plenary 8: research & science - aagl4:00 increase in prophylactic salpingectomy across all...

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AAGLAdvancing Minimally Invasive Gynecology Worldwide

Plenary 8: Research & Science

DISCUSSANTS

MODERATORS

Stuart R. Hart, MDJohn P. Lenihan, MD

Ertan Saridogan, MD, PhD

Joseph (Jay) L. Hudgens, MDMagdy P. Milad, MD, MS

Jessica A. Shepherd, MD, MBAKelly N. Wright, MD

Hye-Chun Hur, MD, MPHAdeoti E. Oshinowo, MD, MPH

Prakash H. Trivedi, MD

Liselotte Mettler, Prof. Dr. med Joseph S. Sanfilippo, MD, MBA Mark B. Woodland, MD, MS

Elizabeth J. Cooney, MDChristopher C. DeStephano, MD, MPH

Xiaoming Guan, MD, PhDMichael R. Polin, MDLauren Thomaier, MD

Patrice Crochet, MDRayan Elkattah, MD

Jamie Kroft, MD, MScDerrick J. Sanderson, DO

Mireille D. Truong, MD

Professional Education Information Target Audience This educational activity is developed to meet the needs of residents, fellows and new minimally invasive specialists in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 1.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.

Table of Contents

Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 3 Development of an Evidence‐Based Virtual Reality Training Curriculum for Laparoscopic Hysterectomy Patrice Crochet .............................................................................................................................................. 5 Can Surgical "Warm‐Up" With Instructor Feedback Improve Operative Performance of Surgical Trainees? Jamie Kroft .................................................................................................................................................... 7 Robot‐Assisted Laparoscopic Myomectomy: A Comparison of Techniques Derrick J. Sanderson ...................................................................................................................................... 9 Retroperitoneal Ureteral and Uterine Artery Identification During Robotic Hysterectomy: Learning Curve and Determinants of Improvement During Fellowship Training Rayan Elkattah ............................................................................................................................................ 11 Increase in Prophylactic Salpingectomy Across All Approaches Following an Educational Initiative Elizabeth J. Cooney ..................................................................................................................................... 13 Crowdsourcing: A Valid Alternative to Expert Evaluation of Robotic Surgery Skills Michael R. Polin .......................................................................................................................................... 16 Laparoscopic and Robotic Skills are Transferable in a Simulation Setting Lauren Thomaier ......................................................................................................................................... 22 Development and Evaluation of a Low‐Cost, Reusable Laparoscopic Entry and Emergency Model Christopher C. DeStephano ......................................................................................................................... 25 Development of an Educational Robotic Psychomotor Skills Model Mireille D. Truong ....................................................................................................................................... 27 Laparoscopic Entry in Patients With Previous Surgical History or Complex Pathology Xiaoming Guan ............................................................................................................................................ 28 Cultural and Linguistics Competency ......................................................................................................... 29

Plenary 8: Research & Science

Moderators: Liselotte Mettler, Joseph S. Sanfilippo, Mark B. Woodland

Discussants: Stuart R. Hart, Joseph (Jay) L. Hudgens, Hye-Chin Hur, John. P. Lenihan, Magdy P. Milad, Adeoti E. Oshinowo, Ertan Saridogan, Jessica A. Shepherd,

Prakash H. Trivedi, Kelly N. Wright

Faculty: Elizabeth J. Cooney, Patrice Crochet, Christopher C. DeStephano, Rayan Elkattah, Xiaoming Guan, Jamie Kroft, Michael R. Polin, Derrick J. Sanderson,

Lauren Thomaier, Mireille D. Truong The session will focus on: advanced surgical, including robotic, approaches to training. Unique usage of virtual reality in training programs, appropriate “feedback” designed to enhance educational approaches to MIS will be explored. Is there an orderly process to proceed from laparoscopic to robotic technology via simulation? Learning Objectives: At the conclusion of this course, the clinician will be able to: 1) Assess techniques for safe laparoscopic entry.

Course Outline 3:20 Development of an Evidence-Based Virtual Reality Training Curriculum

for Laparoscopic Hysterectomy P. Crochet

3:26 Discussant J.L. Hudgens

3:30 Can Surgical "Warm-Up" With Instructor Feedback Improve Operative Performance of Surgical Trainees? J. Kroft

3:36 Discussant J.A. Shepherd

3:40 Robot-Assisted Laparoscopic Myomectomy: A Comparison of Techniques D.J. Sanderson

3:46 Discussant H-C Hur

3:50 Retroperitoneal Ureteral and Uterine Artery Identification During Robotic Hysterectomy: Learning Curve and Determinants of Improvement During Fellowship Training R. Elkattah

3:56 Discussant M.P. Milad

4:00 Increase in Prophylactic Salpingectomy Across All Approaches Following an Educational Initiative E. Cooney

4:06 Discussant P.H. Trivedi

4:10 Crowdsourcing: A Valid Alternative to Expert Evaluation of Robotic Surgery Skills M.R. Polin

4:16 Discussant E. Saridogan

1

4:20 Laparoscopic and Robotic Skills are Transferable in a Simulation Setting L. Thomaier

4:26 Discussant J.P. Lenihan

4:30 Development and Evaluation of a Low-Cost, Reusable Laparoscopic Entry and Emergency Model C.C. DeStephano

4:36 Discussant S.R. Hart

4:40 Video: Development of an Educational Robotic Psychomotor Skills Model M.D. Truong

4:46 Discussant A.E. Oshinowo

4:50 Video: Laparoscopic Entry in Patients With Previous Surgical History or Complex Pathology X. Guan

4:56 Discussant K.N. Wright

5:00 Adjourn

2

PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop and have no conflict of interest to disclose (in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Amber Bradshaw Speakers Bureau: Myriad Genetics Lab Other: Proctor: Intuitive Surgical Erica Dun* Frank D. Loffer, Medical Director, AAGL* Linda Michels, Executive Director, AAGL* Johnny Yi*

