Sponsored by

AAGLAdvancing Minimally Invasive Gynecology Worldwide

Didactic/Porcine Lab: Expanding the Surgical Toolbox: Incorporating Advanced

Minimally Invasive Approaches into Your Practice

PROGRAM CHAIR

Edward J. Tanner, MD

Devin M. Garza, MD Xiaoming Guan, MD, PhD Tae Joong Kim, MD, PhD Kimberly L. Levinson, MD, MPH Peter C.W. Lim, MD Stacey A. Scheib, MD

Abdulrahman K. Sinno, MD R. Scott Walker, MD

AAGL acknowledges that it has received educational grants from the following companies: Applied Medical, CONMED Corporation, Intuitive Surgical, Medtronic, Olympus America Inc.,

Stryker Endoscopy, Teleflex Medical.

AAGL acknowledges that it has received in-kind support from the following companies: Durable Equipment: Applied Medical, CONMED Corporation, Intuitive Surgical, Marina Medical,

Medtronic, Olympus America Inc, Teleflex Medical; Disposable Supplies: Applied Medical, CONMED Corporation, Medtronic, Stryker Endoscopy.

Professional Education Information   Target Audience This educational activity is developed to meet the needs of surgical gynecologists in practice and in training, as well as other healthcare professionals 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 3.75 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 ...................................................................................................................................................... 2  Matching Patients with Procedures: How to Incorporate Innovative Minimally Invasive Surgical Techniques into Your Practice S.A. Scheib  .................................................................................................................................................... 4  Conquering the Tough Case: Tips and Tricks to Expand the Boundaries of Single Port Laparoscopy T.J. Kim  ....................................................................................................................................................... 11  Cultural and Linguistics Competency  ......................................................................................................... 19  

LESS-708: Didactic/Porcine Lab:

Expanding the Surgical Toolbox: Incorporating Advanced

Minimally Invasive Approaches into Your Practice

Edward J. Tanner, Chair

Faculty: Devin M. Garza, Xiaoming Guan, Tae Joong Kim, Kimberly L. Levinson, Peter C.W. Lim, Stacey A. Scheib, Abdulrahman K. Sinno, R. Scott Walker

This course provides experienced minimally invasive surgeons with an opportunity to expand the range

of tools available to perform minimally invasive procedures. While multiport laparoscopy and robotics

may be adequate for most circumstances, a variety of new approaches can now be employed to

improve outcomes. How will a surgeon know when to “make the leap” to these new approaches?

Innovative surgical techniques including single port laparoscopy, single port robotics, micro-laparoscopy,

3D video laparoscopy, and mini-laparotomy will be evaluated by participants in a porcine lab.

Experienced instructors will provide guidance on port placement, micro-laparoscopy instrumentation,

single port laparoscopic/robotic suturing, and retroperitoneal dissection. Didactics will focus on the

selection of appropriate patients for each approach and “tips and tricks” to help surgeons incorporate

these techniques into their practice.

Learning Objectives: At the conclusion of this course, the clinician will be able to: 1) Identify situations

where innovative surgical approaches (single port laparoscopy/robotics, micro-laparoscopy, 3D video

laparoscopy, and mini-laparotomy) can be added to standard laparoscopic or robotic techniques to

improve patient outcomes; 2) demonstrate techniques for suturing using innovative surgical

approaches; and 3) apply techniques to maximize utilization of innovative surgical approaches in

complex or difficult cases.

