Kolkata West Bengal
General Anaesthesia :
The patient should be under GA.
Position the patient in the supine position.
Availability of the following instruments should be checked :
Access instruments: Blade 11, Veress needle, two 10 mm ports, two 5 mm ports.
Optical instruments: 10 mm telescope, camera, light cable.
Operating instruments: Maryland, Traumatic grasper, semi traumatic grasper, endoclips, Curved endoscissor, Vicryl suture, endobag.
Energy instruments: Harmonic, hook connected with monopolar.
Check the function of the monitor, Insufflator, light source, amount of gas cylinder, harmonic setting frequency between 3-5, and check the monopolar function for cutting and coagulation.
Patient and surgeon Positioning :
Table height should be adjusted to the surgeon height (0.49 X surgeon height).
The patient should be prepped form the nipples to the mid-thighs: patient draping and cable arrangement.
The surgeon should stand on the left side of the patient. The monitor at the right side of the patient,1st assistant, should be on the left side of the surgeon and the 2nd assistant at the right side of the patient.
The monitor, target organ, and surgeon should be aligned in coaxial alignment.
The monitor should be at 15 degrees below the surgeon's eyes and 5 times of its diagonal diameter away from the surgeon.
Access and Insufflation:
Umbilicus to hold With Allys Forceps, then using blade 11, 3 mm incision to be made at the inferior crease of the umbilicus.
Size 10 Veress needle insertion: start with checking the veress needle function and patency by flushing it with NS and hearing two clicks of the valve.
The length of the needle which should be inserted should be 4cm + abdominal wall thickness. Veress Needle should be held as a dart at 45 degrees, left the abdominal wall in a way that veress needle should be perpendicular to it and pointed toward the anus. Will feel two areas of resistance, should be intrabdominal after you passed the 2nd area.
Check the position of the Veress needle in three ways:
Flush the needle with NS, which should go easily.
Aspirate, nothing should come.
Hanging drop test: drops of NS are placed at the cannula of the needle, should sink when the lower abdominal wall is lifted.
5. Qudrimanometric 40 liters Insufflator to be on, the following setting should be applied:
a. Set pressure 12 and flow 1 L / min.
6. The gas tube should be flushed with CO2 before attaching it to the veress needle.
7. The gas tube to be attached to the veress needle and start insufflation, making sure that the abdomen is tympanic and distended equally in all quadrants. Insufflator's parameters should be observed during insufflation.
8. Once the actual pressure reaches the set pressure of 12 mmHg, the Veress needle will be removed.
9. At the same umbilical, inferior crease, Using a 10 mm cannula, the area is marked for the incision, then the incision increased to 10 mm, smiley incision.
10. The vetelinointestinal tract is opened and dilated with artery forceps.
11. 10mm port is inserted through the tract and attached to the gas tube.
12. 30 degrees Camera to be adjusted in terms of white balance, and focus.
13. Camera to be inserted and check for any bleeding, adhesion or bowel injury.
Working ports insertion :
Based on the baseball diamond concept, working ports sites are determined and inserted under direct visualization as follows:
10 mm port at the epigastric area at the line between xiphisternum and umbilicus. This port should be inserted left to the falciform ligament but piercing the membranous part and should come out right to it.
5 mm port at the right midclavicular line, around 2 cm below the costal margin.
5 mm port at the right mid-axillary line, around 5-8 cm below the costal margin.
Position the patient in the left lateral, head up.
Through the lateral 5mm port, Using the traumatic grasper, the fundus of the gallbladders should be retracted upward and toward the right shoulder of the patient.
The gall bladder is retracted anteromedially, With the help of the grasper the Hartmans pouch exposed, all adhesions are released with blunt dissection or Harmonic use.
The Gallbladder infundibulum is retracted toward the left shoulder so the anterior peritoneum is exposed.
Making sure that we are above the Rouviere’s Sulcus, dissection to be started at the anterior peritoneum at the Hartmans pouch level using the harmonic.
Then the infundibulum is retracted to the right side, and anterior lateral posterior peritoneum is exposed and dissected.
By this time, a window is created below the infundibulum connecting the anterior and posterior openings.
The critical view of safety (cystic duct, CHD, and the edge of the liver) is viewed, Cystic duct is identified, dissected, and isolated from the artery. Always avoid over traction, to prevent CBD injury.
Using Vicryl suture with Mishra's knot, the cystic duct is ligated near the CBD. Moreover, clips are applied at the distal end of the duct. Using the scissor, the cystic duct is cut between the clips and the knot.
The cystic artery is identified and clipped using the end clips by applying 2 clips proximally and one clip distally. The artery cut using scissors.
Using the Harmonic, the gallbladder is dissected from its bed in the liver surface by cutting the anterior and posterior peritoneum.
Dissection continued till the fundus of the gallbladder, till it is detached from the liver.
The gallbladder bed is inspected for any bleeding and should be controlled by using fulguration by monopolar (using hook).
Using endobag, the gallbladder is retrieved through the epigastric port.
Ports removal and closure:
Under direct vision, 5 mm ports and epigastric port are removed.
Gas insufflation is stopped, the abdomen is deflated, The umbilicus port is removed, facia is closed using Vicryl 0.
All Skin incisions are closed using Rapide Vicryl or staplers.
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 2-3 additional trocars as required.
Identify the gallbladder, liver, common bile duct, cystic duct, and cystic artery.
Use the hook cautery to dissect the cystic artery.
Clip and divide the cystic artery.
Dissect the cystic duct.
Clip and divide the cystic duct.
Use the hook cautery or harmonic scalpel to dissect the gallbladder from the liver bed.
Use a grasper to retract the gallbladder.
Use the hook cautery or harmonic scalpel to dissect the gallbladder from the liver bed.
Use a grasper to retract the gallbladder.
Continue dissection until the gallbladder is free from the liver bed.
Use a retrieval bag to extract the gallbladder.
Inspect the cystic duct and cystic artery for hemostasis.
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 heavy lifting 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.
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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.