Dr. Adrián Castro M.
1. Patient clerkship and physical examination.
2. Informed consent from patient.
3. Check if any extra medical considerations regarding patient’s anamnesis are required
4. Surgical safety checklist
INTRAOPERATIVELY
1. Prophylactic antibiotics on induction
2. General anaesthesia
3. Patient in Trendelenburg position
4. Abdominal shaving
5. Speculum exam
6. Physical examination if not performed earlier
7. Monitors in position 15 to surgeon’s eye axis surgeon on left assistant on the right
8. Second assistant between the legs,
9. Ensure all cables in order
PNEUMOPERITONEUM
- Entry technique as preferred by surgeon and clinical history of patient
- Ports placement: laparoscope is ideally at umbilicus, accessory ports are placed at least 7.5 cm from central trocar lateral to umbilicus. Trocar size 5 mm
- Eye instrument axis must be maintained. the target is the vaginal vault
TASK ANALYSIS
- General endotracheal anesthesia has already been induced.
- Abdomen has already been insufflated with CO2 (see previous section)
- Careful pelvic and upper and lower abdomen exam is performed
- Patient should be placed in Trendelenburg position
- Bowel is swept out of the pelvis if needed
- Using a rectal sizer placed in the vaginal vault, the vault is inverted
- Peritoneal lining should be identified overlying the pubocervical and rectovaginal fascias
- Uterosacral ligaments should be indentified as well as their topographic relation to the urethers (the latter run anterolateral to the ligaments) in order to avoid lesions at this level)
- Follow the uterosacral ligaments as they enter the sacrum
- Tag with suture the unbroken uterosacral ligament bilaterally
- Open the peritoneum overlying the pubocervical and rectovaginal fasciae
- By sharp dissection, identify ventrally the pubocervical fascia that lies between the vagina and the bladder
- Identify posteriorly the rectovaginal fascia
- Excise redundant peritoneum and excess vagina as needed
- Take stitches at the corners on each side in a way they will approximate the edges of the pubocervical to the rectovaginal fascia overlying the vaginal mucosa
- The corner stitch on each side is then incorporated into the ipsilateral uterosacral ligament which had been already tagged
- The now reapproximated fasciae along with the vaginal apex are now incorporated to the uterosacral ligaments as the enter the sacrum on both sides
- The pubocervical and rectovaginal fascia are hence sutured to the unbroken uterosacral ligaments
- The pubocervical fascia is approximated to the rectovaginal fascia acrros the center of the vaginal vault with interrupted sutures
- Reinforcing sutures from the uterosacral ligaments to the posterior rectovaginal fascia are then placed bilaterally, taken into the account not to cross the midline but rather reinforce the attachment of the corner of the vaginal vault to the ipsilateral uterosacral complex
- Cystoscopy should be ideally performed to rule out kinking of the urethers during the suspension of the uterosacral ligaments to the vaginal vault
- Hemostasia is confirmed
- Ports are withdrawn under direct visualization, optical port is withdrawn and closed
- Deinsufflation of abdomen is done
- Skin incisions are sutured
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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.
