Dr.Demir Bio10 10

Richard H. Demir, MD Richard H. Demir, MD Director of Ultrasound, Gynecology & Director of Ultrasound, Gynecology & ObstetricsObstetrics

--Desert Women’s CareDesert Women’s Care

PresidentPresident-Society of Elite Laparoscopic Surgeons-Society of Elite Laparoscopic Surgeons

Richard H. Demir, MD

This program summarizes key aspects of This program summarizes key aspects of Dr. Demir’s ongoing activitiesDr. Demir’s ongoing activities

This synopsis will include various activities, including:This synopsis will include various activities, including:•ClinicalClinical•AdministrativeAdministrative•PhilanthropicPhilanthropic•PublishingPublishing•Teaching Teaching

For additional information please refer to Dr. Demir’s Curriculum VitaeFor additional information please refer to Dr. Demir’s Curriculum Vitae

Clinical ActivitiesClinical Activities

DWC… We care about DWC… We care about patients!patients!

Dr. Demir is proud of his commitment to Dr. Demir is proud of his commitment to Minimally Invasive Surgical principals and Minimally Invasive Surgical principals and offers the most sophisticated procedures offers the most sophisticated procedures so open abdominal surgery can soon be so open abdominal surgery can soon be relegated to history booksrelegated to history books


MINIMALLY INVASIVE SURGERYAT DESERT WOMEN’S CARE

What drives the push toward Minimally Invasive What drives the push toward Minimally Invasive Surgery across specialties?Surgery across specialties?

•Similar or improved efficacy of new techniquesSimilar or improved efficacy of new techniques

•Less post procedure painLess post procedure pain

•Out patient care or shorter In-Patient stayOut patient care or shorter In-Patient stay

•Decreased lost productivity in work placeDecreased lost productivity in work place

•Improved cosmetic resultImproved cosmetic result

•Enhanced patient satisfactionEnhanced patient satisfaction


Gynecologists compared to other surgeons in Gynecologists compared to other surgeons in adopting Minimally Invasive Techniques--adopting Minimally Invasive Techniques--

•Slow to adopt Minimally Invasive Techniques Slow to adopt Minimally Invasive Techniques

•Not taught or harder to teach in residencyNot taught or harder to teach in residency

•No financial reward for performing laparoscopic hysterectomyNo financial reward for performing laparoscopic hysterectomy

•Prohibitive learning curveProhibitive learning curve

•Patient referral issues at work in other specialties do not applyPatient referral issues at work in other specialties do not apply

•Financial dis-incentive to refer to a minimally invasive surgeonFinancial dis-incentive to refer to a minimally invasive surgeon

DWC Minimally DWC Minimally Invasive Surgery Invasive Surgery ProgramProgram

Dr. Demir and DWC offer a full team Dr. Demir and DWC offer a full team commitment to performing and commitment to performing and successfully completing even the most successfully completing even the most complex procedures using Minimally complex procedures using Minimally Invasive techniques.Invasive techniques.



As the Director at DWC, Dr. Demir assures As the Director at DWC, Dr. Demir assures Minimally Invasive therapies are used to treat Minimally Invasive therapies are used to treat common Gynecologic problems for the benefit of common Gynecologic problems for the benefit of our patients. Examples are provided for three our patients. Examples are provided for three common conditions:common conditions:

•Pelvic RelaxationPelvic Relaxation

•Adnexal MassesAdnexal Masses

•Abnormal Bleeding, Fibroids and Secondary DysmenorrheaAbnormal Bleeding, Fibroids and Secondary Dysmenorrhea


PELVIC RELAXATIONPELVIC RELAXATION


Pelvic RelaxationPelvic Relaxation

Most often related to trauma to female pelvis from pregnancy Most often related to trauma to female pelvis from pregnancy and childbirthand childbirth

•Stress Urinary Incontinence and CystoceleStress Urinary Incontinence and Cystocele

•Progressive Pelvic Pain through day exacerbated by strainingProgressive Pelvic Pain through day exacerbated by straining

•Pelvic Organ prolapse including “dropping” of the uterusPelvic Organ prolapse including “dropping” of the uterus

•Common solutions include Paravaginal repair or TOTCommon solutions include Paravaginal repair or TOT


Anterior Compartment Defect with Stress Urinary Anterior Compartment Defect with Stress Urinary IncontinenceIncontinence