Course Outline

12:30 Welcome, Introductions and Course Overview E.J. Tanner

12:35 Matching Patients with Procedures: How to Incorporate Innovative

Minimally Invasive Surgical Techniques into Your Practice S.A. Scheib

1:00 LAB I: Single Port Laparoscopy, Micro-laparoscopy, Minilap, and 3D Video

Laparoscopy Techniques X. Guan, T.J. Kim, K.L. Levinson, S.A. Scheib, A.K. Sinno

• Abdominal Entry, Single Port Placement, Micro-laparoscopy, Trocar Placement

• Porcine Hysterectomy Procedure

• Single Port Laparoscopic Techniques

• Evaluation of 3D Video Laparoscopy Technology

2:25 Conquering the Tough Case: Tips and Tricks to Expand the Boundaries

of Single Port Laparoscopy T.J. Kim

2:50 LAB II: Single Port Robotic Techniques D.M Garza, P.C.W. Lim,

E.J. Tanner, R.S. Walker

• Abdominal Entry, Robotic Single Port Placement

• Porcine Hysterectomy Procedure

• Single Port Robotic Suturing Techniques

• Retroperitoneal Dissection/Ureterolysis

4:15 Questions & Answers All Faculty

4:30 Adjourn

1

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* Edward J. Tanner* 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). Devin M. Garza Consultant: Applied Medical, Boston Scientific Corp., Inc. Speakers Bureau: Intuitive Surgical Xiaoming Guan Consultant: Applied Medical Tae Joong Kim Speakers Bureau: Johnson & Johnson Kimberly L. Levinson*

2

Peter C.W. Lim* Stacey A. Scheib* Abdulrahman K. Sinno* Edward J. Tanner* W. Scott Walker* Content Reviewer has no relationships. Asterisk (*) denotes no financial relationships to disclose.

3

Matching Patients with Procedures: How to Incorporate Innovative Minimally Invasive Techniques into Your Practice

Stacey A. Scheib, MD, FACOGDirector of Minimally Invasive GynecologyDirector of the Multidisciplinary Fibroid Center

Disclosures

I have no financial relationships to disclose.

Objectives

• Explain the theory and rationale behind single port laparoscopy, reduced port laparoscopy, micro-laparoscopy, mini-laparotomy, 3D technology

• Identify the limitations of single port laparoscopy, reduced port laparoscopy, micro-laparoscopy, mini-laparotomy, 3D technology

SINGLE INCISION AND REDUCED PORT LAPAROSCOPY

Background

• Gynecology has been at the forefront of single site surgery starting more than 40 years ago. – The offset operating laparoscope used for

laparoscopic tubal ligations,1-2

– The first complex procedure, a hysterectomy and bilateral salpingo-oophorectomy was performed by Pelosi and Pelosi in 1991, without additional trochars.3

Despite these early efforts, single site surgery did not become a standard surgical technique in gynecologic surgery for several reasons and is now only taken off due to advances in technology.

1.Wheeless CR. J of Reprod Med. 1969; 3: 65-9.2.Wheeless CR, Thompson BH. Obstet Gynec. 1973; 42: 751-8.3.Pelosi MA, Pelosi MA. New England J Med. 1991; 88: 721–6.

Disadvantages

• Restricted by a surgeon’s experience with advanced laparoscopy.

– Loss of triangulation

– Special instrumentation

– Learning curve

4

Morbidity

• Each additional port used potentially increases morbidity4,5

• Bleeding

• Port-site hernia

• Internal organ injury

• Vascular injury

• Post-operative wound infection

• Decreases cosmetic outcome

2 weeks postop

4. Fader AN, Escobar PF. Gynecol Onc. 2009; 114: 157-61.5. Shin JH and Howard FM. J Minim Invasive Gynecol 2012; 19: 448-53.

Pain

• Potential decrease in postoperative pain and need for postoperative pain medications, which might be due to avoidance of multiple muscle-splitting incisions.4,6-8

4. Fader AN, Escobar PF. Gynecol Onc. 2009; 114: 157-61.6. Kim TJ et al. Surg Endosc. 2010 Sep;24(9):2248-52.7. Yim GW et al. Am J Obstet Gynecol. 2010 Jul; 203(1): 26.e1-6.8. Yim GW et al. Surg Innov. 2013 Feb;20(1):46-54

Gynecology and Single Incision

• Anatomy of the Pelvis

• Ease of Specimen Removal

Just Remember

• Follow standard laparoscopic fundamentals

(LESS and reduced port laparoscopy are ACCESS techniques…NOT new procedures)

• Includes using all normal precautionary steps such as identifying and isolating ureters, bladder, and bowel

What will you need to get started?

