Dr. Manju Sree. D.MAS (May 2019)
Desire for fertility
Normal Semen Analysis
Female Age less than 39 years
Tubal occlusion using modified Pomeroy's, Fallope rings, Filshie clip
HSG to assess remnant proximal isthmic portion of the fallopian tube
Attention to detail in:
Respect delicate nature of the tissue
Minimize the use of electrocautery
Irrigate abdominal cavity with normal saline to minimize drying/adhesion
1. Patient in Lithotomy position under general anesthesia
2. Empty urinary bladder
3. Check Veress needle spring action and patency
4. Stab incision in the inferior crease of umbilicus
5. Hold Veress needle like a dart in the dominant hand
6. Lift suprapubic part of abdominal wall with the left hand
7. Insert Veress needle in the created stab incision
8. Perform saline test: infiltration / aspiration / hanging drop
9. Check quadromanometry for intraperitoneal placement of Veress needle
10. Check Insufflator preset pressure and volume settings, the Flow rate of 1 Litre per minute, The maximum pressure to 15 mm
11. Start insufflation of Co2 at 1 liter per minute
12. Check uniform distension of abdomen/obliteration of liver dullness
13. Once the pressure of 15 mm Hg achieved, remove Veress needle
14.Extend the incision to the size of the cannula impression
15.Introduce 10mm port holding the port like a piston
16. Do a diagnostic laparoscopy, with special attention to fallopian tubes
17.Insert uterine manipulator to aid ease of suturing the fallopian tubes
18.Secondary and tertiary port placement
based on the baseball diamond principle
19. Ipsilateral port placement may be desired
20.Dissecting scissors in dominant hand/ Maryland forceps in the other hand
21.Excise the occluded area with an agent of occlusion
22.Freshen up the ends of the fallopian tubes to be anastomosed
24.Approximate the mesosalpinx using interrupted 3-0 vicryl sutures
25. The freshened edges of the fallopian tubes are approximated
26.Preferred suture 4-0 vicryl with cutting edge needle
27. Seromuscular sutures are placed at 2/6/10 'O clock positions
28. Remember to complete both fallopian tubes
29. Patency may be checked using normal saline
30. Check hemostasis
31. Remove all ports under the vision
32.Close 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.