Laparoscopic Para-Vaginal RepairLaparoscopic Para-Vaginal Repair

•Laparoscopic techniqueLaparoscopic technique

•30 to 60 minutes of operating time30 to 60 minutes of operating time

•Out patientOut patient

•Discomfort consistent with laparoscopyDiscomfort consistent with laparoscopy



Laparoscopic Paravaginal RepairLaparoscopic Paravaginal Repair

•Laparoscopic approach with three incisionsLaparoscopic approach with three incisions

•Thirty minutes of surgical timeThirty minutes of surgical time

•Out-patient procedureOut-patient procedure

•Back to work in a weekBack to work in a week

Laparoscopic Paravaginal RepairLaparoscopic Paravaginal Repair

•In photo 1 the bladder is filled and In photo 1 the bladder is filled and anterior margin identifiedanterior margin identified

•In photo 2 and 3 the anterior In photo 2 and 3 the anterior parietal peritoneum is entered and parietal peritoneum is entered and Space if Retzius is dissectedSpace if Retzius is dissected

Photo 1Photo 1

Photo 2Photo 2 Photo 3Photo 3

urethraurethra

bladderbladderDome of the Dome of the Foley Foley cathetercatheter

Sutures Sutures suspend suspend paravaginal paravaginal tissuetissue



Trans-Obturator Tape Procedure or TOTTrans-Obturator Tape Procedure or TOT

•Perineal approachPerineal approach

•Two punctiform incisions and a single 2 cm vaginal incisionTwo punctiform incisions and a single 2 cm vaginal incision

•Regional block or generalRegional block or general

•15 to 20 minutes of operating time15 to 20 minutes of operating time

•Out patientOut patient

Uretex® TOTrans-Obturator Urethral

Support System

Twenty Minute Repair for Stress Urinary Incontinence

TransObturator Approach as effective as open TransObturator Approach as effective as open abdominal surgery with 1 – 2 day recovery abdominal surgery with 1 – 2 day recovery time and virtually no time off worktime and virtually no time off work

Enquire… your physician has no idea Enquire… your physician has no idea that you may have Stress Incontinence that you may have Stress Incontinence


ADNEXAL PATHOLOGY & FIBROIDSADNEXAL PATHOLOGY & FIBROIDS


Adnexal Masses and Fibroids can be treated Adnexal Masses and Fibroids can be treated without resorting to laparotomy without resorting to laparotomy

An example of Laparoscopic Myomectomy is presentedAn example of Laparoscopic Myomectomy is presented

•Laparoscopic approach is done as an out-patientLaparoscopic approach is done as an out-patient

•A morcellator is used to remove large masses through little holesA morcellator is used to remove large masses through little holes

•Two to three day recovery for most patients at home prior to Two to three day recovery for most patients at home prior to returning to work or normal activitiesreturning to work or normal activities

Pedunculated sub-serosal Pedunculated sub-serosal uterine myoma is clearly uterine myoma is clearly demonstrated at laparoscopydemonstrated at laparoscopy

Myoma is attached to the Myoma is attached to the uterus on a stalk that is uterus on a stalk that is clearly identifiedclearly identified

Once free within the Once free within the abdominal cavity the myoma abdominal cavity the myoma is morcellated and removed in is morcellated and removed in long fragmentslong fragments

Excision of this myoma Excision of this myoma leaves a denuded area leaves a denuded area that is covered with an that is covered with an anti-adhesive barrier prior anti-adhesive barrier prior to concluding the to concluding the procedureprocedure


Benign Ovarian Tumors can also be removed Benign Ovarian Tumors can also be removed laparoscopicallylaparoscopicallyAdnexal Mass not suspicious for ovarian neoplasm can be safely Adnexal Mass not suspicious for ovarian neoplasm can be safely removed using Minimally Invasive Surgery. Criteria include:removed using Minimally Invasive Surgery. Criteria include:

•CA125 < 200 U/mlCA125 < 200 U/ml

•No ascitesNo ascites

•No evidence of metastatic disease (abdominal or distant)No evidence of metastatic disease (abdominal or distant)

•No 1No 1stst degree relatives with ovarian or breast malignancy degree relatives with ovarian or breast malignancy

ACOG Committee Opinion Number 280, December, 2002ACOG Committee Opinion Number 280, December, 2002

Ultrasound demonstrates an abnormal Ultrasound demonstrates an abnormal mass within the ovarymass within the ovary

The same mass is demonstrated The same mass is demonstrated on laparoscopyon laparoscopy