• Port

• Laparoscope – Angled or Flexible Tip

• Instruments – Traditional Straights

• Energy – Anything but ultrasonic technology

• Uterine Manipulator

Initial Patient Selection

• BMI < 40

• Uterus 14 weeks or less

• No more than 1 prior abdominal surgery

• No prior history of pelvic inflammatory disease (PID)

5

Putting in the Port Cross Over Technique

• Grasper goes in contralateral trocar from the direction of retraction

• If you are clashing instruments, most likely instruments are in the wrong trocars…pull everything out and reassess

• Set yourself up to be successful…camera, then grasper, and finally energy

Cross Energy Above or Below the Grasper?

ABOVE

• Round ligament

• Bladder flap

• Colpotomy

• Cervical amputation

BELOW

• Infundibulopelvic ligament

• Utero-ovarian ligament

• Fallopian tube

• Round Ligament

• Uterine artery

• Colpotomy

• Cervical amputation

Guiding Principles

• Always retract in such a way that the handle of the instrument moves lateral, away from the camera and central are above the umbilicus

• Plan the procedure and choose instrumentation and techniques that minimize the need for instrument exchanges

• Use a good uterine manipulator

• If significant difficulty is encountered at any time during the procedure, an additional trocar can always be considered

Seeing the Principles in Action Worst Case Scenario

• Add another trocar!!!

6

Cuff Closure

• Vaginal closure

• Laparoscopic suturing device with an articulating laparoscopic grasper

• Vertical laparoscopic closure with a “puppet string” at 12 o’clock (advanced single incision laparoscopic technique)

Umbilical Closure

• Close the fascia • May need to stitch

base of umbilicus down to fascia

• Subcutaneous stitch to reapproximate skin

• Discourage use of skin glue

Single Site Robotics (R-LESS)

• May make LESS more accessible to the general gynecologist

• Limited instrumentation and energy options

9. Scheib SA, Fader AN. Am J Obstet Gynecol. 2015 Feb;212(2):179.e1-8.

Endometriosis

• Advanced LESS skill set

• May need articulating instruments

Myomectomy Pregnancy

10. Scheib SA et al. J Minim Invasive Gynecol, 2013 Sep-Oct; 20(5):701-7.

7

MICRO-LAPAROSCOPY

Micro-Laparoscopy

• 3mm or less incisions

• Pain mapping11

• Can be used with benign GYN pathology, urogyn procedures, REI, and gyn oncology12-17

11.Steege JF. J Am Assoc Gynecol Laparosc, 2001; 8(2): 263-6.12.Rosenblatt PL et al. J Minim Invasive Gynecol, 2013; 20(4): 411.13.Ghezzi F et al. Eur J Surg Oncol, 2013; 39(10): 1094-100. 14.Ghezzi F et al. Gynecol Oncol, 2009; 113(2):170-5.15.Marianowski P, et al. Neuro Endocrinol Lett, 2007; 28(5): 704-7.16. Ikeda F, et al. J Reprod Med, 2005; 50(10): 771-8. 17. Ikeda F, et al. Rev Hosp Clin Fac Med Sao Paulo, 2001; 56(4): 115-8.

Advantages

• Less pain16,18

• Lower consumption of analgesics16

• Quicker return to daily activities16

• Postoperative recovery time16,18

• Reduced healthcare costs16

• Improved cosmesis18

• Decreased in trocar site hernias19

16. Ikeda F et al. J Reprod Med, 2005; 50(10): 771-8.18.Palter S, Olive D. Office microlaparoscopy under local anesthesia. In: Azziz RW, Murphy A, eds.

Surgical Technology International IV. New York: Springer Verlag; 1997.19.Kavic MS, Levenson CJ, eds.; Wetter PA, exec ed. Prevention and Management of Laparoendoscopic

Surgical Complications. Miami, Fl: Society of Laparoendoscopic Surgeons; 1999.

Limitations

• Light and picture quality is reduced20,21

• Delicate nature of the graspers, scissors and other instrumentation, and difficult in removing bulky tissue through the smaller trocars.20,21

• Learning curve related to the above22

20.Haeusler G et al. Acta Obstet Gyncol Scand, 1996; 75: 672-5.21.Risquez F et al. Hum Reprod, 1997; 12(8): 1645-8.22.Palter SF. Obstet Gynecol Clin North Am, 1999; 26(1): 109-20.

