Task Analysis of Laparoscopic and Robotic Procedures

Laparoscopic Heller’s Myotomy for Achalasia Cardia
General Surgery / May 21st, 2019 11:40 am     A+ | a-
Dr. Pranoti Arjunrao Pol    
M.S. General Surgeon, World Laparoscopy Hospital 2019 Batch, India

Achalasia Cardia (Cardiospasm)
  • Achalasia is a rare primary motility disorder of the esophagus that affects one person in 100,000 per year and is characterized by the absence of esophageal peristalsis and incomplete relaxation of a frequently hypertensive lower esophageal sphincter (LES) in response to swallowing.
  • Achalasia cardia is a precancerous condition 7 times the chances of Squamous cell carcinoma (8% after 15 years).
  • Etiology: Autoimmune-mediated destruction of inhibitory neurons in response to an unknown insult in genetically susceptible individuals. Stress, Vit B1 deficiency, Chaga’s disease caused by Trypanosoma cruzi common in South America called Sleeping sickness. Diffuse oesophageal spasm Corkscrew esophagus.
  • Pathological changes in Achalasia: Auerbach’s Myenteric plexus inflammation with injury and loss of ganglion cells and fibrosis of myenteric nerves. There is a significant reduction in the synthesis of nitric oxide and vasoactive intestinal polypeptide along the entire length of esophagus more in LOS. There is a pencil-shaped narrowing of the cardia(O-G junction) with enormous dilatation of proximal esophagus which contains foul-smelling fluid and is more prone n for aspiration pneumonia.
  • Symptom
Dysphasia with solids and liquids                   
Regurgitation of undigested food                                   TRIAD
 Weight loss.
Chest pain,  nocturnal cough
  1. Proximal dilatation , 4cm,
  2. Dilatation between 4-6cm,
  3. Dilatation .6cm,
  4. Sigmoid dilatation.
  1. No weight loss or dysphagia or retrosternal pain or regurgitation.
  2. Weight loss, 5kg occasional dysphagia retrosternal pain, regurgitation.
  3. Weight loss5-10kg daily dysphagia retrosternal pain regurgitation.
  4. Weight loss.10kg dysphagia and regurgitation during each meal retrosternal pain several times a day.
  • Achalasia cardia is more common in females age group: 20 to 40 years.
  • Barium esophagogram: There is a smooth tapering of the lower esophagus leading to the closed LES, resembling a “bird’s beak.”  Dilatation of proximal esophagus- cucumber esophagus,  Absence of fundic gas bubble, sigmoid esophagus or megaoesophagus.
  • Esophageal manometry establishes the diagnosis showing esophageal peristalsis and insufficient LES relaxation with swallowing. All patients should undergo an upper endoscopy to exclude pseudoachalasia arising from a tumor at the gastroesophageal junction.
 Chest X-ray:   patches of pneumonia. The double meditational strip of the dilated esophagus and on lateral view air-fluid level in the posterior mediastinum.
  • Oesophagoscopy: confirm the diagnosis, rule out carcinoma. On oesophagoscopy there will be closed LES rosette-like) with atonic, dilated proximal esophagus. Oesophagoscopy with biopsy is preferred.

Conservative &  Surgical.

Conservative management: All available treatment options are directed at the palliation of symptoms only.
 1. Pharmacotherapy Smooth muscle relaxants - calcium channel blockers and long-acting nitrates sublingually. Botulinum toxin injections- associated with a high recurrence rate.
2. Dilatation: Plummers pneumotic dilatation using  30-40 mm diameters, but the risk of perforation 5 %, Negus hydrostatic balloon dilatation- 30mm diameter balloon is inflated for 3 minutes.
3.Esophageal stents,
4. POEM Per Oral Endoscopic Myotomy.
5. Surgical Treatment of Achalasia: The goal of surgery is to alleviate the distal esophageal obstruction by a division of the circular muscle fibers comprising the LES.

Per Oral Endoscopic Myotomy

APPROACHES:   Five different technical approaches:
  • Open transabdominal.
  • Open transthoracic:  Resection of OG junction / transhiatal total oesophagectomy in severe cases- megaoesophagus/ metaplasia.
  • Thoracoscopic.
  •  Laparoscopic Heller Myotomy and Dor Fundoplication.
  • Robotic approach.

1. Procedural steps

 General anesthesia followed by Patient positioning,
 Clean  and sterile draping
 Pneumoperitoneum is created with  CO 2  Insufflation  via veress needle at 5cm superior to the umbilicus 
 Insertion of ports
 Liver retraction by Nathanson's retractor and identification of pars flacida
 Exposing the right and left crura of the diaphragm
 Mobilization of esophagus intra-abdominally
 Approximating the gap between both crura through sutures
 Mobilization and preparation of stomach for wrapping by dividing short gastric  vessels
 Plication of the fundus of the stomach around the mobilized esophagus
 Haemostasis achieved 
 Removal of ports under the vision 
 Skin closure.