Mass is Mass is removed and removed and bleeding bleeding controlledcontrolled

Capsule is Capsule is opened and opened and mass mass shelled outshelled out

Capsule of ovary is Capsule of ovary is closed with closed with absorbable suturesabsorbable sutures


Benign Ovarian TumorsBenign Ovarian Tumors

The abnormal tissue is removed from the ovary first by opening the The abnormal tissue is removed from the ovary first by opening the capsule then by shelling it out. The normal ovarian capsule is then capsule then by shelling it out. The normal ovarian capsule is then over-sewn. Benefits of this approach include:over-sewn. Benefits of this approach include:

•Small “pencil like” incisions as opposed to a “bikini” scarSmall “pencil like” incisions as opposed to a “bikini” scar

•Return to work in a day or two Return to work in a day or two

•Decreased likelihood of scarring in the abdomenDecreased likelihood of scarring in the abdomen


HYSTERECTOMY & ALTERNATIVESHYSTERECTOMY & ALTERNATIVES


HYSTERECTOMYHYSTERECTOMY

Most Common Benign IndicationsMost Common Benign Indications

•Abnormal bleedingAbnormal bleeding

•Pain and secondary dysmenorrheaPain and secondary dysmenorrhea

•Compression from large myomasCompression from large myomas

•Prolapse / Pelvic RelaxationProlapse / Pelvic Relaxation

•EndometriosisEndometriosis


TRADITIONAL HYSTERECTOMYTRADITIONAL HYSTERECTOMY

Total Abdominal HysterectomyTotal Abdominal Hysterectomy

•Significant incision with cosmetic implicationsSignificant incision with cosmetic implications

•Four to five days post-operative hospital stayFour to five days post-operative hospital stay

•Significant post-operative painSignificant post-operative pain

•Four to six weeks recovery and time off of work and activitiesFour to six weeks recovery and time off of work and activities


HYSTERECTOMY ALTERNATIVEHYSTERECTOMY ALTERNATIVE

Embolization performed by Interventional RadiologistEmbolization performed by Interventional Radiologist

•Post-Op pain secondary to infarction of muscle Post-Op pain secondary to infarction of muscle

•Potential uterine rupture if pregnancy follows Potential uterine rupture if pregnancy follows

•High probability of eventual hysterectomy with recurrence of myomas High probability of eventual hysterectomy with recurrence of myomas (myomas tend to be multi-focal and recurrent)(myomas tend to be multi-focal and recurrent)

•Menses continueMenses continue



Endometrial AblationEndometrial Ablation

•Objectionable discharge for several weeks post procedureObjectionable discharge for several weeks post procedure

•Potential for endometritisPotential for endometritis

•Must be sterilized to be a candidate Must be sterilized to be a candidate

•Must have normal uterine cavity & benign endometriumMust have normal uterine cavity & benign endometrium

•Low probability of Secondary Amenorrhea: 26% in Gynecare Low probability of Secondary Amenorrhea: 26% in Gynecare LiteratureLiterature

TM

*Based on Intent-To-Treat population 1. Extirpated uteri data on file, ETHICON, INC. 2. Loffer FD, Grainger D. Five-year follow-up of patients participating in a randomized trial of uterine balloon therapy versus rollerball ablation for treatment of menorrhagia. J AM Assoc Gynecol Laparosc. 2002;9(4):429-435. 3. NovaSure. Instructions for Use © 2004, Cytyc Corporation 4. Cooper J, Gimpelson R, Laberge P, et al. A randomized, multicenter trial of safety and efficacy of the NovaSure system in the treatment of menorrhagia. J Am Assoc Gynecol Laparosc. 2002;9:418-428. 5. GYNECARE THERMACHOICE® III. Instructions for Use. © 2008 ETHICON, INC. 6. Her Option®. Instructions for Use. © 2006 American Medical Systems, Inc. 7. Hydro ThermAblator® System. Instructions for Use. © 2005 Boston Scientific Corporation.

has a conforming balloon which leads to

improved coverage, treatment and efficacy vs earlier generationGYNECARE THERMACHOICE®

products1

is introduced, providing a silicone balloon material and fluid

circulation

the first GEA device, is

introduced 4

5 6

4

of menstrualbleeding or lower



Endometrial AblationEndometrial Ablation

•Low secondary amenorrhea rateLow secondary amenorrhea rate

•Need to be sterilizedNeed to be sterilized

---Combination Thermachoice & essure require HSG in 3 months---Combination Thermachoice & essure require HSG in 3 months

---Combnation Thermachoice and Scope TL comes with scope risks---Combnation Thermachoice and Scope TL comes with scope risks