SCIENTIFIC PROGRAM COMMITTEE Arnold P. Advincula Consultant: Intuitive Royalty: CooperSurgical Sarah L. Cohen* Jon I. Einarsson* Stuart Hart Consultant: Covidien Speakers Bureau: Boston Scientific, Covidien Kimberly A. Kho Contracted/Research: Applied Medical Other: Pivotal Protocol Advisor: Actamax Matthew T. Siedhoff Other: Payment for Training Sales Representatives: Teleflex M. Jonathon Solnik Consultant: Z Microsystems Other: Faculty for PACE Surgical Courses: Covidien FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Elizabeth J. Cooney* Patrice Crochet* Christopher C. DeStephano* Rayan Elkattah* Xiaoming Guan Speakers Bureau: Applied Medical Stuart R. Hart Consultant: Covidien Speakers Bureau: Boston Scientific Corp., Inc., Covidien Joseph (Jay) L. Hudgens* Hye-Chun Hur Royalty: UpToDate Jamie Kroft Speakers Bureau: AbbVie John P. Lenihan Speakers Bureau: Intuitive Surgical, Mimic Technologies Liselotte Mettler* Magdy P. Milad* Adeoti E. Oshinowo*

3

Michael R. Polin* Derrick J. Sanderson* Joseph S. Sanfilippo* Ertan Saridogan Other: Honorarium: Johnson & Johnson Other: Advisory Panel Fees: Johnson & Johnson Consultant: Gedeon Richter Jessica Shepherd* Lauren Thomaier* Prakash H. Trivedi* Mireille D. Truong* Mark B. Woodland* Kelly N. Wright Other: Educational Proctor: Applied Medical Asterisk (*) denotes no financial relationships to disclose.

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Development of an Evidence-based Virtual Reality Training Curriculum for Laparoscopic Hysterectomy

Patrice Crochet MD

I have no financial relationships to disclose

• Assess the validity of a Virtual Reality (VR) program for Laparoscopic Hysterectomy (LH)

• Discuss the steps necessary to develop an evidence-based curriculum

• Explain how simulation enables training on complexlaparoscopic procedures outside the operating room

Introduction

• Positive impact of simulators on training1. Zendejas B, Ann Surg 2013

2. Fraser et al. Surg End 2003

• Lack of procedure-specific curricula 3. Larsen et al. BMJ 2009

• VR programs need to be explored4. Stephanidis et al, Ann Surg 2015

Aims:

to evaluate a VR LH program

to develop an evidence-based stepwise curriculum.

• VR simulator: LapMentor*

– LH

– LH with guidance

• Assessment tools:– Quantitative: Metrics

– Qualitative: OSATS5. Aggarwal R et al. Ann Surg. 2008

• Validity and learning curves6. Palter et al. J Grad Med Educ, 2011

Methods Methods

Novices Intermediates

n=8Experienced

n=8Group A n=14 Group B n=10

2 LH+

1 LH with guidance

2 LH+

1 LH with guidance 10 LH

8 LH with guidance

+2 LH

Baselines2 Basic tasks

5

ResultsMetrics

Group A => LH

ResultsOSATS

p> 0.001 (Kriskal‐Wallis)p=0.034

LH with guidance

Laparoscopic Hysterectomy

Basic tasksClipping and grasping Two-handed maneuvres

Time < 1100 s; path length < 2300 cm; no of movements < 1300;idle time < 300

Time taken < 100 s Time taken < 90 sNo. of movements <

100Path length < 440 cm

Time < 1000 s; path length < 2000 cm; no of movements < 1300;idle time < 250; no injuries to bladder, ureter, colon or iliac vessels

OSATS score ≥ 25

Discussion

• Validity evidence and learning curves:– Metrics - Bladder injuries - Qualitative scores

• Training on a range of operative skills:– manipulator and camera placement, forward planning

• Limitations: – standardized procedure – non intervention through the curriculum

7. Palter et al. Ann Surg 2014

• Further research:– Test on a multicenter setting – Transfer of skills acquired to the OR

1. Zendejas B, Brydges R, Hamstra SJ, Cook DA. State of the evidence on simulation‐based training for laparoscopic surgery: a systematic review. Ann Surg. 2013;257(4):586–93.

2. Fraser SA, Klassen DR, Feldman LS, Ghitulescu GA, Stanbridge D, Fried GM. Evaluating laparoscopic skills: setting the pass/fail score for the MISTELS system. Surg Endosc. 2003;17(6):964–7.

3. Larsen CR, Soerensen JL, Grantcharov TP, Dalsgaard T, Schouenborg L, Ottosen C, et al. Effect of virtual reality training on laparoscopic surgery: randomised controlled trial. BMJ. 2009;338:b1802.

4. Stefanidis D, Sevdalis N, Paige J, Zevin B, Aggarwal R, Grantcharov T, et al. Simulation in Surgery: What’s Needed Next? Ann Surg. 2015;261(5):846–53.

5. Aggarwal R, Grantcharov T, Moorthy K, Milland T, Darzi A. Toward feasible, valid, and reliable video‐based assessments of technical surgical skills in the operating room. Ann Surg. 2008;247(2):372–9.

6. Palter VN. Comprehensive training curricula for minimally invasive surgery. J Grad Med Educ. 2011;3(3):293‐8.

7. Palter VN, Grantcharov TP Individualized deliberate practice on a virtual reality simulator improves technical performance ofsurgical novices in the operating room: a randomized controlled trial. Ann Surg. 2014 Mar;259(3):443‐8

Thank you for your attention

6

CAN SURGICAL "WARM-UP" WITH INSTRUCTOR FEEDBACK IMPROVE OPERATIVE PERFORMANCE OF SURGICAL TRAINEES?

Plenary Session 8: Research and Science, November 18, 2014

Jamie Kroft, MD, MSc, FRCSCSunnybrook Health Sciences CentreUniversity of Toronto

Disclosures

¨ Speakers Bureau: AbbVie

Objectives

At the completion of this talk, participants willbe able to: Summarize the benefits of pre-operative surgical

warming-up Identify the benefits of instructor feedback for

learning advanced laparoscopic skills Interpret the results to demonstrate how addition

of instructor feedback may contribute to an improved pre-operative surgical warm-up

Formulate hypotheses on how surgical warming-up can be optimized and incorporated into a residency training curriculum

Background

Athletes and musicians commonly warm-up or practice beforea game or performance but surgeons do NOT typically

Several recent studies have shown a benefit of pre-op warm-up on surgical performance by trainees1

Evidence that trainees who receive instructor feedback learnmore efficiently when performing laparoscopy2, 3

At a time when resident work hours and learning in the ORare being reduced, it is important to develop new, innovativemethods for surgical education

Therefore warm-up with directed feedback from an expertsurgeon may provide even additional improvement in ORperformance compared to either alone

Study Objectives

To determine if warm-up by surgical trainees, withinstructor feedback, compared to either warm-up orfeedback alone, improves surgical efficiency, precisionand quality.