Anesthesia:   General anesthesia

1. Patient Position:

The patient is placed in supine atop a beanbag to create a saddle under the perineum to avoid sliding when in steep reverse Trendelenburg. Pneumatic compression stockings are used for prophylaxis of deep vein thrombosis.
General endotracheal anesthesia is given and an oro-gastric tube is placed to keep the stomach decompressed and tube is removed before starting the myotomy.
The legs are placed in stirrups with knees flexed 20–30°.
The surgeon stands between the patient’s legs, with an assistant on the patient’s left and one on the patient’s right side

Fig: Position of the patient and the surgical team in the operating room.
Port placement according to SAGES guideline
2. Quadro manometric parameters:

1) Preset pressure:  15 mm of Hg.
2) Cautery: monopolar and patient return plate, Harmonic device.
3) A light source and coaxial alignment with the surgeon  are checked.
4) Co2 cylinder checked for availability of sufficient Co2 for insufflation.
5) Working status of all the lap instruments along with insulation is checked properly.

3. Operative steps:
Access and Insufflation

1. Veress needle is checked for patency and spring action.
2. A small stab incision using number 11 blade at  5cm superiorly to  the umbilicus is made
3. Lift the lower abdominal wall between your palm and four fingers 
4. Measure the thickness of the abdominal wall 
5. Hold the Veress needle like a dart exposing only 4cm + the measured abdominal wall thickness, and direct it at 45 degrees to the patient abdominal axis yet 90 degrees to the abdominal wall aiming towards the anus 
6.  Feel two give away clicks.  
7. Veress needle correct placement inside the abdominal cavity using the following tests :
i) Irrigation and suction test: free flow of 5cc saline with no resistance, then on suction, only air must come back 
ii) Hanging drop test : put one drop of saline at the opening of the veress needle then lift the abdominal wall, the drop must go through the needle 
iii) Connect to the insufflator : intra-abdominal pressure must be zero
8. Start insufflation with Co2 gas at flow rate of 1L/min and quadromanometric readings on the insufflator  is checked to make sure that the rise in the intraabdominal pressure is proportional to the total amount of gas pumped 
i) When reaching 12 mmHg pressure  incision is enlarge to 1.1 cm (smiling incision) then insert a size 10mm port at 90 degrees using screw movement to the right and left 
9. Remove  the trocar and connect the gas tube to the port
10. Connect the 30° telescope to the camera head and white balance setting is achieved.
11. Insert the telescope into the abdominal cavity above the umbilicusdiagnostic laparoscopy is performed to look for any intrabdominal pathology.
Liver retraction: Through the epigastric 5mm port a Nathanson’s self-retaining retractor is  introduced and liver is lifted and retracted exposing the gastro-esophageal junction and pars flacida ligament
4. Port placement: All ports are made according to “ baseball diamond concept
Five 10 mm trocars are used for the operation
A)  First trocar (A) in the midline, 14 cm distal to the xiphoid process, and it is used for the 30° scope. This trocar can also be placed slightly to the left of the midline. This port must be placed with caution since the insertion site is just above the aorta. Initially inflate the abdomen to a pressure of 18 mm Hg to increase the distance between the abdominal wall and the aorta. Once this port is placed, the intraperitoneal pressure is reduced to 15 mm Hg and the other trocars are placed under direct vision.
B) Second trocar (B) in the right midclavicular line at the same level of the previous trocar, and from where the insertion of Nathanson Liver retractor is done to lift the left lateral segment of the liver to expose the oesophagogastric junction. Hold the retractor in place by a self-retaining system fixed to the operating table.

Port placement

C).  Third trocar (C) in the left midclavicular line at the same level as the other 2 trocars and the Babcock clamp is inserted or it is used for instruments used to divide the short gastric vessels.
D). Fourth (D) and Fifth (E) trocars under the right and left costal margins are placed so that their axis forms an angle of about 120° with the camera. These ports are used for the dissecting and suturing instruments

5. Dissection:

Identification of Pars flacida: 
After liver is retracted using Nathanson Karl Storz self-retaining retractor, pars flacida is identified as it is the thinnest (transparent) layer of peritoneum devoid of any fat. 
Dissection is started by dividing this layer and exposing the caudate lobe of the liver. 
Just medial to caudate lobe lies the inferior vena cava, care is taken not to do overshooting of the instruments. 
Division of the Gastro hepatic Ligament; Identification of the Right Crus of the Diaphragm; and the Posterior Vagus Nerve:  
Dissection starts above the caudate lobe of the liver & continued toward the diaphragm until the right crus is identified. Then, by blunt dissection, the crus is separate from the right side of the esophagus, and the posterior vagus nerve identify. Since monopolar current tends to spread laterally and the posterior vagus nerve may sustain damage even without direct contact, bipolar instrument is safe- Harmonic.
Division of Gastrohepatic ligament                                          Retro oesophageal window
Division of Peritoneum and Phreno-esophageal membrane above the Oesophagus:  Identification of the Left Crus of the Diaphragm and Anterior Vagus Nerve

Transaction of  the peritoneum is done and phrenoesophageal membrane above the esophagus. Anterior Vagus Nerve is embedded into the oesophageal wall. By blunt dissection separation of  the left crus from the esophagus is done . Continue the dissection into the mediastinum, lateral, and anterior to the esophagus, to expose 6–7 cm of the esophagus but not deep into mediastinum as it may cause pneumothorax. Dissection of Left Crus
Division of the Short Gastric Vessels: Division of short brevis artery by putting traction on stomach anteromedially.
 Dissection of brevis vessel.

