A) Patient Position:
1. The patient is placed in the Trendelenburg position to make bowel fall away from the operative site
B) Instruments and Surgeon’s Position:
1. The height of the table should be 0.49 times the surgeon's height.
2. The monitor should be at a distance of 5 times its diagonal length from Surgeon.
3. The surgeon should stand on the right side.
4. The Surgeon, the hernia site, and the monitor should be along the same axis.
1) The Optical Port should be placed at infra umbilical crease.
2) The other two-port is placed according to the baseball diamond concept,i.e., one on the right side and other on the left side.
Access to peritoneal cavity:
1. Make an incision 2 mm with 11 no blade at the inferior crease of umbilicus.
2. Lift the abdominal wall and insert the Veress needle directing towards anus through the incision at a 450 angle to the spine and perpendicular to the lifted abdominal wall.
3. Make confirmation of intraperitoneal entry by double click sound, Hanging drop test, and Plunger test.
1. Connect the CO2 either to the Veress needle & begin inflating the intra-peritoneal space initially at one ltr/min and later at three ltr/min till the intra-abdominal pressure reaches the preset pressure of 12-15mmHg,
2. Take the veress needle out of the abdomen
3. Enlarge the infra umbilical incision up to 11mm.
4. Put the cannula inside the trocar
5. Slowly screw the cannula with the trocar into the peritoneal cavity in the perpendicular direction to the abdominal wall.
6. The camera is white-balanced and then focused.
7. The telescope is then advanced through the umbilical port into the abdominal cavity under direct vision.
8. Perform diagnostic laparoscopy/peritenoscopy and locate the site of pathology
9. Make two 5mm operating ports on either side of the optical umbilical port under direct vision on the concept of baseball diamond concept.
1. Define the laparoscopic anatomy, Start the peritoneal dissection at 2 O’clock position at a distance of 6 cm from the outer margin of the hernia defect.
2. Hold the peritoneum by Maryland and lift it and cut the peritoneum with a scissor at a point mentioned above
3. Allow the CO2 to enter inside which will create the plane of dissection
4. Then lift the leaf of peritoneum & start dissecting the peritoneum using scissor till you reach the medial umbilical ligament.
5. While dissecting the peritoneum, push the fat and fibrous strands towards the anterior abdominal wall.
6. Make medial Pocket: Push the bladder down and push the fibrous tissue towards anterior abdominal wall till u see the coopers ligament(lighthouse).
7. Make lateral pocket:
• Push the fibrous tissues towards the abdominal wall and push the posterior leaf downwards
• Complete dissection over the triangle of doom and pain
8. Start dissection of sac
• Hold the sac with Maryland
• Do blunt dissection by pulling the sac towards you and pushing the vas deferens, spermatic vessels away till the sac separate from spermatic cord.
1. Take Prolene mesh – 10*15 cm and make a roll of mesh outside the abdomen.
2. Hold the mesh with a needle holder and put it inside the reducer
3. Introduce the mesh assembly through the 10 mm optical port.
4. Put the telescope in and unroll the mesh under vision.
Fixation of Mesh:
1. Fix the medial corner of the mesh to the cooper’s ligament using either tackers.
2. Apply one tacker on mesh over rectus abdominis in the anterior abdominal wall
3. Apply one tacker on mesh over transverse fascia in the anterior abdominal wall
1. Hold the need holder with the right hand and rotate it anticlockwise and take bite over cooper ligament and mesh and fix with intracorporeal surgeon knot
2. Take a bite on rectus abdominis muscle and mesh and fix with intracorporeal surgeon knot.
3. Take a bite on transverse fascia and mesh and fix with intracorporeal surgeon knot.
1. Do double breasting of the lower leaf over the upper leaf of peritoneum and apply tackers.
1. Start Suturing from medial to lateral with continuous intracorporeal suture with vicryl 2.
1. The port entry sites are examined for bleeding.
2. Close the optical port using a veress needle under vision with 5 mm telescope from 5 mm cannula.
3. Pneumoperitoneum is deflated.
4. The Cannula is removed with a telescope within so as to make nothing comes along with it and.
5. Tighten the knot after removal of the canula.
6. The other two-port site is closed.
7. The skin around the port site is cleaned with an antiseptic solution.
8. Dry sterile dressings are applied to the port sites.
Elaboration of Steps:
Position the patient in the supine position.
Administer general anesthesia.
Insert a urinary catheter to empty the bladder.
Preoperative antibiotics are administered.
Make a 10-12mm incision at the level of the umbilicus.
Use a Veress needle to insufflate CO2 into the abdomen.
Insert a 10mm trocar through the incision.
Insert a laparoscope through the trocar and visualize the abdominal cavity.
Identify the hernia sac and reduce the hernia contents.
Identify the left inguinal region.
Make an additional 5mm incision lateral to the left rectus muscle.
Insert a 5mm trocar through the incision.
Use a laparoscopic grasper to retract the peritoneum.
Use a monopolar or bipolar electrosurgical device to incise the peritoneum along the left inguinal region.
Create a dissection plane between the peritoneum and the transversalis fascia.
Develop the preperitoneal space using a balloon dissector or other blunt instrument.
Insert a 10mm trocar through the left lower quadrant.
Use a laparoscopic grasper to retract the peritoneum.
Use a monopolar or bipolar electrosurgical device to dissect the peritoneum and develop the preperitoneal space.
Insert a self-retaining retractor to maintain the preperitoneal space.
Dissect the hernia sac and reduce any hernia contents.
Reduce the hernia sac by pulling it into the preperitoneal space.
Close the hernia defect with sutures or mesh.
Use a laparoscopic stapler to secure the mesh in place.
Ensure adequate mesh coverage and fixation.
Close the peritoneum with sutures.
Inspect the surgical site for any bleeding or hematomas.
Remove the self-retaining retractor.
Deflate the abdomen and remove the trocars.
Close the incisions with sutures or staples.
Apply sterile dressing to the incisions.
The patient is awakened from anesthesia.
Extubate the endotracheal tube.
Move the patient to the post-anesthesia care unit.
Administer analgesics for pain management.
Monitor vital signs and urine output.
Check the dressing for bleeding or drainage.
Observe the patient for any signs of infection or complications.
Advise the patient to avoid strenuous activity for 2-4 weeks.
Advise the patient to avoid lifting heavy objects for 2-4 weeks.
Schedule a follow-up appointment.
Evaluate the patient's postoperative course.
Monitor for any complications, such as bleeding or infection.
Evaluate the patient's recovery of bowel and bladder function.
Adjust medication as needed.
Evaluate the healing of the incisions.
Provide the patient with a detailed report of the procedure and postoperative care.
Advise the patient on any potential complications or side effects of the procedure.
Provide the patient with instructions on follow-up appointments and monitoring.
Advise the patient on when to resume normal activities, such as driving, work, and exercise.
The patient follows up with the surgeon at regular intervals.
The surgeon evaluates the patient's healing and progress at each follow
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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.