Video

MINI-LAPAROTOMY

8

Somewhere in Between

• Can be combined with laparoscopy

• Equivalent to laparoscopy for reproductive outcomes with shorter operative times23

• Shorter hospital times compared to laparotomy but worse than laparoscopy23,24

• Pain better than laparotomy but equivalent than laparoscopy23,25

23.Palomba S, et al. Reprod Biomed Online, 2015; 30(5): 462-8124.Perron-Burdick M, et al. J Minim Invasive Gynecol, 2014; 21(4): 619-23. 25.Sirisabya N, Manchana T. J Obstet Gynaecol, 2014; 34(1): 65-9.

3D TECHNOLOGY

Benefits

• Helps shorten the learning time of basic laparoscopic skills to novices26,27

• Appears to improve speed and reduce the number of performance errors when compared to 2D laparoscopy28

• Operation time is reduced and procedural error margin is decreased26,28

26.Poudel S, et al. Surg Endosc, 2016 Jun 28. [Epub ahead of print]27.Usta TA, Gundogdu EC. Curr Opin Obstet Gynecol. 2015 Aug;27(4):297-30128.Sørensen SM. Surg Endosc. 2016 Jan;30(1):11-23.

Limitations

• More expensive

• Having the obligation to wear glasses

• Big and heavy camera probe

• Headaches and dizziness

27.Usta TA, Gundogdu EC. Curr Opin Obstet Gynecol. 2015 Aug;27(4):297-301

Take Home

• These are techniques…NOT new procedures

• Expect every step to take more thought and concentration

• Be aware of a tendency to accept less anatomic visualization than conventional laparoscopic and don’t accept this…Patient Safety First!

• If it is necessary, place an additional trocar

References

1. Wheeless CR. A rapid, inexpensive and effective method of surgical sterilization by laparoscopy.Journal of Reproductive Medicine. 1969; 3: 65-9.

2. Wheeless CR, Thompson BH. Laparoscopic sterilization: review of 3600 cases. Obstetrics and Gynecology. 1973; 42: 751-8.

3. Pelosi MA, Pelosi MA. Laparoscopic hysterectomy with bilateral salpingo-oophorectomy using a single umbilical puncture. New England Journal of Medicine. 1991; 88: 721–6.

4. Fader AN, Escobar PF. Laparoscopic single-site surgery (LESS) in gynecologic oncology: Technique and initial report. Gynecologic Oncology. 2009; 114: 157-61.

5. Shin JH, and Howard FM. Abdominal wall nerve injury during laparoscopic gynecologic surgery: incidence, risk factors, and treatment outcomes. J Minim Invasive Gynecol 2012; 19:448-53.

6. Kim TJ et al. Single-port-access laparoscopic-assisted vaginal hysterectomy versus conventional laparoscopic-assisted vaginal hysterectomy: a comparison of perioperative outcomes. Surg Endosc. 2010 Sep;24(9):2248-52.

7. Yim GW et al. Transumbilical single-port access versus conventional total laparoscopic hysterectomy: surgical outcomes. Am J Obstet Gynecol. 2010 Jul; 203(1): 26.e1-6.

8. Yim GW et al. Is Single-Port Access Laparoscopy Less Painful Than Conventional Laparoscopy for Adnexal Surgery? A Comparison of Postoperative Pain and Surgical Outcomes. Surg Innov. 2013 Feb;20(1):46-54

9. Scheib SA, Fader AN. Gynecologic robotic laparoendoscopic single-site surgery: prospective analysis of feasibility, safety, and technique. Am J Obstet Gynecol. 2015 Feb;212(2):179.e1-8.

10. Scheib SA et al. Laparoendoscopic Single-Site Surgery for the Management of Adnexal Masses in Pregnancy: A Case Series. J Minim Invasive Gynecol, 2013 Sep-Oct; 20(5):701-7.

9

References

11. Steege JF. J Am Assoc Gynecol Laparosc, 2001; 8(2): 263-6.

12. Rosenblatt PL et al. J Minim Invasive Gynecol, 2013; 20(4): 411.

13. Ghezzi F et al. Eur J Surg Oncol, 2013; 39(10): 1094-100.

14. Ghezzi F et al. Gynecol Oncol, 2009; 113(2):170-5.

15. Marianowski P, et al. Neuro Endocrinol Lett, 2007; 28(5): 704-7.

16. Ikeda F, et al. J Reprod Med, 2005; 50(10): 771-8.

17. Ikeda F, et al. Rev Hosp Clin Fac Med Sao Paulo, 2001; 56(4): 115-8.

18. Palter S, Olive D. Office microlaparoscopy under local anesthesia. In: Azziz RW, Murphy A, eds. Surgical Technology International IV. New York: Springer Verlag; 1997.

