Panel Session 5: Back to Basics: Setting Yourself Up …Panel Session 5: Back to Basics: Setting...
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AAGLAdvancing Minimally Invasive Gynecology Worldwide
Panel Session 5: Back to Basics: Setting Yourself Up for Success in the OR
PROGRAM CHAIR
Matthew T. Siedhoff, MD, MSCR
Michelle Louie, MD Cecile A. Unger, MD, MPH Amanda C. Yunker, DO
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 (ACCME) to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 1.0 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 ...................................................................................................................................................... 2
Moving the Needle: Key Steps for Efficient Open Laparoscopic Entry M. Louie ....................................................................................................................................................... 3
Exploiting Your Electrosurgical Tools: When to Use Which Energy Device M.T. Siedhoff ................................................................................................................................................ 4
Patient Positioning and OR Setup A.C. Yunker ................................................................................................................................................... 7
Closing the Cuff: Demonstration of Successful Techniques C.A. Unger .................................................................................................................................................... 9
Cultural and Linguistics Competency .......................................................................................................... 11
Panel Session 5: Back to Basics: Setting Yourself Up for Success in the OR
Matthew T. Siedhoff, Chair Faculty: Michelle Louie, Cecile A. Unger, Amanda C. Yunker
This session provides an introduction to some core principles in endoscopic surgery—laparoscopic entry, OR setup and patient positioning, relative advantages of different electrosurgical tools, and fundamentals of laparoscopic cuff closure. The format will include brief faculty “pearls” from the literature and their own experience, followed by a robust and interactive panel discussion regarding various approaches to these fundamentals. Learning Objectives: At the conclusion of this course, the clinician will be able to: 1) Use systematic steps
to consistently enter the abdomen with an open laparoscopic approach; 2) use the correct
electrosurgical tool for the tissue problem at hand; 3) position patients in ways that maximize exposure
and surgeon comfort and minimize patient injury; and 4) utilize fundamental steps of laparoscopic cuff
closure to promote good healing and avoid cuff separation.
Course Outline
11:00 Welcome, Introductions and Course Overview M.T. Siedhoff
11:05 Moving the Needle: Key Steps for Efficient Open Laparoscopic Entry M. Louie
11:10 Exploiting Your Electrosurgical Tools: When to Use Which Energy Device M.T. Siedhoff
11:15 Patient Positioning and OR Setup A.C. Yunker
11:20 Closing the Cuff: Demonstration of Successful Techniques C.A. Unger
11:25 Panel Discussion All Faculty
12:00 Adjourn
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PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop (listed in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* R. Edward Betcher* Amber Bradshaw Speakers Bureau: Myriad Genetics Lab Other: Proctor: Intuitive Surgical Sarah L. Cohen Consultant: Olympus Erica Dun* Joseph (Jay) L. Hudgens Contracted Research: Gynesonics Frank D. Loffer, Medical Director, AAGL* Suketu Mansuria Speakers Bureau: Covidien Linda Michels, Executive Director, AAGL* Matthew T. Siedhoff Consultant: Applied Medical, Intuitive Surgical, Olympus, Teleflex Medical Karen C. Wang* Johnny Yi* SCIENTIFIC PROGRAM COMMITTEE Sawsan As-Sanie Consultant: Myriad Genetics Lab Jubilee Brown* Aarathi Cholkeri-Singh Consultant: Smith & Nephew Endoscopy Speakers Bureau: Bayer Healthcare Corp., DySIS Medical, Hologic Other: Advisory Board: Bayer Healthcare Corp., Hologic Jon I. Einarsson* Suketu Mansuria Speakers Bureau: Covidien Andrew I. Sokol* Kevin J.E. Stepp Consultant: CONMED Corporation, Teleflex Stock Ownership: Titan Medical Karen C. Wang* 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). Michelle Louie Consultant: Teleflex Matthew T. Siedhoff Consultant: Applied Medical, Intuitive Surgical, Olympus, Teleflex Medical Cecile A. Unger* Amanda C. Yunker* Content Reviewer has no relationships. Asterisk (*) denotes no financial relationships to disclose.