Study Methods

7

Results Results

Comparison of Average Scores for Laparoscopic Salpingectomy

Non-parametric Regression Adjusting for Baseline Score

Overall Score (average) Mean (SD) Median (Range) Estimate (SE) from model

Non‐parametric test

Warm‐up (n=6) 19.67 (11.07) 14.50 (10 – 34) ‐‐ Reference

Feedback (n=6) 22.17 (8.24) 21.25 (10.5 – 32) 2.50 (5.46) .654

Warm‐up and Feedback (n=6)

28.92 (8.86) 32.750 (15 – 36) 9.25 (5.46) .111

Overall Score (average) Parameter Estimate

Standard Error Non‐parametric test

Warm‐up (n=6) ‐‐ ‐‐ Reference

Feedback (n=6) 5.213 4.607 .282

Warm‐up and Feedback (n=6) 9.217 4.599 .071

Results

Non-Parametric Analysis Adjusting for Baseline Score and Removing Participants with Intra-op Feedback

Overall Score (average) Mean (SD) Range Estimate (SE) from model

Non‐parametric test


21.44 (9.40) 10 ‐ 34 Reference


31.70 (6.32) 21 ‐ 36 8.54 (3.64) .048

Discussion

Study limitations: Likely underpowered due to higher standard deviation then used in

sample size calculation Possible bias from intra-operative feedback

Study strengths: RCT with use of stratified randomization to attempt to account for

baseline skill level Use of validated tools to measure baseline skill and operative

capabilities for primary outcome Use of two blinded assessors of outcome measure

Future Directions: Ideal type of warm-up and feedback? Does benefit of warm-up translate to clinically relevant

differences? How do you make warming-up logistically feasible?

Summary

Pre-operative surgical warm-up combined with instructor feedback may improve operative performance of surgical trainees compared to either a warm-up or feedback alone

Further research is needed to elicit the ideal type of warm-up and feedback, which has the potential to provide enhanced resident training of surgical skill aquisition

References

1. Abdalla G, Moran-Atkin E, Chen G, Schweitzer MA, Magnuson TH, Steele KE. The effect of warm-up on surgical performance: a systematic review. Surg Endosc. 2015;29(6):1259-1269. doi: 1210.1007/s00464-00014-03811-00464. Epub 02014 Aug 00423.

2. Strandbygaard J, Bjerrum F, Maagaard M, et al. Instructor Feedback Versus No Instructor Feedback on Performance in a Laparoscopic Virtual Reality Simulator: A Randomized Trial. Ann Surg. 2013.

3. Grantcharov TP, Schulze S, Kristiansen VB. The impact of objective assessment and constructive feedback on improvement of laparoscopic performance in the operating room. Surg Endosc. 2007;21(12):2240-2243.

8

Robot-Assisted Laparoscopic Myomectomy: A Comparison of Techniques

Derrick Sanderson, DO

Sisters of Charity HospitalBuffalo, NY

• I have no financial relationships to disclose.

• At the conclusion of this activity, participants will be better able to:– Describe the current techniques for robot-assisted

laparoscopic myomectomy

– Articulate the advantages, and disadvantages of incorporating the 4th robotic arm into surgical procedures

– Interpret the impact of using the 4th robotic arm in robot-assisted laparoscopic myomectomy

Introduction• Robot-assisted laparoscopic myomectomy is a well

established surgical approach to minimally invasive fibroid removal in woman desiring uterine preservation.– The literature describes this technique using both 3 and 4

operative robotic arms.1-8

– There are no studies comparing perioperative outcomes between a 3-arm and 4-arm technique.

• Retrospective cohort study (Canadian Task Force classification II-2)

Techniques and Methods

3-arm technique1-4,6,8 4-arm technique4-5,7

Results4-arm technique N=60 (CI)

3-arm technique N=41 (CI)

P value

Mean Age 36 (34 - 38) 35 (33 - 36) 0.68

BMI 29 (27 - 32) 31 (29 - 33) 0.33

ASA classification 1.7 (1.5 - 1.8) 1.7 (1.6 - 1.9) 0.38

Gravidity 1.2 (0.7 - 1.7) 0.8 (0.4 - 1.1) 0.77Parity 0.6 (0.4 - 0.9) 0.2 (0 - 0.4] 0.91

9

Results4-arm technique N=60 (CI)

3-arm technique N=41 (CI)

P value

Operative time 128 (116 - 140) 218 (196 - 240) <0.01EBL 112 (71 - 152) 166 (90 - 243) 0.26Number of fibroids 2 (1 - 3) 2 (1 - 3) 0.48Fibroid weight (g) 203 (159 - 247) 174 (118 - 231) 0.65Morphine in PACU 5 (4 - 6) 6 (4 - 7) 0.34Pain score in PACU 2.5 (2 - 3) 2.6 (2 - 3) 0.46Length of stay (days) 0.1 (0 - 0.2) 0.2 (0 - 0.5) 0.25

Results4-arm techniqueN=60

3-arm technique N=41

Cases with additional procedures 15 (25%) 16 (39%)

number of cases converted 2 1

EBL > 500 mL 3 3

greatest EBL 800 1100

transfusions 0 1

Discussion• The use of the 4th robotic arm had a significant impact on

operative time (-90 minutes, p<0.01)

– Patient demographics and all other perioperative variables were similar between both groups

• There were no untoward events associated with use of the 4th robotic arm

– Pain scores, morphine equivalents administered in PACU, and length of stay were similar

Conclusions

• The use of 4-arm robot-assisted laparoscopic myomectomy technique is associated with a significantly shorter operative time, with all other perioperative variables and patient demographics being similar

1. Advincula AP, Song A, Burke W, Reynolds RK. Priliminary experience with robot‐assisted laparoscopic myomectomy. J Am Assoc Gynecol Laparosc. 2004 Nov;11(4):511‐18.

2. Advinicula AP, Xu X, Goudeau S 4th, Ransom SB. Robot‐assisted laparoscopic myomectomy versus abdominal myomectomy: a comparison of short‐term surgical outcomes and immediate costs. J Minim Invasive Gynecol. 2007;14:698‐705.

3. Ascher‐Walsh CJ, Capes TL. Robot‐assisted laparoscopic myomectomy is an improvement over laparotomy in women with a limited number of myomas. J Minim Invasive Gynecol. 2010;17(3)306‐10.

4. Barakat EE, Bedaiwy MA, Zimburg S, Nutter B, Nosseir M, Falcone T. Robot‐Assisted, Laparoscopic, and Abdominal Myomectomy: A comparison of Surgical Outcomes. Obstet Gynecol. 2011; 117(2):256‐265.

