Task Analysis of Total Laparoscopic HysterectomyDR VELPULA SRI LAKSHMI [ MS OBGY, F.MAS, D.MAS]
It is a minimal surgical procedure were nonprolapsed uterus is removed through vaginal route.it is a type 5 in GARRY AND REICH classification
Uterine size more than 12 wks
Severe COPD or cardiac disease
Previous extensive abdominal surgery
Huge cervical or broad ligament myoma
1. Informed consent from the patient.
2. Laxative Dulcolax 2 tabs night before surgery and clear liquids one day before surgery.
3. The patient should be given general anesthesia and bladder catheterization done.
4.Patient in lithotomy positions
5.The surgeon on the left side, one assistant on the right side to hold the camera and second assistant in between legs for uterine manipulator
6. Monitor on the opposite side of the surgeon so that the center of the monitor, target of dissection, the eye of the surgeon should be in the same line ie, coaxial alignment.
7. The height of the table should be 0.49 cm× height of surgeon in cms, so that handle of instrument is at the level of the elbow.
8. The distance of the monitor from the eye should be five times the diagonal length of the screen as an image will come on to macula.
9. Check the veress needle for its spring action and patency.
10. Take 2allis forceps to evert and hold on either side of the umbilicus.
11. Use the number 11 blade to place a small horizontal stab wound on the inferior crease of umbilicus.
12. Mosquito artery to dissect subcutaneous adipose tissue and expose rectus sheath.
13. Measure abdominal wall thickness and add 4cm for distance to hold veress needle.
14. Veress needle should be held like a dart.
15. Lift suprapubic part of the abdominal wall with the left hand.
16. Insert veress needle in stab incision with 45-degree elevation angle, and distal end pointed towards anus and perpendicular to the abdominal wall.
17. The surgeon can hear two click sounds and maintain the 45-degree angle.
18.Confirm correct veress needle placement by irrigation test, aspiration test, and hanging drop test.
19.Connect the carbon dioxide gas tube to the veress needle.
20.Check quadromanometry for intraperitoneal placement of veress needle.
21.Check uniform distension of the abdomen and obliteration of liver dullness.
22.Pneumoperitoneum is created with veress needle with preset pressure of 12-15mmhg and a set flow rate of 1- 2.5lit/min at the inferior crease of umbilicus.
23.After the actual flow rate becomes 0, actual pressure equals preset pressure then removes the veress needle.
24.Take a cannula of 10mm and mark its impression on the skin.
25.Extend incision to the size of the cannula impression.
26.Introduce a 10mm port by holding it like a piston, perpendicular to the abdomen.
27.Confirm intraabdominal placement of port by escaping air sound and audible click.
28.Put the main optical 10mm port in the inferior crease of the umbilicus, and after entering into the abdominal cavity, set the flow rate between 6-10 lit/min.
29.Patient in Trendelenburg position.
30.Put two ipsilateral accessory ports, 1st ipsilateral 10mm port is 7.5cm below and lateral to the optical port.
31.Second ipsilateral 5mm port is 7.5cm below and lateral to the first accessory port
32.If the uterus is greater than 8wks follow the baseball diamond concept of port placement using the supraumbilical port and one extra accessory contralateral port placement.
33.Put Mangeshkar uterine manipulator, so that mobilization of the uterus is easy
34Can use infrared ureteric stenting so that the entire ureter will glow to avoid injury.
35.Use ligasure or bipolar cautery with scissors for pedicles.
36.First, keeping the uterine manipulator at 9*clock position coagulate and cut right round ligament 4cm lateral to the uterus, coagulate and cut right fallopian tube mesosalpinx 3cm lateral to the uterus, coagulate cut right ovarian ligament mesovarium 2cm lateral to the uterus.
37.Keeping uterine manipulator at 3*clock position coagulate cut the left round ligament 4cm lateral to the uterus, coagulate and cut left fallopian tube, mesosalpinx 3cm lateral to the uterus, coagulate cut left ovarian ligament mesovarium 2cm lateral to the uterus.
38.Do bilateral symmetrical to have more flexibility, so that first do upper bilateral adnexa.
39.Keep uterine manipulator at 5*clock position and stretch anterior left peritoneum with a left-hand atraumatic grasper and cut with scissors, hook or harmonic with a right hand and open an anterior leaf of the broad ligament, and push peritoneum as lateral as possible.
40.Uterine manipulator at 6*clock position and separate anterior UV fold.
41.Uterine manipulator at 7*clock position and stretch anterior right peritoneum with a left-hand atraumatic grasper and cut with scissors, hook or harmonic with the right hand and open an anterior leaf of the broad ligament, and push peritoneum as lateral as possible.
42.Again come back to 6*clock position with the uterine manipulator, with the help of pledget or 3×4cms gauge four folded hide in reducer to separate bladder from anterior vaginal wall till you see pearl white cervical fascia with longitudinal blood vessels.
43.The bladder can be pushed down with the help of suction irrigation cannula by blunt dissection.
44.Keeping a light cable at 6*clock position and uterine manipulator 1,12,11* clock and again to 12*clock position separate posterior peritoneum and reach up to cervical part of uterosacral ligaments.
45.Keeping uterine manipulator at 3,9*clock position coagulate cut left and right uterine artery with mackendrots.
46.With active tip end of harmonic or with hook do colpotomy and cut vagina with in-ring of full circle colpotomiser, coagulate and cut as near to cervix, one half of colpotomy is done from one side and another half from another side.
47. Coagulate and cut 2cm above uterosacral ligaments.
48.Never touch the vaginal part of the uterosacral.
49.Uterus with the cervix is free of all its supports.
50.Pull uterus with cervix by tenaculum of the manipulator by making up down right and left movements.
51.Glove packed with a cotton pad is used to pack the vagina to prevent a gas leak.
52.Bilateral salpingo-oophorectomy was done by giving anteromedial traction and take a specimen out from vault.
53.Vault closed in full-thickness, including vaginal epithelium with a square knot or Dundee jamming knot with Aberdeen termination.
54.Take 5mm accessory ports under vision.
55.Close 10mm ports with veress needle or port closure needle after desufflation.
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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.