Gynecology, December 23rd, 2019
1. Laparoscopic drapes, insufflators, light source, HD camera with a 30-degree telescope (10 mm), seven parameter monitor, LCD monitor.
2. Veres needle 12 cm with 10 ml NS syringe, and 10 ml xylocaine 2 % for subcutaneous injection before doing skin incision.
3. Two 10 mm and one 5 mm port.
4. 11, number scalpel.
5. The length of suture used in the extracorporeal knot for the free structure is 75 cm by no.1 vicryl.
6. Bhandarkar Knot Pusher.
8. An Atraumatic grasper.
1. The procedure can be performed under GA or LA.
2. Put the patient in a supine position with 15 degrees head down.
3. Quadrimanometric device ready, the preset pressure should not be more than 12 mm, and the gas flow rate 1L/min.
4. Position of the surgical team: Surgeon on the left side of the patient and coaxial alignment with the target organ (the tubes) and the monitor at a distant about 5*diameter of the monitor and the table height 0,49* surgeon height.
5. Disinfect the abdomen from the nipple till the pubic symphysis line and to the level of anterior iliac spines laterally.
6. Xylocaine 10 ml is subcutaneously infiltrated around the umbilicus.
7. By the use of an 11 mm blade, 2 mm incision at the lower umbilical skin crease.
8. Verres needle is checked for valve action and patency by n/s irrigation.
9. Hold it like a dart and skin thickness is elicited by holding it at the level of the umbilicus and add to it 4 cm for needle tenting, the needle should be perpendicular to the abdominal wall and directed toward anus, left hand should hold the lower abdominal to make it 45 degrees toward the patient body.
10. Two clicks are heard at this time, during the rectus and peritoneum entry, then check by suction-irrigation test, hanging drop test.
11. The insufflator is switched on and connected to the veress needle.
12. Check the flow rate and the actual pressure at this time, the flow rate, not more than 1,5 L/min, the actual pressure increasing gradually, and not exceeding preset pressure.
13. When the actual pressure becomes equal to the preset pressure, take out the needle and do a 10 mm smiling incision in the lower umbilical crease.
14. Insert artery holding forceps to the incision to dilate the vitellointestinal duct and separate the recti muscle (Scandanavian technique).
15. Insert a 10 mm umbilical port and connect the insufflator and close the valve for continuous pneumoperitoneum.
16. Insert a 10 mm 30 degree telescope and take a panoramic view.
17. 10 mm port is inserted under direct vision in the left iliac fossa 7,5 cm lateral to the umbilicus and 5 mm port is inserted under direct vision in the right iliac fossa 7,5 cm lateral to the umbilicus according to Baseball Diamond Theory.
18. Prepare of the length of suture in the extracorporeal knot for the free structure is 75 cm by vicryl no.1
19. Take the Bhandarkar knot pusher in the left hand and pass 2 cm suture through. The eye in the tail end of the Bhandarkar knot pusher by the right hand.
20. The knot pusher is now reversely feed in the 3 mm reducer. Reverse feeding is important.
21. Once the reducer is fed, the thread is pulled out from the eye of the tail of the knot pusher. The job of the eye in the tail is just to pass the suture safely from the reducer.
22. Now the other end of the suture is passed through the eye of the head end using the right hand.
23. Ask the assistant for finger and make the configuration of Mishra’s knot is 1-1-1-1-1-1-1. One hitch one wind one lock, 2nd wind second lock and 3rd wind, and the final lock.
24. Make the diameter of loop 6 cm by sliding the loop by right hands finger and thumb.
25. After that, hide the knot and its loop under the reducer.
26. Now the knot pusher and the reducer are introduced through the 10 mm port. If it is introduced through the 10 mm, port additional 5 mm reducer should be introduced.
27. An Atraumatic grasper should also be introduced from the contralateral port (5 mm port in the right hand).
28. The loop of the knot should go near to the Right or Left Fallopian Tube.
29. The Atraumatic grasper should have to enter or introduced in the loop and catch the left fallopian tube.
30. Now the knot pusher should go to feed the loop behind the left fallopian tube. The same way as our hands goes behind when we put garland on someone’s neck.
31. The knot now can be slide to the left fallopian tube. By establishing the knot pusher with the left hand and pulling the suture with the right hand.
32. After tightening the knot consecutively three times, the knot pusher after that coagulation and cutting by Ligasure (Bipolar).
33. 5mm reducer is pulled, and hook scissors is introduced from the same port, and the suture is cut, leaving 1 cm tail.
34. The same is repeated on the right fallopian tube. Remove the applicator.
35. Take a 5 mm telescope after white balancing and fixation before insertion through the 5 mm port.
36. Prepare the veress needle and make a loop of thread (proline) to use it for the closure of the 10 mm port to prevent future hernia.
37. Close the umbilical 10 mm port and 10 mm second port in the left hand under direct vision by no.1 vicryl.
38. Deflate the abdomen gradually making jerky movement by the 5 mm telescope to avoid intestinal entrapment to the port.
39. Put a surgical dressing on the port sites.
Elaborated Steps of other technique
Position the patient in the supine position with both arms tucked.
Administer general anesthesia.
Place a Foley catheter to empty the bladder.
Preoperative antibiotics are administered.
Insufflate the abdomen using CO2.
The laparoscope is inserted through a 10mm port at the umbilicus.
Place 1-2 additional trocars as required.
Identify the fallopian tubes.
Apply Mishra's Knot or
Use the bipolar cautery or monopolar cautery to coagulate the isthmic portion of the tubes.
Apply a second layer of cautery to ensure complete occlusion of the tubes.
Remove the laparoscope.
Remove the trocars.
Deflate the abdomen.
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 intercourse 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-up appointment.
The surgeon orders any necessary imaging or laboratory tests to evaluate progress.
The surgeon adjusts medications or treatment as needed.
The surgeon monitors the patient for any signs of complications or side effects.
The surgeon communicates with the patient's primary care physician to ensure continuity of care.
The surgeon provides the patient with information on any further treatment or follow-up care.
The patient continues to follow the surgeon's instructions and attend regular follow-up appointments.
|Older Post||Home||Newer Post|
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.