5. Lönnerfors C, Persson A. Robot‐assisted laparoscopic myomectomy; a feasible technique for removal of unfavorably localized myomas. Acta Obstet Gynecol Scand. 2009;88(9):994‐9.

6. Pluchino N, Litta P, Freschi L, Russo M, Simi G, Santoro A, Angioni S, Gadducci A, Cela V. Comparison of the initial surgical experience with robotic and laparoscopic myomectomy. Int J Med Robot. 2014 Jun;10(2):208‐12.

7. Quaas AM, Einarsson JI, Srougi S, Gargiulo AR. Robotic myomectomy: a review of indications and techniques. Rev ObstetGynecol. 2010 Fall; 3(4): 185‐91.

8. Senapati S, Advincula AP. Surgical techniques: robot‐assisted laparoscopic myomectomy with the da Vinci® surgical system. J Robot Surg. 2007;1(1):69‐74.

Thank you

• Questions?

10

Retroperitoneal Ureteral and Uterine Artery Identification during Robotic Hysterectomy: Learning Curve and

Determinants of Improvement during Fellowship Training

Rayan A. Elkattah, MD

FMIGS - Women’s Surgery Center

University of Tennessee Chattanooga

I have no financial relationships to disclose

1. Describe how to identify the retroperitoneal ureteral and uterine arteryduring robotic hysterectomy

What the Literature says…

Uterine Artery Ligation: Reduces blood loss, operation duration

and hospital stay - Kale et al. 2015

Reduces intra-operative complications–Poojari et al. 2014

Our Pre-Hysterectomy Retroperitoneal Routine

1. Identify the ureter at the pelvic brim

2. Follow it caudally along the medial leaf of the broad ligament

3. Identify and clip the uterine artery

Right Round Ligament Right Infundibulo-pelvic Ligament

Right Ureter Right Uterine Artery

11

Int Iliac A

Sup Ves A

Lt Ureter

Our Study

Comparison of T1, T2 and total time T1+T2

between two rotations R1 and R2

Timings for the retroperitoneal identification of:

T1: Ureter

T2: Uterine artery + Clipping

Variables that were factored in: Age / BMI / Uterine mass / Laterality / Adhesions / Past abdominal or pelvic surgeries

Results

Shorter dissection times were noted in T2 and in T1+T2

between R1 and R2 (p < .05)

Age, adhesions, surgical history, uterine mass andlaterality of dissection had no significant effect on timings

T1 increased with increasing BMI (p < .05)

T1+T2 plateaued by the 15th case

Time (sec) R1 R2

T1 273.7 ± 30.4 s 188.2 ± 32.9 s

T2 129.6 ± 16.4 s 83.3 ± 10.7 s

T1 + T2 230.9 ± 23.2 s 106.5 ± 10.3 s

Conclusions

1. A fellow in MIGS training requires aminimum of 15 robotic hysterectomycases to become adept at retroperitonealidentification of the ureter and the uterineartery

2. Increasing body mass index increasesthe time to identify the ureter

1. Kale A, Aksu S, Terzi H, Demirayak G, Turkay U,Sendag F. Uterine artery ligation at the beginning oftotal laparoscopic hysterectomy reduces total bloodloss and operation duration. J Obstet Gynaecol 2015Aug 24: 1-4. (Epub ahead of print)

2. Poojari V, Bhat V, Bhat R. Total laproscopichysterectomy with prior uterine artery ligation at itsorigin. Int J Reprod Med 2014. Hindawi Press (openaccess).

12

Increase in Prophylactic Salpingectomy Across All Approaches Following an Educational Initiative

Presenter: Elizabeth Cooney, MD

Christiana Care Hospital

Department of Women’s Health

Newark, DE

Disclosure

I have no financial relationships to disclose.

Objectives

• At the conclusion of this activity, the participant should be better able to …

– Articulate the potential benefits of salpingectomy when performed during benign hysterectomy

– Identify barriers to the performance of salpingectomy

– Recognize the value of educational initiatives on evidence‐based surgical practice

Background

• “Evidence‐based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.1”

• Ovarian cancer – Most lethal gynecologic malignancy– No validated screening tests– Best‐available data suggest a potential for reduction in ovarian cancer via salpingectomy2

• Discussion regarding prophylactic salpingectomy– ACOG3

– SGO4

– Canadian GOC5

Materials and Methods

• Intervention:– A 10‐slide PowerPoint presentation was dispersed to gynecologic surgeons at Christiana Care Hospital5‐7

– A 10‐question, anonymous survey was attached

• Data Collection:– Retrospective chart review of benign hysterectomies for 18 months

– Primary outcomes: rate of salpingectomy, route of hysterectomy

– Secondary outcomes: BMI, Δ Hgb, age, race, length of stay; physician attitudes

Survey Results

• Response: 20/49 (41%)• Surgical Practice:

– 40% perform 0‐10 hysterectomies per year– 10% perform greater than 40 per year– 95% report routine salpingectomy

• Adnexal Counseling:– 100% discuss ovarian preservation– 95% discuss salpingectomy

• Impact on practice:– 40% stated would increase salpingectomy rate > 40%

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Main ResultsPatient Characteristics

Pre‐Intervention(N = 318)

Post‐intervention(N = 351)

p‐value

Mean age (years) 46.2 45.5 p = 0.39

Mean BMI (kg/m2) 30.8 30.7 p = 0.82

RaceWhiteBlack

HispanicOther

19797177

213110237

p = 0.97a

RouteVaginal

LaparoscopicAbdominal

5316996

6518997

p = 0.70a

Mean length of stay (days)

1.48 1.56 p = 0.33

Mean Δ Hgb (mg/dl)

1.59 1.84 p = 0.17

a = Fisher’s exact

Main ResultsPre‐intervention

0

50

100

150

200

250

300

350

Vaginal Abdominal Laparoscopic Total

No Salpingectomy

Salpingectomy

15.1%

39.6%

76.9%

55.3%% = cases with salpingectomy

Route of Hysterectomy

Number of Cases

Main ResultsPost‐Intervention

0

50

100

150

200

250

300

350

400

Vaginal Abdominal Laparoscopic Total

No Salpingectomy

Salpingectomy

29.2%

64.9%

87.8%

70.7%

Route of Hysterectomy

Number of Cases

% of cases with salpingectomy

Pre/Post Data

0

10

20

30

40

50

60

70

80

90

100

Vaginal Abdominal Laparoscopic

Pre

Post

% of cases with salpingectomy

Strengths/Weaknesses

Strengths

• No reliance on CPT codes

• Diverse surgeon population

• Consistent patient characteristics pre/post intervention

Weaknesses

• Retrospective design

• Inability to assess ‘intent‐to‐treat’

• Unable to control for natural trend

Discussion

• Visual presentation of educational material appears to be effective in promoting uptake of best‐surgical practice

• Vaginal hysterectomy remains underutilized and is least likely to incorporate salpingectomy

• Salpingectomy should continue to be discussed with patients undergoing benign hysterectomy desiring ovarian preservation

14

References

1. Sackett DL, Rosenberg WM, Gray JM et al. Evidence‐based medicine: what it is and what it isn’t. Brit Med J. 1996;312:71‐72.