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Moving the Needle: Key Steps for Efficient
Open Laparoscopic Entry
Michelle Louie, MD
University of North CarolinaDivision of Minimally Invasive Gynecology Surgery
Chapel Hill, NC, USA
Disclosures
• Consultant: Teleflex
Objectives
• Why: Discuss the advantages of the open laparoscopic entry approach
• How: Perform successful and efficient open laparoscopic entry
Advantages of open abdominal entry
• Compared to Veress needle, optical, or direct trocar entry:
– Less likely to cause a major vascular injury
– Less likely to have occult bowel injury
– Less likely to have failed entry and pre-peritoneal insufflation
Tips and Tricks• Apply upward tension to abdominal wall • Make vertical incision directly into the base of
umbilicus• Do not dissect • Use hemostat to grasp abdominal wall layers • Use knife; do not use electrosurgery• Once S-retractor is placed intraperitoneally, do not
remove• Tag fascial edges • Remove all hemostats prior to trocar placement• Use S-retractor as shoehorn
References
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Exploiting Your Electrosurgical Tools: When to Use Which Energy Device
Matthew Siedhoff, MD MSCRAssociate ProfessorCenter for Minimally Invasive Gynecologic Surgery
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• Consultant: Applied Medical, Intuitive Surgical, Olympus, Teleflex Medical
Disclosures
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• Explain the difference between monopolar and bipolar electrosurgery• Discuss the available advanced electrosurgical tools available for laparoscopic
surgery• Use the proper tools to accomplish various surgical tasks in gynecologic
endoscopy
Objectives
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• Monopolar
• Bipolars–Conventional–“Advanced”, ”vessel sealing”
• Ultrasonic• Plasma• Thermal
Electrosurgery tools
Non‐contact Contact
”Cut” waveform Vaporization Dessication
”Coag” waveform Fulguration Dessication
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Electrosurgery tools
LigaSure PK EnSeal Harmonic
Thermal spread
Time to seal
Plume
Visibility
Burst pressure
Electrosurgery Tools
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9 10
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• Lamberton GR, Hsi RS, Jin DH, Lindler TU, Jellison FC, Baldwin DD. Prospectivecomparison of four laparoscopic vessel ligation devices. J Endourol. 2008Oct;22(10):2307-12. doi: 10.1089/end.2008.9715. PubMed PMID: 18831673.
References
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Patient Positioning and OR Set‐upAmanda Yunker, DO, MSCR
Assistant Professor
Vanderbilt University Medical Center
Department of OBGYN
Disclosures
• I have no financial relationships to disclose
Objectives
• Describe the proper patient positions for laparoscopic surgery
• List risks of improper positioning
• Review optimal OR set up for efficient and safe surgery
Patient positioning Goals• 3 goals
• Patient safety• Nerve protection
• Protection against the table/moving parts
• Anesthesia access
• Surgeon ergonomics/access• Be comfortable while operating
• See your screen(s)
• Access abdomen and vagina
• Cords out of your way
• Equipment accessibility• Tower/suction/generators/fluids
Where are the patient’s parts in regards to the patient’s body?
Where is the patient’s body is regards to the table?
Where is the table in regards to the room?
Table specifics• Access to perineum/vagina
• Appropriate padding• Non‐slip surface
• Foam, pad, bean bag, etc.
• Stirrups• Ability to tuck arms
• Extenders, draw sheet, sleds
• Added padding• Position in room
• Away from anesthesia• Proximity to suction, tower, etc
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Scrub tech/instruments
Scrub tech/instruments
Suction/fluids
generator
Scrub tech/instruments
Suction/fluids
generator
learner
learner
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learner
learner
learner
learnerlearner
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References
• Barnett JC, Hurd W, Rogers R, et al. Laparoscopic positioning and nerve injuries. JMIG 2007;14:664‐72.
• Abdalmageed O, Bedaiwy M, Falcone T. Nerve injuries in gynecologic laparoscopy. JMIG 2016; in press.
• Van Det MJ, Meijerink WJ, Hoff C, et al. Optimal ergonomics for laparoscopic surgery in minimally invasive surgery suites: a review and guidelines. Surg Endosc 2009;23:1279‐85.
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Closing the Cuff: Demonstration of Successful
Techniques
Cecile A. Unger, MD MPH
Center for Urogynecology & Pelvic
Reconstructive Surgery
Cleveland Clinic
Disclosures
• I have no financial relationships to disclose
Objective
• Utilize fundamental steps of laparoscopic cuff
closure to promote good healing and avoid
cuff separation
Goals of Closure
• Minimize cuff dehiscence
• Prevent post‐hysterectomy vaginal apex
prolapse
Minimizing Dehiscence• Vaginal 0.2%, Laparoscopic 0.6%, Robotic 1.6%
• Risk factors: diabetes, smoking, malignancy
• Same technique as open closure
• Technique: sutures ~5mm apart and ~5mm deep
• Two layer closure is superior
• Suture – absorbable, delayed‐absorbable, barbed
• Does use of electrosurgery on the cuff matter?
• Vaginal v. laparoscopic closure
• Horizontal v. vertical closure
Cuff Closure
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Preventing Prolapse References• Ucella et al. (2012) Obstet Gynecol 120(3):516‐23
• Hur et al. (2007) JMIG 14(3):311‐17
• Nick et al. (2011) Gyn Onc 120(1):47‐51
• Jeung et al. (2010) Arch Gynecol Obstet 282(6):631‐8
• Fanning et al. (2013) JSLS 17:414‐17
• Bogliolo et al. (2015) Arch Gynecol Obstet 292:489‐97
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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%
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