•Must have concordance of pre-op expectation with post-op reality to Must have concordance of pre-op expectation with post-op reality to assure patient satisfactionassure patient satisfaction


LAPAROSCOPIC HYSTERECTOMYLAPAROSCOPIC HYSTERECTOMY

Laparoscopic Hysterectomy-- SupraCervical or CompleteLaparoscopic Hysterectomy-- SupraCervical or Complete

•100% guarantee of no further vaginal bleeding post-recovery100% guarantee of no further vaginal bleeding post-recovery

•Return to work within ten to fourteen days in most casesReturn to work within ten to fourteen days in most cases

•No unsightly abdominal scarNo unsightly abdominal scar

•Fewer incisions than with Robotic approachFewer incisions than with Robotic approach

•Technique capable of treating even the largest fibroids with DWC Technique capable of treating even the largest fibroids with DWC Surgeons having removed up to 7 pound uterus in 2007Surgeons having removed up to 7 pound uterus in 2007



Supra-Cervical HysterectomySupra-Cervical Hysterectomy

•100% guarantee of no further vaginal bleeding post-recovery100% guarantee of no further vaginal bleeding post-recovery

•Return to work within ten to fourteen days in most casesReturn to work within ten to fourteen days in most cases

•TheoreticTheoretic maintenance of pelvic support of cervix by conserving maintenance of pelvic support of cervix by conserving attachment of utero-sacral and cardinal ligamentsattachment of utero-sacral and cardinal ligaments

•Eliminates incidence of cuff cellulitis by not opening the vaginaEliminates incidence of cuff cellulitis by not opening the vagina

Ultrasound demonstrates a Ultrasound demonstrates a large fibroid tumor within the large fibroid tumor within the myometriummyometrium

Laparoscopy clearly demonstrates the enlarged uterus with Laparoscopy clearly demonstrates the enlarged uterus with irregularity of the fundusirregularity of the fundus

Ligasure device is used to divide the attachments of the Ligasure device is used to divide the attachments of the uterusuterus

The bladder is located and moved out of the way to assure it is The bladder is located and moved out of the way to assure it is not injurednot injured

In Supra-cervical In Supra-cervical hysterectomy, the corpus is hysterectomy, the corpus is divided from the cervical stumpdivided from the cervical stump

Once the body of the uterus is free, Once the body of the uterus is free, it must be morcellated so that it can it must be morcellated so that it can be removed through the “pencil-be removed through the “pencil-like” abdominal incisionslike” abdominal incisions

The parietal peritoneum is The parietal peritoneum is sewn over the cervical stump sewn over the cervical stump sealing the abdominal cavitysealing the abdominal cavity



Complete Laparoscopic HysterectomyComplete Laparoscopic Hysterectomy

•Patient preference for no future Cervical CytologyPatient preference for no future Cervical Cytology

•Prior history or current cervical diseasePrior history or current cervical disease

KohKohColpotimizerColpotimizer

RumiRumiManipulatorManipulator


COMPLETE LAPAROSCOPIC HYSTERECTOMYCOMPLETE LAPAROSCOPIC HYSTERECTOMY

Once the uterus is free within the abdominal-pelvic cavity it can be Once the uterus is free within the abdominal-pelvic cavity it can be removed in a variety of ways:removed in a variety of ways:

--in one piece through the vagina --in one piece through the vagina

--morcellated through the vagina--morcellated through the vagina

--morcellated laparoscopically--morcellated laparoscopically

The vagina may be closed transvaginally or laparoscopicallyThe vagina may be closed transvaginally or laparoscopically

•In this case, the uterus was morcellated and the vaginal barrel is closed In this case, the uterus was morcellated and the vaginal barrel is closed

with a suturing device called “endo-stitch.”with a suturing device called “endo-stitch.”

•The second photo shows the closed vaginaThe second photo shows the closed vagina

•The parietal peritoneum is then closed over this area in the usual mannerThe parietal peritoneum is then closed over this area in the usual manner


MINIMALLY INVASIVE HYSTERECTOMYMINIMALLY INVASIVE HYSTERECTOMY

ACOG and entire body of available literature concur--ACOG and entire body of available literature concur--

Recognized superiority of minimally invasive hysterectomy, whether Recognized superiority of minimally invasive hysterectomy, whether vaginal or laparoscopic, over traditional total abdominal vaginal or laparoscopic, over traditional total abdominal hysterectomy with faster recovery, less post-operative pain, hysterectomy with faster recovery, less post-operative pain, improved cosmetic appearance and similar complication rates. improved cosmetic appearance and similar complication rates. ACOG Committee Opinion 388, November 2007 ACOG Committee Opinion 388, November 2007

So… every hysterectomy should be So… every hysterectomy should be MIS,MIS, Right?Right?