19. Kavic MS, Levenson CJ, eds.; Wetter PA, exec ed. Prevention and Management of Laparoendoscopic Surgical Complications. Miami, Fl: Society of Laparoendoscopic Surgeons; 1999.

20. Haeusler G et al. Acta Obstet Gyncol Scand, 1996; 75: 672-5.

21. Risquez F et al. Hum Reprod, 1997; 12(8): 1645-8.

22. Palter SF. Obstet Gynecol Clin North Am, 1999; 26(1): 109-20.

23. Haeusler G et al. Acta Obstet Gyncol Scand, 1996; 75: 672-5.

24. Risquez F et al. Hum Reprod, 1997; 12(8): 1645-8.

25. Palter SF. Obstet Gynecol Clin North Am, 1999; 26(1): 109-20.

26. Poudel S, et al. Surg Endosc, 2016 Jun 28. [Epub ahead of print]

27. Usta TA, Gundogdu EC. Curr Opin Obstet Gynecol. 2015 Aug;27(4):297-301

28. Sørensen SM. Surg Endosc. 2016 Jan;30(1):11-23.

10

Tae Joong Kim, MD., PhD.

Assistant Professor

Division of Gynecologic Oncology

Department of Ob/Gyn

Sungkyunkwan Univ. School of Medicine

Conquering the Tough Case: Tips and

Tricks to Expand the Boundariesof Single Port Laparoscopy

Disclosure

• Speakers Bureau: Johnson & Johnson

Discuss how to incorporate single port laparoscopy

into your practice.

Objectives

Less scar and more convenience

I started Single-port LAVH using the home-made glove port and

an Endo GIA roticulator™ on

May 2008

I started Single-port LAVH using the home-made glove port and

an Endo GIA roticulator™ on

May 2008

Lee YY, Kim TJ et al. JMIG 2009Single-Port Access Laparoscopic-Assisted Vaginal Hysterectomy: A Novel

Method with a Wound Retractor and a Glove

Lee YY, Kim TJ et al. JMIG 2009Single-Port Access Laparoscopic-Assisted Vaginal Hysterectomy: A Novel

Method with a Wound Retractor and a Glove

0 200 400 600 800 1000

Hysterectomy

Adnexectomy

Ovarian cystectomy

Myomectomy

Staging c LND

Others

1808 cases of LESS experiences

May 2008~ Aug 2016

11

3616 (1808 x 2)

less trocar scars...

Bellybutton makes post-op time

Convenientfor women

Ergonomics for gynecologic surgeons

Single port access laparoscopic adnexal surgeryKim TJ, Lee YY, JMIG, 2009Single port access laparoscopic adnexal surgeryKim TJ, Lee YY, JMIG, 2009

Poor ergonomicsInstrument collision

Poor ergonomicsInstrument collision

Poor ergonomics in gynecologic surgery Long instruments & 30º scope

12

One articulating instrument My posture & OR set up (29 Oct 2015)

Cuff closure

Use fixator and gravity

SPA ovarian cystectomy using a fixator

Gravity

13

“Barb” for traction or fixation

Retroperitoneal dissection

RPDUterine a. ligation

Ureterolysis

LN dissection

Is LESS Retroperitoneal Hysterectomy Feasible? : Surgical Outcomes of Initial 27 Cases

27 consecutive patients (Sep 2012~Feb 2013)27 consecutive patients (Sep 2012~Feb 2013)

Kim TH, Kim TJ, TJOG 2015

1. Pull IP lig.2. Open broad lig. 3. Find ureter near the pelvic brim4. Journey following the ureter5. Develop pararectal space6. Meet uterine artery7. Develop paravesical space8. Skeletonize and ligate uterine a.