2. Walker JL, Powell B, Chen LM et al. Society of gynecologic oncology recommendations for the prevention of ovarian cancer. Cancer. 2015;121:2108‐20.

3. Salpingectomy for ovarian cancer prevention. Committee Opinion No. 620. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;125:279‐81.

4. Society of Gynecologic Oncology. SGO clinical practice statement: salpingectomy for ovarian cancer prevention. Committee Statement, 2013.

5. The Society of Gynecologic Oncology of Canada. GOC statement regarding salpingectomy and ovarian cancer prevention. Committee Statement, 2011.

6. Kurman RJ, Shih le M. The origin and pathogenesis of epithelial ovarian cancer: a proposed unifying theory. Am J Surg Pathol 2010;34:433‐43.

7. Morelli M, Venturekkka R, Mocciaro R, Di Cello A, Rania E, Lico D, D’Alessandro P, Zullo F. Prophylactic salpingectomy in premenopausal low‐risk women for ovarian cancer: Primum non nocere. Gyn Onc 2013;129:448‐451.

8. Wright JD, Herzog TJ, Tsui J et al. Nationwide trends in the performance of inpatient hysterectomy in he United States. Obstet Gynecol 2013;122:233‐41.

Additional Slides

• National trends in route of hysterectomy as examined by Wright et al8 showed in 2010

– Vaginal hysterectomy at a rate of 16.7%

– Abdominal hysterectomy 54.2%

– Laparoscopic 8.6%

– Robotic 8.2%

Generalist/Specialist

• Prior to education– 71% of cases performed

by specialist had salpingectomy

– 45% of cases performed by generalist had salpingectomy

• Following education– 75% of cases performed

by specialist had salpingectomy

– 68% of cases performed by generalist had salpingectomy

0

10

20

30

40

50

60

70

80

Pre Post

Specialist

Generalist

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All Rights Reserved, Duke Medicine 2007

Crowdsourcing: A valid alternative to expert evaluation of robotic surgery skills

Michael R. Polin MD


Disclosures

I have no financial relationships to disclose.


Learning Objective

• Discuss an alternative resource for evaluating trainee surgical skills.


Introduction

• Robotic-assisted gynecologic surgery is common, but requires unique training.


Introduction

• Robotic Training Network (RTN) was developed to standardize robotic surgery training.– Created in 2010– Originally 9 academic sites, now over 50


1. Martin JA, et al. Br J Surg 1997; 84: 273-8.2. Siddiqui NY, et al. Obstet Gynecol 2014; 123: 1193-99.

• Standardized assessment tool needed

• Objective Structured Assessment of Technical Skills (OSATS)1

• Robotic-Objective Structured Assessment of Technical Skills (R-OSATS)– Validated by RTN2

Introduction

16


• Robotic-Objective Structured Assessments of Technical Skills (R-OSATS)

Introduction

Tower Transfer Roller Coaster Big Dipper Train Tracks Figure of Eight


Introduction

• OSATS require expert surgeons to evaluate trainees.

We sought to find a better way of assessing trainees.


Introduction

• Crowdsourcing is the process of getting work from a large group of people.


Introduction

• Crowdworkers are the general public

• Complete human intelligence tasks (HITs)

• Receive training specific to the task


Objective

vs.Crowd Expert

R-OSATS scoring


Methods

• Methods-comparison study

• Crowdworker selection and training

• Study:

– Expert Evaluator scores

– Crowdsourced scores

– Comparison of crowd vs. expert

17


Methods



• Study:





• Tasks posted on

• Crowdworkers screened3:– 95% approval rating

– Passed screening test

– Passed attention question

• Crowdworker training:– Viewed extremes, good and bad, for dry lab drill

Methods – crowd selection and training

3. Chen C, et al. J Surgical Research 2014; 187: 65-71.


Methods



• Study:





Methods – expert scores

• Expert evaluator scores:– Videos from validation study

– 3 expert evaluators scored using R-OSATS


• For each dry lab drill, mean expert evaluator scores were calculated.

• Mean scores separated into quartiles.

Methods – expert scores

100%

75%

50%

25%


Methods



• Study:




18


Methods – crowd scores

• Crowdsourced scores:

– Crowdworkers assessed videos randomly selected from each scoring quartile per drill.


Methods – crowd scores

• Average crowd scores calculated using linear mixed effects models4

• ≥30 crowd assessments needed per video to obtain tight confidence intervals5,6

4. Laird NM, et al. Biometrics 1983; 38: 963-74.5. Holst D, et al. J Endourology 2015; 29:604-9.

6. Chen C, et al. J Surgical Research 2014; 187: 65-71.


Methods



• Study:





Methods - comparison

Crowd

vs.

Expert


Methods - comparison

• Pearson correlation coefficients & linear regression models to assess the correlation between crowdsourced vs. expert scores.

vs.


Results

19


Results

• 448 crowdworkers 2,119 R-OSATS assessments


Results

• 448 crowdworkers 2,119 R-OSATS assessments

16 hours


r = 0.3 r = -0.7 r = 0.7


ResultsTower Transfer

r=0.75me

an

ex

pe

rt R

-OS

AT

S s

co

re

mean crowd R-OSATS score


Results

r=0.87

r=0.76r=0.91me

an

ex

pe

rt R

-OS

AT

S s

co

re

me

an

ex

pe

rt R

-OS

AT

S s

co

rem

ea

n e

xp

ert

R-O

SA

TS

sc

ore



Roller Coaster

Figure of Eight

me

an

ex

pe

rt R

-OS

AT

S s

co

re


Big Dipper


r=0.86

Train Tracks


Results

• Correlation UNIVERSALLY HIGH

• Correlation coefficients for each task:tower transfer r=0.75

roller coaster r=0.91

big dipper r=0.86

train tracks r=0.76

figure-of-eight r=0.87

20


Strengths/Limitations

• Strengths– Study design

– Use of a validated assessment tool

– Large number of crowdworker scores obtained in small amount of time

• Limitations– Limited to dry lab surgical skills


Conclusions

• Crowdsourced assessments of dry lab robotic surgical skills using R-OSATS are a suitable alternative to faculty expert evaluation.