Fig: The myotomy includes cutting of the muscular layer of the oesophagus & the upper part of the stomach.
The esophagus is mobilized several centimeters into the mediastinum until there is enough room for the Myotomy. The fat pad is removed to expose the gastroesophageal junction in order to expose the right side of the esophagus. Use a Babcock clamp to pull the stomach downward and to the left. The surgeon and assistant each grasp one side of the esophagus and retract in opposite directions to provide better exposure for myotomy. The esophageal muscle fibers are split and dissected laterally and the longitudinal fibers and the circular fibers are cut until a small pocket is made between the circular fibers and the mucosa. The myotomy is continued up the esophagus for at least 4 cm and taken onto the stomach for approximately 2 cm. Care should be taken to avoid perforation of the esophageal mucosa.
The completeness of the myotomy is checked at the end of the procedure which is done with an endoscope where the lower esophagus is inspected or with the use of intraoperative manometry.
In patients who have had previous treatment with botulinum toxin injection, fibrosis can occur at the level of the gastroesophageal junction leading to loss of the normal anatomic planes. In these cases, there is an increased risk of mucosal perforation which is close with fine absorbable material (5–0), and test the repair with saline or methylene blue. Bleeding may also occur during the myotomy,  from submucosal veins at the level of the gastroesophageal junction applying pressure with a sponge helps to control it.

Extension of Myotomy.

Dor Fundoplication: GERD  occurs in about 50% of patients if a myotomy alone is performed. A 360° fundoplication, is avoided due to postoperative dysphagia.
A partial fundoplication anterior Dor fundoplication is the procedure of choice. The Dor fundoplication is constructed using two rows of sutures. The first row of sutures is on the left side of the esophagus and has three stitches. The uppermost stitch incorporates the gastric fundus, the muscle layers of the left side of the esophagus, and the left pillar of the crus. The second and the third stitch incorporate the muscle layers of the left side of the esophagus and the gastric wall only. The fundus is then folded over the exposed mucosa so that the greater curvature of the stomach lies next to the right pillar of the crus.

Laparoscopic view: DOR FUNDOPLICATION
The second row of sutures also consists of three stitches. The uppermost stitch incorporates the gastric fundus, the right side of the cut edge of the muscle layers, and the right pillar of the crus. The second and third stitches are placed between the greater curvature of the stomach and the right pillar of the crus  Finally, two additional stitches are placed between the anterior rim of the oesophageal hiatus and the superior aspect of the fundoplication (without incorporating the esophageal wall) to decrease the tension on the right row of sutures.
  • Oesophageal leak,
  • Pneumothorax,
  • Dysphagia,
  • Abnormal gastroesophageal reflux :  in 6–33%

Postoperative day 1  Soft meal diet is advised and instructed to avoid meat and bread for 2 weeks.  Patients are discharged within 23 h and 90% of patients are discharged within 48 h.
Most patients are able to resume regular activities in 7–14 day.
1.Burpee SE, Mamazza J, Schlachta CM, et al. Objective analysis of gastroesophageal reflux after laparoscopic Heller myotomy: an anti-reflux procedure is required. Surg Endosc. 2005;19:9–14.
2. Chen Z, Bessell JR, Chew A, Watson DI. Laparoscopic cardiomyotomy for achalasia: clinical outcomes beyond 5 years. J Gastrointest Surg. 2010;14:594–600.
3. Patti MG, Fisichella PM. Laparoscopic Heller myotomy and Dor fundoplication for esophageal achalasia. How I do it. J Gastrointest Surg. 2008;12:764–6.
4. Portale G, Costantini M, Rizzetto C, et al. Long-term outcome of laparoscopic Heller-Dor surgery for esophageal achalasia. Possible detrimental role of previous endoscopic treatment. J Gastrointest Surg. 2005;9:1332–9.
Dr. Dinesh Singh
May 22nd, 2020 12:41 pm
This is a very interesting Article and this is a useful learning tool for surgeons and gynecologists of the whole World. Thanks for sharing the Laparoscopic Heller’s Myotomy for Achalasia Cardia.
Dr. Sunil Yadav
May 22nd, 2020 12:47 pm
Very good Article with a clear and simple explanation! very useful! keep up the good work! Thanks for uploading Laparoscopic Heller’s Myotomy for Achalasia Cardia.
Dr. Mohan Lal
Apr 30th, 2021 6:03 am
Your information is very interesting. Thank you for sharing the Laparoscopic Heller’s Myotomy for Achalasia Cardia article.

Dr. Mamta Kumari
Apr 30th, 2021 6:11 am
Your topic is very nice and helpful to us … Thanks for uploading this educational article of Laparoscopic Heller’s Myotomy for Achalasia Cardia.
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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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