Early decrease from Scope Hyst (LH)Early decrease from Scope Hyst (LH)

Early increase from Scope Hyst (LH)Early increase from Scope Hyst (LH)

Late decrease from Scope Hyst Late decrease from Scope Hyst (LH)(LH)


So why are most hysterectomies not done using MIS So why are most hysterectomies not done using MIS techniques?techniques?

•Increased uterine sizeIncreased uterine size•Elevated patient BMIElevated patient BMI•Previous abdominal surgeries / prior C - SectionsPrevious abdominal surgeries / prior C - Sections•Complicating medical conditionsComplicating medical conditions•Surgeon’s experienceSurgeon’s experience

Traditional exclusion criteria are dealt with at DWC.Traditional exclusion criteria are dealt with at DWC.

DWC Offers Total Team Commitment to MIS DWC Offers Total Team Commitment to MIS hysterectomyhysterectomy


GUINNESS WORLD RECORD DWCGUINNESS WORLD RECORD DWC

Awarded November 30, 2008, for a surgery in October, 2007Awarded November 30, 2008, for a surgery in October, 2007

•3200 grams uterus removed without resorting to laparotomy3200 grams uterus removed without resorting to laparotomy

•Patient back to work in two weeksPatient back to work in two weeks

•Co-surgeon, Greg Marchand, MDCo-surgeon, Greg Marchand, MD

•Technique of Extended Hysterectomy employedTechnique of Extended Hysterectomy employed

Should increased uterine size Should increased uterine size disqualify?disqualify?


LAPAROSCOPIC HYSTERECTOMY AT DWCLAPAROSCOPIC HYSTERECTOMY AT DWC

Demonstrated history of accomplishment at DWCDemonstrated history of accomplishment at DWC

•Of our last 547 Hysterectomy cases attempted for benign Of our last 547 Hysterectomy cases attempted for benign indications (excluding cases of invasive carcinoma) indications (excluding cases of invasive carcinoma) 542 cases successfully completed laparoscopically with 542 cases successfully completed laparoscopically with

overall success rate of 99.08%overall success rate of 99.08%

•Our series includes large uteri, elevated BMI, scarred abdomen, etc.Our series includes large uteri, elevated BMI, scarred abdomen, etc.

(7 pound uterus, 350 pound patient, 5 prior CS) (7 pound uterus, 350 pound patient, 5 prior CS)


With Minimally Invasive Techniques DWC reliably offers--With Minimally Invasive Techniques DWC reliably offers--

•Similar or improved efficacy of new techniquesSimilar or improved efficacy of new techniques•Less post procedure painLess post procedure pain•Out patient care or shorter In-Patient stayOut patient care or shorter In-Patient stay•Decreased lost productivity in work placeDecreased lost productivity in work place•Improved cosmetic resultImproved cosmetic result•Enhanced patient satisfactionEnhanced patient satisfaction•And,,,, high actual completion rateAnd,,,, high actual completion rate

Anybody Anybody need some need some help here?help here?


When compared with Robotics, DWC’s Minimally Invasive When compared with Robotics, DWC’s Minimally Invasive Techniques reliably offer--Techniques reliably offer--

•Reduced operating timeReduced operating time•Less time under general anesthesiaLess time under general anesthesia•Fewer abdominal incisions (three or four as opposed to five with Fewer abdominal incisions (three or four as opposed to five with the DaVinci Robot)the DaVinci Robot)•Markedly lower costMarkedly lower cost

DWC DWC Multidisciplinary Multidisciplinary Pelvic Pain ProgramPelvic Pain Program

CENTER FOR PELVIC PAINAT DESERT WOMEN’S CENTER

Multidisciplinary care for women suffering from chronic pelvic pain:

--undiagnosed pain --urethral syndrome

--unresponsive pain --trigonitis

--endometriosis --nephrolithiasis

--interstitial cystitis --hernias

--pelvic adhesions --myofascial dysfunction

--uterine retroversion --degenerative disc disease

--irritable bowel syndrome --scoliosis

--inflammatory bowel disease --nerve entrapment

--diverticular disease --arthritis

--depression --auto-immune disorders


Offering a multi-specialty, collaborative diagnostic evaluation of femalepelvic pain in our state-of-the-art facilities. Providing individualizedtreatment plans and meticulous follow-up for superior results. Relief of painand patient satisfaction are our highest goals. Don’t suffer any longer, allowour physicians to bring their extensive experience to bear on your situationtoday.