• Crowdsourcing provides a rapid and accurate method of assessing technical skills of trainees while minimizing burdens on faculty time.


References

• Martin JA, Regehr G, Reznick R, MacRae H, Murnaghan J, Hutchinson C, et al. Objective structured assessment of technical skills (OSATS) for surgical residents. Br J Surg 1997; 84: 273-8.

• Siddiqui NY, Galloway ML, Geller EJ, Green IC, Hur HC, Langston K, Pitter MC, TarrME, Martino MA. Validity and Reliability of the Robotic Objective Structured Assessment of Technical Skills. Obstet Gynecol 2014; 123: 1193-99.

• Chen C, White L, Kowalewski T, Aggarwal R, Lintott C, Comstock B, Kuksenok K. Aragon C, Holst D, Lendvay T. Crowd-Sourced Assessment of Technical Skills (C-SATS): A Novel Method to Evaluate Surgical Performance. J Surgical Research 2014; 187: 65-71.

• Laird NM, Ware JH. Random effects models for longitudinal studies. Biometrics 1983; 38: 963-74.

• Holst D, Kowalewski TM, White L, Brand T, Harper J, Sorenson M, Kirsch S, LendvayTS. Crowd Sourced Assessment of Technical Skills (CSATS): An Adjunct to Urology Resident Surgical Simulation Training. J Endourology 2015; 29:604-9.

21

October 6, 2015 1

Laparoscopic and Robotic Skills are Transferable in a Simulation Setting

Lauren Thomaier, MD

Department of Gynecology and Obstetrics, Johns Hopkins Hospital

Disclosure

• I have no financial relationships to disclose

2

Objective

• To assess the transferability of skills from the robotic to the laparoscopic simulation platform and vice versa among simulation naïve participants.

3

Introduction

• Increasing number of procedures performed using robotic technique

• Residents with less experience in abdominal and laparoscopic procedures

• Simulation platforms are effective for surgical training- are skills transferable?

Methods

• 40 simulation naïve medical students

• Randomized controlled single-blinded trial – N=20 Robotic group: pegboard 1 exercise on Mimic dV-trainer

– N=20 Laparoscopic group: peg transfer task on Fundamentals of Laparoscopic Skills (FLS) Laparoscopic Box trainer

• Baseline and Post-training evaluation– Objective measures (time to task completion, error rate, motion

metrics on Mimic dV-trainer)

– Objective Structured Assessment of Technical Skills (OSATS)

• completed by blinded robotic and laparoscopic surgeons

5

Tasks

6

Pegboard 1 Exercise Peg transfer task

22

Methods

7

40 simulation naïve medical students

Baseline evaluation: Laparoscopic task, Robotic task

Laparoscopic group N=20: 10 repetitions on peg transfer

Robotic group N=20: 10 repetitions on pegboard 1

Post-training evaluation: peg transfer, pegboard 1 exercise

Primary outcome measures

• Time to task completion (seconds)

• Error rate

• Modified Global Rating Scale (GRS) for Laparoscopic and Robotic Operative Performance:

– evaluating depth perception, bimanual dexterity, efficiency and tissue handling (0-5)

• Reznick Laparoscopic and Robotic Assessment: – evaluating respect for tissue, time and motion, instrument handling and flow

of operation (0-5)

• Composite GRS score = GRS + Reznick score (0-40)

• Motion metrics:– time to task completion (s), economy of motion (cm), number of instrument

collisions, excessive force (s), time instruments are out of view (s), workspace range (cm), and number of drops

8

Results

• No significant differences between the two groups at baseline– Age, sex, hand dominance, experience

with hand-eye coordination activities

– Objective measures (time, error rate, motion metrics)

– Composite Global Rating Scale (GRS)

9

Results: Laparoscopic task

10

Laparoscopic task

Baseline time to completion (mean, seconds)

Baseline composite GRS score (mean)

Post-training time to completion (mean)

Post-training composite GRS score (mean)

Laparoscopic 201 15.4 100 s 25.8

Robotic 226 14.8 158 s 18.8

p-value 0.46 0.71 0.003 < 0.001

Results: Robotic task

11

Robotic Task

Baseline Time to completion (mean)

Baseline Composite GRS score (mean)

Post -Time to completion (mean)

Post-Composite GRS score (mean)

Post-Economy of motion (cm)

Post-Instruments out of view (cm)

Laparoscopic 167 s 15.2 120 s 19.6 241 3.06

Robotic 166 s 15.5 71 s 26.9 161 0.91

p-value0.94 0.87 <0.001 0.002 <0.001 0.02

Results: Transferability

• Composite GRS score improvement

• Laparoscopic group – GRS score on Robotic task: 15 to 20 (p= .091)

• Robotic group – GRS score on LSC task: 15 to 19 (p = .02)

12

23

Discussion

• Simulation training improves performance on both platforms

• Laparoscopic and robotic skills are transferable in simulation setting

• Robotic skills are more transferable to the laparoscopic simulation platform

13

Clinical implications

• Robotic vs. laparoscopic simulation training programs

• Can formal training programs in one technique substitute for the other?

• Resident training in robotic technique improved performance in laparoscopic technique

14

References

• Hussain A, Malik A, Halim MU, Ali AM. The use of robotics in surgery: a review. Int J Clin Pract. 2014;68(11):1376–1382.

• Kenngott HG, Muller-Stich BP, Reiter MA, Rassweiler J, Gutt CN. Robotic suturing: technique and benefit in advanced laparoscopic surgery. Minim Invasive Ther Allied Technol. 2008;17(3):160–167.

• Sarlos D, Kots L, Stevanovic N, Felten von S, Schär G. Robotic compared with conventional laparoscopic hysterectomy: a randomized controlled trial. Obstet Gynecol. 2012;120(3):604–611.

• Seymour NE, Gallagher AG, Roman SA, et al. Virtual reality training improves operating room performance: results of a randomized, double-blinded study. Annals of Surgery. 2002;236(4):458–63– discussion 463–4.

• Gala R, Orejuela F, Gerten K, et al. Effect of validated skills simulation on operating room performance in obstetrics and gynecology residents: a randomized controlled trial. Obstet Gynecol. 2013;121(3):578–584..

