Task Analysis of Laparoscopic and Robotic Procedures

Task Analysis For Management Of Interstitial Pregnancy
Gynecology / Sep 2nd, 2021 3:06 pm     A+ | a-
Management of Interstitial Pregnancy

About 1-2% of all pregnancies may be ectopic which is a very risky and possibly life-threatening condition. Of these, 95-97% occur in the fallopian tubes. Recent advanced techniques in diagnosis and management have reduced the mortality rates by almost half.
Laparoscopic management is offered when:
1. patient is hemodynamically stable
2. beta HCG >10,000 mUI/ml
3. mean sac diameter>=4cm
4. contraindication to medical management by methotrexate
5. patient cannot be followed up adequately post medical management

Task Analysis For Management Of Interstitial Pregnancy
1. Veress needle checked for spring action and patency. Other instruments were also checked for proper functioning.
2. Patient in the supine position
3. General anaesthesia given
4. Painting and draping done
5. Umbilicus everted with Allis after selecting the port site:
            a.Intra umbilical in obese patients
            b.Supra umbilical in patients with previous surgery
            c.Inferior crease of umbilicus in all other patients                    
6. With the aid of a No.11 blade, a stab wound was given of approximately 2mm in the selected port site..
7. Lift the loose part of the abdomen using thenar, hypothenar, and all fingers of both surgeon and assistant.
8. Hold the veress like a dart by shielding it at a distance of abdominal wall thickness plus 4cm and insert it.
9. Hear the two clicks. First of the piercing of the rectus sheath and second of the piercing of the peritoneum.
10. Confirm correct placement of the veress needle by:
                                           (a)Irrigation test
                                           (b)Suction test
                                           (c)Hanging drop test
                                           (d)Plunging test
11. Connect the insufflation cable to veress and create pneumoperitoneum with a set pressure of 12-15mmHg.
12. Check the pneumoperitoneum by:
                              (a)liver dullness
                              (b)distention of abdomen
                              (c)Actual flow rate of ‘0’
While keeping a watch on the patient’s EtCO2.
13. Remove the veress needle.
14. Make a marking of 10mm trocar and then increase the incision up to 11-12mm.
15. Dilate the urachus with artery forceps as per the Scandinavian technique
16. Insert the 10mm trocar with cannula held like a piston with the index finger pointing to control the depth of insertion, head of the trocar on the thenar eminence, and middle finger wrapped around the gas channel with screwing motion of the wrist while lifting the abdominal wall till give away feeling and then change the direction towards the pelvis. At this point, a hissing sound is heard of the air leaking out.
17. Remove the trocar.
18. Clean the cannula with a gauze held in a grasper for clear passage of the telescope.
19. Check for any injury during the passage of the veress and trocar and get a general view of the pelvis.
20. Look for any sign of ruptured ectopic pregnancy:
                                       (a)presence of hematoma
                                       (b)presence of clots
21. Decide the target of the surgery by inspecting bilateral tubes.
22. Using the baseball diamond concept, make a secondary port 7.5cm away from the primary port on the same arc under vision by transilluminating the area over the ectopic.
23. Using an atraumatic grasper in the secondary port and the telescope in the primary port, perform a diagnostic lap inspecting the following:
             a. Right iliac fossa
             b. Caecum
             c. Appendix                                
             d. Right hypochondrium
             e. Ascending colon
             f. Hepatic flexure of colon              
             g. Anterior pouch
             h. Bladder
             i. UV fold of peritoneum
             j. Median ligament                   
             k. Medial ligament
             l. Cooper ligament
             m. Posterior pouch
             n. Uterosacral ligament
             o. Rectum
             p. Uterus- fundus, anterior and posterior surface
             q. Bilateral adnexal- ovaries, tubes, round ligament, IP ligament, ovarian 
                     fossa, and ligaments
             r. Sacral promontory
             s. Right and left pelvic sidewalls, deep ring, ureter, the triangle of doom, 
                     trapezoid of disaster
             t. Right lobe of the liver
             u. Gall bladder
             v. Stomach
             w.Falciform ligament
             x. Left lobe of the liver and left hypochondrium
             y. Spleen
             z. Left iliac fossa and sigmoid colon
24. Another port is inserted along the same arc, 7.5cm lateral to the secondary port to achieve two ipsilateral ports under vision.
25. Identify the diseased fallopian tube with the aid of an atraumatic grasper and a Maryland.
26. Contralateral tube inspection is also done.
27. Affected tube is mobilized by dissection of the mesosalpinx using a bipolar or harmonic if needed. Retraction of the fallopian tube in anterior and medial direction is done to give adequate space for dissection and to avoid injury to the pelvic wall. Avoid injury to the ovarian artery (causes devascularisation of ovaries).
28. Five units of vasopressin in 20ml normal saline are injected to minimize bleeding with a 20 gauge spinal needle in the area of the tubal segment containing trophoblastic tissue and the uterine surface adjacent to it. Notice the blanching of the tissue.
29. Stabilize tube with a grasper in the left hand.
30. Circumfentially incise around the cornua containing the ectopic pregnancy. Traction and counter traction is maintained to develop a plane of dissection.
31. The products of conception are placed in the posterior cul de sac for removal later.
32. The defect is repaired in multiple layers. Usually, two layers of the myometrium and then the third layer of serosa is repaired separately.
33. Close inner myometrium by continuous suturing using barbed suture or 2-0 vicryl.
34. Outer myometrium is closed by baseball suturing with 1-0 vicryl or absorbable braided suture.
35. Serosa is repaired by baseball suturing.
36. Salpingectomy is done with the help of bipolar and scissors successively of the affected tube since the cornua were resected and hence the fallopian tube will not be normal. The mesosalpinx and meso ovarian are coagulated and cut with the right hand while the left-hand holds the fallopian tube with an atraumatic grasper. This dissection must be from the lateral to the medial side. 
36. The products and tube are removed by either pulling through the 10mm port site by aligning the tissue longitudinally or by using an endo bag.
37. Hemostasis is achieved.
38. Suction and irrigation are done if there is any spillage of blood.
39. Final inspection of the tube is done.
40.10mm port is closed using a veress needle or cobbler needle.
41. All ports are removed slowly to avoid any fascial injury or entrapment of the omentum or bowel.
42. Superficial closure of all port sites is done.
43. Abdomen is cleaned.
44. Antiseptic dressing done
45. Post-op vitals are noted and the patient is shifted to the recovery room.
46. Tissue that is retrieved is sent for histopathology. 

Elaborated Steps

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.

Place a uterine manipulator to manipulate the uterus.

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 round ligament and fallopian tube.

Dissect the round ligament to enter the broad ligament.

Identify the interstitial portion of the fallopian tube.

Place a uterine artery clamp across the proximal part of the tube.

Divide the tube proximal to the clamp.

Remove the products of conception from the interstitial space.

Use suction to remove the contents of the pregnancy.

Inspect the tube and cornual area for bleeding.

Control bleeding by electrocoagulation or suturing.

Use suction to clear any remaining blood clots.

Inspect the surrounding structures for any additional bleeding.

Place a drain to monitor any potential bleeding or fluid accumulation.

Remove the uterine manipulator.

Remove the laparoscope.

Close the ports.

Deflate the abdomen.

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 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.
Dr. Shyamali Kumari
Sep 2nd, 2021 3:44 pm
Excellent Task Analysis For Management Of Interstitial Pregnancy. Very useful to perform surgery following these steps. Thank You.
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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.

Task Analysis of Laparoscopic Surgery

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.

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