GynecologyGynecology

GastroenterologyGastroenterology

Pain ManagementPain Management

NeurologyNeurology

PsychiatryPsychiatry


BENEFITS TO THIS TYPE OF PROGRAM Prevents dead-end transfers Prevents unnecessary surgical interventions Decreases habituation to narcotic analgesics More expeditious: quicker time from entry to relief Immediate recognition of psychiatric implications



GYNECOLOGY Conditions- 70% of cases:• dysmenorrhea

• infection

• cycts

• myomas

• polyps

• prior surgeries / adhesions

• endometriosis

• endosalpingiosis

• adenomyosis

• pelvic congestion



GYN UROLOGY Conditions- 5% of cases:• urethral syndrome

• trigonitis

• interstitial cystitis

• peritoneal endometriosis overlying urinary tract

• bladder endometriosis



GASTROENTEROLOGY Conditions- 10% of cases:• irritable bowel syndrome

• inflammatory bowel disease

• diverticular disease

• chronic appendicitis

• adhesions

• bowel endometriosis



NEUROLOGY (Musculoskeletal) and Pain Management Conditions- 15% of cases:• hernias (incisional, inguinal, femoral, sciatic and ventral)• fasciitis• nerve entrapment• fascial tears• myofascial dysfunction• scoliosis• degenerative disc disease• pelvic trauma• trigger points



PSYCHIATRIC Conditions- 80% of cases

• Depression causing pain

• Pain causing Depression


WHY WE ARE DIFFERENT Unified laboratory and imaging evaluation available to each

team member Patient seen by each specialist with specific additional work-up

as deemed necessary Regular meetings of team to discuss cases and develop

integrated treatment plans Shorter time to diagnosis minimizing reliance on narcotic

analgesics Early recognition and treatment of psychiatric aspects in chronic

pain sufferers

Administrative ActivitiesAdministrative Activities


ADMINISTRATIVE ACTIVITIES

Dr. Demir is Medical Director at DWCDr. Demir is Medical Director at DWC

Dr. Demir has held various administrative positions in Maternal - Dr. Demir has held various administrative positions in Maternal - Child Health services over the last twenty years. In addition to his Child Health services over the last twenty years. In addition to his clinical role in OB/GYN he has developed and directed services in clinical role in OB/GYN he has developed and directed services in Assisted Reproduction / IVF, Maternal - Fetal Medicine, General Assisted Reproduction / IVF, Maternal - Fetal Medicine, General Pediatrics, Sub-Specialty Pediatrics, Family Practice, Internal Pediatrics, Sub-Specialty Pediatrics, Family Practice, Internal Medicine, General Surgery and Laboratory. Medicine, General Surgery and Laboratory.


•Management physicians & mid-level providersManagement physicians & mid-level providers•Strategic planning and development of sub-specialty services:Strategic planning and development of sub-specialty services:

Maternal – Fetal MedicineMaternal – Fetal MedicineGynecologic ONCGynecologic ONCLaboratoryLaboratory

•MarketingMarketing•Development of Clinical Practice Guidelines and modeling of Development of Clinical Practice Guidelines and modeling of

provider adherence to published principals of careprovider adherence to published principals of care•Directs Quality Assurance, Utilization Review and Satisfaction Directs Quality Assurance, Utilization Review and Satisfaction Assessment functions at groupAssessment functions at group

Dr. Demir is Director of Gynecology, Obstetrics and Dr. Demir is Director of Gynecology, Obstetrics and Ultrasound at DWCUltrasound at DWC


•Insurance companies have long used actuaries, attorneys, Insurance companies have long used actuaries, attorneys, business men and physicians to develop algorithms to deny care to business men and physicians to develop algorithms to deny care to patients and to assure that the lowest cost guidelines are patients and to assure that the lowest cost guidelines are implementedimplemented•Dr. Demir has developed Clinical Practice Guidelines to assure that Dr. Demir has developed Clinical Practice Guidelines to assure that appropriate care is always offered to DWC patientsappropriate care is always offered to DWC patients•Clinical Practice Guidelines are developed to assure appropriate Clinical Practice Guidelines are developed to assure appropriate resources are committed to patient’s problems and revenues at resources are committed to patient’s problems and revenues at DWC are enhancedDWC are enhanced