• Blavier A, Gaudissart Q, Cadière G-B, Nyssen A-S. Comparison of learning curves and skill transfer between classical and robotic laparoscopy according to the viewing conditions: implications for training. Am J Surg. 2007;194(1):115–121.

• Chandra V, Nehra D, Parent R, et al. A comparison of laparoscopic and robotic assisted suturing performance by experts and novices. Surgery. 2010;147(6):830–839.

• Ahmed K. et al. Observational tools for assessment of procedural skills: a systematic review. Am J of Surgery. 2011. 202(4):469-480

• M. Anderberg, J. Larsson, C.C. Kockum, E. Arnbjörnsson. Robotics versus laparoscopy--an experimental study of the transfer effect in maiden users. Ann Surg Innov Res, 4 (2010), p. 3

• L. Panait, S. Shetty, P.A. Shewokis, J.A. Sanchez. Do laparoscopic skills transfer to robotic surgery? J Surg Res, 187 (1) (2014), pp. 53–58

• Hassan et al. Conventional Laparoscopic vs Robotic Training: Which is Better for Naive Users? A Randomized Prospective Crossover Study. J Surg Educ. 2015 Jul-Aug;72(4):592-9. doi: 10.1016/j.jsurg.2014.12.008. Epub 2015 Feb 14

• Dawe et al. Systematic review of skills transfer after surgical simulation-based training. Br J Surg. 2014 Aug;101(9):1063-76. Epub 2014 May

15

24

Development and evaluation of a low‐cost, reusable laparoscopic entry and emergency model

Christopher DeStephano, MD, MPHMinimally Invasive Gynecology Fellow

Mayo Clinic FloridaJacksonville, Florida

• I have no financial relationships to disclose

• Develop a laparoscopic emergency model using on‐hand, low‐cost, widely available materials

• Determine whether the model and scenario were acceptable for use by surgical residents and attendings

• Explore whether differences existed in the identification and management of hemodynamic instability following laparoscopic entry

BACKGROUND

• Injury to a major retroperitoneal vessel is a rare (0.01%‐0.64%) but serious complication of laparoscopic entry

– Incidence: 0.01‐0.64%

– Mortality: 12‐23%

• Obstetric emergency drills have resulted in improved communication, recognition, and management

• Needs assessment of residents:

– Of 93 respondents, 84% participate in OB simulation drills

– Of 90 respondents, 8% participate in laparoscopic emergency simulations

MODEL DESIGN METHODS

• Convenience sample of OB/GYN and general surgery residents (n=20) and attendings (n=9)

• Laparoscopic entry followed by hemodynamic instability

• Study was designed to establish content, response process, and relations with other variables evidence

– Performance checklists during the scenario

– Post‐simulation surveys

25

SCENARIO RESULTS

• Performance checklist

– A difference (p=0.005) existed in decision to perform an ex lap

• Junior resident group(n=12): 41.7%

• Senior resident, fellow, attendings (n=17): 82.4%

• Median (range) time: 3 (2‐5) minutes

– Hematoma identified laparoscopically (p=0.87)

• Junior resident group (n=12): 25%

• Senior resident, fellow, attendings (n=17): 23.5%

RESULTS

Post‐Simulation Survey Neither agree nor disagree

Agree Strongly Agree

The simulated drill approximates the stress of a vascular injury during laparoscopy

2 (6.9%) 14 (48.3%) 13 (44.8%)

The model is useful in improving knowledge of the differential diagnosis for hypotension during laparoscopy

3 (10.3%) 15 (51.7%) 11 (37.9%)

The model is useful in improving management of a vascular emergency

1 (3.6%) 17 (60.7%) 10 (35.7%)

The model is useful in improving recognition of a vascular emergency

1 (3.4%) 18 (62.1%) 10 (34.5%)

The model set up appears appropriate for approximating a retroperitoneal hematoma

2 (6.9%) 20 (69%) 7 (24.1%)

RESULTS

• Of the 29 participants, 22 (75.9%) rated the simulation drill as more effective than M&M in improving knowledge of surgical complications

• Acceptable price range for model:

– <$50 (6.9%)

– $51‐100 (17.2%)

– $101‐200 (31%)

– $201‐300 by 5 (17.2%)

– >$300 by 8 (27.6%)

CONCLUSION

• The reusable, laparoscopic simulation model and emergency scenario were rated favorably by participants

• The majority of participants did not retract the bowel and attempt to identify the simulated retroperitoneal hematoma laparoscopically

• There was a statistically significant difference in the decision to perform an exploratory laparotomy between junior residents and more experienced surgeons

• 1. Chapron C, Fauconnier A, Goffinet F, Breart G, Dubuisson JB. Laparoscopic surgery is not inherently dangerous for patientspresenting with benign gynaecologic pathology. results of a meta‐analysis. Hum Reprod. 2002 May;17(5):1334‐42.

• 2. Chapron C, Querleu D, Bruhat MA, Madelenat P, Fernandez H, Pierre F, et al. Surgical complications of diagnostic and operative gynaecological laparoscopy: A series of 29,966 cases. Hum Reprod. 1998 Apr;13(4):867‐72.

• 3. Chapron CM, Pierre F, Lacroix S, Querleu D, Lansac J, Dubuisson JB. Major vascular injuries during gynecologic laparoscopy. J Am Coll Surg. 1997 Nov;185(5):461‐5.

• 4. Baggish M. Analysis of 31 cases of major‐vessel injury associated with gynecologic laparoscopy operations. Journal of Gynecologic Surgery. 2003;19(2):63.

• 5. Seidman DS, Nasserbakht F, Nezhat F, Nezhat C. Delayed recognition of iliac artery injury during laparoscopic surgery. Surg Endosc. 1996 Nov;10(11):1099‐101.

• 6. Makai G, Isaacson K. Complications of gynecologic laparoscopy. Clin Obstet Gynecol. 2009 Sep;52(3):401‐11.

• 7. Sandadi S, Johannigman JA, Wong VL, Blebea J, Altose MD, Hurd WW. Recognition and management of major vessel injury during laparoscopy. J Minim Invasive Gynecol. 2010 Nov‐Dec;17(6):692‐702.

• 8. Mitchell EL, Lee DY, Arora S, Kenney‐Moore P, Liem TK, Landry GJ, et al. Improving the quality of the surgical morbidity and mortality conference: A prospective intervention study. Acad Med. 2013 Jun;88(6):824‐30.

