Task Analysis of Laparoscopic Procedures

Task analysis of Laparoscopic Sacrouteropexy
Gynecology / May 26th, 2019 4:42 am     A+ | a-
TASK ANALYSIS OF SACROUTEROPEXY
Dr. Ashwin Rao (D.MAS May 2019)

 
PREOPERATIVE STEPS:
 
1. History taking and clinical examination of the patient.
2. Any medical co-morbidities and absolute or relative contraindications.
3. Informed consent.
4. Pre-Surgical checklist.
 
INTRA-OPERATIVE STEPS:
 
1. Prophylactic antibiotics half an hour prior to surgery after test dose.
2. Connect patient for vital signs monitoring and EtCo2 monitor.
3. Induction with general anesthesia.
4. Patient in Trendelenburg position.
5. Preparation of surgical site.
6. Speculum and per vaginal examination.
7. Monitors for vision should be placed appropriately for the surgeon and assistants.
8. Second assistant between the legs for uterine manipulation if required.
9. Make sure that all the cables and patient return plate are properly connected and the
required energy sources are in working condition.
10. Pre operative checklist is reconfirmed.
 
PNEUMOPERITONEUM AND ENTRY:
1. The mode of entry is decided by the operating surgeon based on ergonomics and previous surgical history.
2. The target of dissection is taken as the fundus of the uterus in the prolapsed position.
3. Ports placement: Telescope is ideally at the Supra umbilical port position, accessory ports (5mm ports) are placed according to the baseball diamond principle.
 
 
PROCEDURE STEPS:
1. The mesh is sutured to the posterior uterocervical junction at the level of the uterosacral ligaments.
2. Dissection of the peritoneum over the sacral promontory.
3. Attaching the mesh to the anterior longitudinal ligament over the sacral promontory.
TASK ANALYSIS OF THE PROCEDURE:
1. First a diagnostic laparoscopy is performed in order to identify the different structures and look for other pathologies as well.
2. Bowel is swept out of the pelvis if needed. And the uterus is identified.
3. A polypropylene mesh of size 15*3 cms is prepared. 
4. The uterus is held in the anteverted position with the manipulator. 
5. The mesh is brought posterior to the uterus. An endoski needle with 1- silk or Dacron is introduced. 
6. The first bite is taken on the medial part of the left/right uterosacral ligament and the mesh is attached. The knot is secured by an extracorporeal square knot with a Clark's knot pusher.
7. Similarly, the same step is performed on the other uterosacral ligament. Hence one end of the mesh is fixed.
8. Then the assistant is asked to lift the mesh towards the anterior abdominal wall.
9. Then 2 cms above the previous stitch above the left uterosacral ligament, the next bite is taken at a depth of 1cm which includes the mesh and the posterior wall of the uterus and secured with an extracorporeal square knot.
10. Similarly a stitch is placed 2cm above the right uterosacral ligament.
11. The idea behind placing 4 knots is to create fibrosis along that path to create a neo uterosacral ligament.
12. Now the peritoneum over the right border of the sacral promontory is lifted and dissected with harmonic scalpel/ monopolar scissors. Care should be taken to cut only the peritoneum and avoid the rectum and the medial sacral artery to the left. Hence a para rectal pouch is created.
13. The para rectal pouch is approximately 6-7 cms.
14. The fascia over the sacral promontory is dissected until the anterior longitudinal ligament is seen as a pearly white structure.
15. Now the assistant again lifts the uterus by about 9cms.
16. The mesh is brought to the sacral promontory and anchored to the anterior longitudinal ligament with a tacker. Care should be taken to stabilize the tacker with both hands in order to avoid injury to the medial sacral artery.
17. Alternately an intracorporeal surgeons knot may also be taken to secure the mesh to the anterior longitudinal ligament. Note that the bite is taken longitudinally and not transversely in order to avoid injuring the medial sacral artery. The excess mesh is cut.
18. The mesh is then buried into the pouch and the peritoneum has to be sutured over it to avoid internal hernia and small bowel adhesions.
19. The suture is initiated by a Dundee jamming knot followed by continuous locking sutures. After completely covering the mesh, the suture is terminated by an Aberdeen knot. During the entire process of suturing, the peritoneum is lifted up to prevent injury to the underlying structures.
20. Hemostasis is secured and wash is given.
21. Ports are withdrawn under direct visualization, optical port is withdrawn and closed.
22. Desufflation of abdomen is done.
23. Skin incisions are sutured.

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