand hold right long limb & right hand to hold short left limb of suture.Short limb of suture to cross over the long posterior limb such that the short limb is above the anterior limb.
H2 Intersection point of suture to be held between left index finger and left thumb opposed
H3 Pass the short limb in between loop from below upwards using thumb and middle finger of right hand the short limb should be pulled downwards  by thumb and index finger of right hand to make first hitch
Making a Wind 
W1 Hold short limb in right thumb and middle finger and pass over whole loop from below
W2.pull short limb from up by index finger and thumb of right hand 
W3 place the first wind over the first hitch without overriding.
Making a half Lock 
L1 Short limb to be passed inside the loop from below upwards using index finger and thumb of Right hand
L2 once short limb project up push it down by thumb inside loop to make half locking knot
L3 Pull tail from below to tighten knot repeat w1, w2, w3 for making 2nd wind
Repeat steps  w1w2w3 for making 2nd wind
Repeat L1 L2 L3 for making 2nd halflock
Repeat w1w2w3 for making 3rd wind
Repeat L1 L2 L3 for making 3rd half lock
Reconfirm Mishras knot configuration 1-1-1-1-1-1-1
How to Slide the knot
S1- suture should be neatly stacked one above the other in order. Avoid overriding ,check for knot configuration again
S2-check if knot slides easily over long posterior limb.
S3-cut the short anterior limb 1cm from knot.
Mishras knot is now ready for tightening.
14 feed the suture from head end and Bhandarker Knot Pusher and take out from the tail end.
15 3mm reducer reversely feed over Bhandarker Knot Pusher. 
16Assistant removes finger and now knot pusher and reducer is introduced inside 5mm reducer. Focus telescope to visualize the placement of knot slowly from cannula to the structure.
17-slowly push the Bhandarker Knot Pusher and shorten the loop.
18-keep the tip of  Bhandarker Knot Pusher  where the knot is required to be placed and pull the suture from left hand and push the knot pusher from right hand.
19 do not over pull the structure.Gently twist the Bhandarker Knot Pusher such that the knot will automatically slide to the site of desired structure.
20 after placing the knot and tightening;  Push and Pull 3 times ;push the knot pusher and pull the suture gently .
21-remove 3mm  reducer ,introduce scissors in same port and cut suture leaving 1cm from knot.
Advantages of Mishra’s Knot
  1. Simple
  2. Safe 
  3. Easy
  4. Quick
  5. Strongest knot strength
  6. Highest knot security
  7. For any continuous tubular structure upto 22mm diameter 
  8. Can be tied with any suture size.
  9. Disadvantage of Mishra’S knot:
  10. Whole suture length required for one knot.
Suturing and knotting is the most important skill every gynecologist must know.Mishra’s knot is SAFEST easiest and quick knot which can be tied with any suture material of any size and has got the highest knot strength and lock security. 
1.Mastering the technique of laparoscopic suturing and knotting by Dr. R. K   Mishra ,Jaypee Publication 2013 report.
2.Role of Mishra’s Knot in various surgeries in lap pg 114,115 original article from World Journal of Laparoscopic Surgeons;10.5005/jp journal-1003-1286. 
Dr Nitish Kumar Yadav
May 23rd, 2020 4:36 pm
This article is very well presented, which helped me to learn new knoting knowledge quickly. Thanks for published Task Analysis of Laparoscopic Mishra’s Knot. Thanks for uploding.
Dr Vikash kumar
May 23rd, 2020 4:38 pm
Excellent article and lot's of information very helpful step of suture. Thanks for posting this Task Analysis of Mishra's Knot.
Dr. Mammai Kutti
May 23rd, 2020 4:46 pm
Thanks for these wonderful Task analysis sir. Love You So Much. Because of you, I can able to understand these Laparoscopic all type of Extracorporeal and Intracorporeal knot Excellent teaching.
Thanks for posting.

Dr. Monalisa
May 23rd, 2020 4:52 pm
Thanks for posting this Task Analysis of Laparoscopic Extracorporeal Mishra's Knot !! Dr. Mishra is so helpful and he make it so much easier to understand better than the textbook! Keep it up!! Thank you so much sir.
Dr. Radhika Balla
May 23rd, 2020 5:34 pm
Super job Dr. Mishra, i am quite amazed at your precision in speed method of teaching in Laparoscopy. Thanks posting this Laparoscopic Task Analysis of Mishra's Knot.
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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.

Task Analysis of Laparoscopic Surgery

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.

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