• 9. Villamaria FJ, Pliego JF, Wehbe‐Janek H, Coker N, Rajab MH, Sibbitt S, et al. Using simulation to orient code blue teams to anew hospital facility. Simul Healthc. 2008 Winter;3(4):209‐16.

• 10. Deering S, Rowland J. Obstetric emergency simulation. Semin Perinatol. 2013 Jun;37(3):179‐88.

• 11. Cook DA, Zendejas B, Hamstra SJ, Hatala R, Brydges R. What counts as validity evidence? examples and prevalence in a systematic review of simulation‐based assessment. Adv Health Sci Educ Theory Pract. 2014 May;19(2):233‐50.

• 12. American Educational Research Association, American Psychological Association, and National Council on Measuring in Education. Standards for educational and psyschological testing. Washington DC: American Educational Research Association; 1999.

• 13. Acero NM, Motuk G, Luba J, Murphy M, McKelvey S, Kolb G, et al. Managing a surgical exsanguination emergency in the operating room through simulation: An interdisciplinary approach. J Surg Educ. 2012 Nov‐Dec;69(6):759‐65.

26

Development of an Educational Robotic Psychomotor Skills Model

Mireille D. Truong, MD Columbia University Medical Center, New York, New York

Objective: To demonstrate the development of a robotic psychomotor skills model for implementation

in the Fundamentals of Robotic Surgery curriculum and its clinical application in gynecologic surgery.

Design: Demonstration of the process of creating a psychomotor skills model from a low to high fidelity

prototype followed by clinical application examples via narrated video footage.

Setting: The psychomotor skills dome is a comprehensive all-in-one multiuse model that was developed

to incorporate core robotic surgery skills into 7 tasks established by the Fundamentals of Robotic

Surgery committee. The model was designed to include skills that are universal to robotic surgery across

all fields. Low fidelity prototypes using household materials were first created to allow for efficient and

economical testing and modifications. Once this step was complete and a final design was achieved, a

high fidelity model using 3-D stereolithography and industrial grade silicone material was constructed.

Interventions: Seven different tasks are included in the psychomotor skills dome and were designed to

assess multiple robotic skills within each task. The tasks include Docking and Instrument Insertion, Ring

Tower Transfer (endowrist manipulation, camera control), Knot Tying, Railroad Track (suturing exercise),

4th Arm Cutting (multi-arm control), Puzzle Piece Dissection (dissection and atraumatic tissue handling),

and Vessel Energy Dissection (dissection, energy source control). In this video, specific clinical examples

of how these skills are applied in gynecologic surgery are also shown.

Conclusion: As robotic surgery continues to grow, it is important to develop, improve and implement

training and assessment tools for robotic surgical skills acquisition and maintenance. The psychomotor

skills model shown in this video serves as an example of a robotic training tool that is currently

undergoing validation, both as a physical model and a virtual reality model.

27

Laparoscopic Entry in Patients with Previous Surgical History or Complex Pathology

Ciaoming Guan, MD, PhD Baylor College of Medicine, Houston Texas

Objective: To demonstrate the feasibility and advantages of Guan’s Point as an entry point for complex laparoscopic surgeries.

Design: A video demonstrating the use of Guan’s Point for accomplishing total laparoscopic hysterectomy for endometrial hyperplasia and symptomatic uterine fibroids. The video provides a step-by-step explanation of Guan’s Point port entry technique.

Setting: Insertion of the first trocar is the most dangerous step in laparoscopic surgeries1,3. Traditionally, surgeons have been using Palmer’s Point for port placement in patients with previous surgical history or large pathology1,2. Using Guan’s Point as the site of incision for complex laparoscopic surgeries is superior to using Palmer’s Point because Guan’s Point can be used as a camera and gas port, is not associated with risk of injury to stomach and liver, avoids adhesions, and can be used for patients who have had previous RUQ surgery. Compared to the traditional umbilical entry, Guan’s Point entry is associated with similar occurrence rates of large vessel injury, but less frequent rates of bowel injury when the patient has previous history of lower midline skin incision or large pathology.

Interventions: We present two cases of total laparoscopic hysterectomies; one for endometrial hyperplasia and the other for management of symptomatic uterine fibroids. Palmer’s Point has traditionally been associated with risk of injury to liver and stomach, limited use as a camera and gas port, and cannot be used in those with RUQ surgery. Using Guan’s Point as a first port entry, we were able to perform complex laparoscopic surgeries with no risk of liver or stomach injury on patients who have had RUQ surgery, and the site of entry can be still be used as a camera and gas port. This video demonstrates the use of Guan’s Point to successfully accomplish two safe port entries for complex pathology.

Conclusion: We have found that because the anatomic layers in the abdominal wall at Guan’s Point are similar to Palmer’s Point, the surgeon does not need to relearn any new techniques to be familiar with Guan’s Point. Performing first laparoscopic port entry in complex pathology using Guan’s Point is an alternative to using Palmer’s Point.

References: 1. Dar S, Lazer T, Baratz A . Is Palmer’s Point really safe? J Obstet Gynaecol Can. 2013 Dec; 35(12):1063-4 2. Chang FH, Lee CL, Soong YK. Use of Palmer’s Point for Insertion of the Operative Laparoscope in Patients with Severe Pelvic Adhesions; Experience of Seventeen Cases. J Am Assoc Gynecol Laparaosc. 1994 Aug; 1(4, Part 2):S7 3. Tabrizian P, Jayakrishnan TT, Zacharias A, Aycart S, Johnston FM, Sarpel U, Labow DM, Turaga KK. Supraumbilical primary trocar insertion for laparoscopic access: the relationship between points of entry and retroperitoneal vital vasculature by imaging. J Surg Oncol. 2015 Jun; 111(8):1035-40

28

CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as

the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians

(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which

recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).

California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws

identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org

Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from

discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national

origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the

program, the importance of the services, and the resources available to the recipient, including the mix of oral

and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.

Executive Order 13166,”Improving Access to Services for Persons with Limited English

Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,

including those which provide federal financial assistance, to examine the services they provide, identify any

need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.

Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every

California state agency which either provides information to, or has contact with, the public to provide bilingual

interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.

~

If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.

A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.

US Population

Language Spoken at Home

English

Spanish

AsianOther

Indo-Euro

California

Language Spoken at Home

Spanish

English

OtherAsian

Indo-Euro

19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%

29

http://www.imq.org/

http://www.usdoj.gov/crt/cor/pubs.htm

http://www.usdoj.gov/crt/cor/13166.htm

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538

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