Clinical Practice GuidelinesClinical Practice Guidelines


•Patient care must be viewed in its totality to assure that all aspects Patient care must be viewed in its totality to assure that all aspects are maximizedare maximized•Variables such as cost reduction, revenue enhance, risk avoidance Variables such as cost reduction, revenue enhance, risk avoidance and patient satisfaction have to be quantified for all disease states, and patient satisfaction have to be quantified for all disease states, risks and benefits weighed and appropriate management must be risks and benefits weighed and appropriate management must be determineddetermined•Through such an analysis outcomes can be maximizedThrough such an analysis outcomes can be maximized

Clinical Practice GuidelinesClinical Practice Guidelines

A full website is up and running for Desert A full website is up and running for Desert Women’s Care. Communication with Women’s Care. Communication with patients featuring text, photos and videos patients featuring text, photos and videos is available online.is available online.


Philanthropic Activities

• Demir Foundation

Demir Foundation

Demir Foundation was responsible for administering more than $2.5 million in immunizations to children of the working poor in the Chicago area’s North West suburbs

Demir Medical Group through its Pediatric branch oversaw the program and contributed substantially to the community

Demir Foundation

Demir Foundation also contributed to the beautification of the Elgin area with two works of civic sculpture

Artist David Powers was the creative force behind both works

The “Raise The Flag” The “Raise The Flag” project returned the US project returned the US flag to walton Island on flag to walton Island on

the Fox River in Elginthe Fox River in Elgin

Demir Foundation

“Seven at the Gates of Dawn” located at the Foundation’s park symbolized the efforts of the Group’s philanthropic efforts on behalf of the Women and Children of the greater Elgin area

X

““Seven at the Gates of Seven at the Gates of Dawn”Dawn”•Elgin Image Award, Elgin Image Award, 19981998•Elgin Cultural Arts Elgin Cultural Arts Commission Award, Commission Award, 19981998

Demir Foundation

Dr. Demir continues to be proud of the Foundation’s work and the legacy of beautification provided by its civic art donations.

Raise The Flag ProjectRaise The Flag Project

Flag Day Dedication, Flag Day Dedication, June 14, 2002June 14, 2002Elgin Image Award Elgin Image Award Nominee, 2003Nominee, 2003

PublishingPublishing


Dr. Demir has over twenty peer-reviewed Dr. Demir has over twenty peer-reviewed publications including articles, abstracts, publications including articles, abstracts, videos and book chapters.videos and book chapters.


““Laparoscopic Cervical Cerclage in 18 Laparoscopic Cervical Cerclage in 18 weeks Pregnant Uterus” was presented in weeks Pregnant Uterus” was presented in June, 2010, at BICOG in Belfast, UK, and June, 2010, at BICOG in Belfast, UK, and in September at SLS in New York Cityin September at SLS in New York City


Dr. Demir and Dr. Marchand won Honorable Mention Dr. Demir and Dr. Marchand won Honorable Mention GYN Video Award at 2010 Annual Meeting of Society of GYN Video Award at 2010 Annual Meeting of Society of Laparoendoscopic Surgeons in New York CityLaparoendoscopic Surgeons in New York City

Dr. Demir won 2010 Spotlight Award from Dr. Demir won 2010 Spotlight Award from Cooper Surgical for outstanding surgical Cooper Surgical for outstanding surgical video– video–

SELS Laparoscopic MyomectomySELS Laparoscopic Myomectomy

Teaching ActivitiesTeaching Activities

TEACHING ACTIVITIES

•Dr. Demir is a founding member of SELSDr. Demir is a founding member of SELS•Society is dedicated to the advancement and increased availability Society is dedicated to the advancement and increased availability of Minimally Invasive Surgery in Gynecology of Minimally Invasive Surgery in Gynecology• Membership is growing to include leaders in Minimally Invasive Membership is growing to include leaders in Minimally Invasive Gynecologic Surgery around the worldGynecologic Surgery around the world•Accessing the SELS website puts prospective patients in touch with Accessing the SELS website puts prospective patients in touch with capable surgeons in their own region capable of offering Minimallycapable surgeons in their own region capable of offering Minimallyinvasive Gynecologic Surgeryinvasive Gynecologic Surgery

SELS SELS

TEACHING ACTIVITIES

1.1. Increase awareness of benefits of Minimally Invasive Surgical Increase awareness of benefits of Minimally Invasive Surgical techniques in the general patient populationtechniques in the general patient population

2.2. Increase physician awareness of benefits of Minimally Invasive Increase physician awareness of benefits of Minimally Invasive Surgical techniquesSurgical techniques

3.3. Increase availability of Minimally Invasive Surgical procedures to Increase availability of Minimally Invasive Surgical procedures to patients world widepatients world wide

4.4. Increase compensation to physicians by insurance companies Increase compensation to physicians by insurance companies who spend the additional time and accept the heightened risks of who spend the additional time and accept the heightened risks of performing Minimally Invasive Surgical proceduresperforming Minimally Invasive Surgical procedures

SELS PLATFORM SELS PLATFORM

TEACHING ACTIVITIES

•Our First Annual Meeting will be held in October 2 - 3, 2011, at the Our First Annual Meeting will be held in October 2 - 3, 2011, at the Arizona Biltmore ResortArizona Biltmore Resort•Members and Guests will enjoy a two day scientific programMembers and Guests will enjoy a two day scientific program

SELS CONFERENCE SELS CONFERENCE

SELS HomepageSELS Homepage

Surgical Videos of the SocietySurgical Videos of the Society

•Log onto www.YouTube.comLog onto www.YouTube.com•Go to EliteLaparosccopic channelGo to EliteLaparosccopic channel•28,000 views in its first year of operations28,000 views in its first year of operations•Teaching videos on numerous Teaching videos on numerous gynecological surgeriesgynecological surgeries

TEACHING ACTIVITIES

•Dr. Demir is a founding member of the Two Kilo ClubDr. Demir is a founding member of the Two Kilo Club•Site dedicated to recognizing excellence in the practice of Minimally Site dedicated to recognizing excellence in the practice of Minimally Invasive Gynecologic SurgeryInvasive Gynecologic Surgery•Members must have removed at least a 2000 gram fibroid without Members must have removed at least a 2000 gram fibroid without resorting to use of laparotomy or “hand assisted” laparoscopic resorting to use of laparotomy or “hand assisted” laparoscopic techniquestechniques

Two Kilo Club Two Kilo Club

Two Kilo Club HomepageTwo Kilo Club Homepage

TEACHING ACTIVITIES

The Two Kilo Club is an organization for the recognition of laparoscopic and The Two Kilo Club is an organization for the recognition of laparoscopic and minimally invasive skills and achievements, especially those that were minimally invasive skills and achievements, especially those that were previously thought to be "impossible." We recognize that difficult previously thought to be "impossible." We recognize that difficult laparoscopic and minimally invasive surgery is not based solely on the size laparoscopic and minimally invasive surgery is not based solely on the size of the uterus, and that one particular surgical feat does not prove any of the uterus, and that one particular surgical feat does not prove any particular surgeon to be especially adept.particular surgeon to be especially adept.

However, the Two Kilogram uterus is a significant challenge whether by However, the Two Kilogram uterus is a significant challenge whether by vaginal or laparoscopic approach. Accordingly we use this as our standard vaginal or laparoscopic approach. Accordingly we use this as our standard and invite gynecologic surgeons to this challenge. We recognize the and invite gynecologic surgeons to this challenge. We recognize the successful with membership and praise.successful with membership and praise.


This list encompasses all surgeons who have successfully qualified to be This list encompasses all surgeons who have successfully qualified to be counted among the ranks of the two kilo club by successfully removing a uterus counted among the ranks of the two kilo club by successfully removing a uterus weighing greater than 1999 grams without resorting to laparotomy. Member list weighing greater than 1999 grams without resorting to laparotomy. Member list is updated monthly. Surgeons may apply by submitting official documentation is updated monthly. Surgeons may apply by submitting official documentation in order to be considered immediately. In addition, TKC staff performs regular in order to be considered immediately. In addition, TKC staff performs regular literature searches of reliable sources and data collection agencies in order to literature searches of reliable sources and data collection agencies in order to attempt to compile a comprehensive list of all surgeons internationally who attempt to compile a comprehensive list of all surgeons internationally who have accomplished this feat.have accomplished this feat.


Richard H. Demir, MD

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This synopsis has included various activities, including:This synopsis has included various activities, including:•ClinicalClinical•AdministrativeAdministrative•PhilanthropicPhilanthropic•PublishingPublishing•Teaching Teaching

For additional information please refer to Dr. Demir’s Curriculum VitaeFor additional information please refer to Dr. Demir’s Curriculum Vitae

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