Kim TH, Kim TJ, TJOG 2015

RPD for uterine a. ligation

14

36 aH (Nov 2011~Aug 2012) vs. 36 rH (Sep 2012~May 2013)36 aH (Nov 2011~Aug 2012) vs. 36 rH (Sep 2012~May 2013)

Retroperitoneal Approach in Single-Port Laparoscopic Hysterectomy Kim TH, Kim TJ, JSLS 2016

Kim TH, Kim TJ, JSLS 2016

2012(n=12)

2013 (n=28)

2014 (n=60)

2015 (n=?)

2016 (n=?)

Rt. RP UAL 9m17s 6m28s 4m41s ? ?

Lt. RP UAL 8m28s 6m19s 4m24s ? ?

Total OP time

91m26s

77m4s56m29

s? ?

My SPA-rH

x 1.3

Hysterectomy d/t adenomyosisHysterectomy d/t myoma in the lower bodyHysterectomy d/t huge myoma

Myomectomy in women who have finished child

Non-touching oophorectomy

My RPD for benign disease

LESS/SPA in oncology

15

Angle of approachparallel to iliac vessels and psoas muscle

SPA Rt. PLND using barbed suture material to pull the hypogastric a.

Choi HJ, Kim TJ, Gynecol Oncol, 2015

Benefits of LESS/SPA

16

9 liters

EasySpecimen OUT

Transumbilical knife morcellation

within an endobag

Using a bigger opening - Minilaparotomy

- Easier specimen out

- Wound protection

Efficient approach to all directions

BenefitsLess scar & SPA!

• May 2008, SPA-LAVH d/t a home-made glove port and an Endo GIA roticulator

• Nov 2008, SPA-Cystectomy or oophorectomy for larger size d/t articulating grasper

• Jan 2009, SPA-SH, SPA-M d/t transcervical or transumbilical morcellation

• May 2010, SPA-staging operating including LND

• Oct 2010, SPA-TLH (below suture) d/t advanced bipolar device

• Sep 2012, SPA-TLH thru retroperitoneal dissection

• Jul 2013, SPA-TLH (above suture) d/t barbed suture

• Jun 2015, SPA-high paraaortic LND d/t articulating energy device

• Jan 2016, SPA-triage for advanced ovarian cancer

• Jun 2016, SPA-radical hysterectomy (type II)

• Jul 2016, SPA-IDS

17

Tips and Tricks to Expand the Boundaries

of LESS/SPA

✓Believe in less scar & SPA!

✓Understand SPA ergonomics

✓Use a fixator & gravity

✓Understand ‘approach of angle’ of instruments

from umbilicus

✓Use a bigger umbilical opening

Lee YY., Kim TJ, et al. Single port access laparoscopic assisted vaginal hysterectomy (SPALAVH): a novel method using a wound retractor and a glove. J Minim Invasive Gynecol, 16: 450-453, 2009.

Kim TJ, Lee YY, et al. Single port access laparoscopic adnexal surgery. J Minim Invasive Gynecol, 16: 612-615, 2009.

Kim TJ, Lee YY, et al. Single port access laparoscopic-assisted vaginal hysterectomy versus conventional laparoscopic-assisted vaginal hysterectomy: A comparison of peri-operative outcomes. Surg Endos, 2010, 24, 2248-52

Yoon G, Kim TJ, et al. Single Port Access (SPA) Subtotal Hysterectomy with Transcervical Morcellation: A Pilot Study. J Minim Invasive Gynecol, 2010, 17, 78-81

Lee YY, Kim TJ, et al. Single port access laparoscopic adnexal surgery versus conventional laparoscopic adnexal surgery: A comparison of peri-operative outcomes. Eur J Obstet Gynecol Reprod Biol, 2010, 151, 181-4

Song T, Kim TJ, et al. Single-Port Access Laparoscopic-Assisted Vaginal Hysterectomy (SPA-LAVH) for large uterus weighing exceeding 500 g: Technique and initial report J Minim Invasive Gynecol, 2010, 17, 456-60

Kim TJ, Choi MY, et al. Single-port access laparoscopic prophylactic bilateral salpingo-oophorectomy in BRCA-positive breast cancer patient: a case report. J Breast Cancer, 2010, 13, 437-42

Park HS, Kim TJ, et al. Single-port access (SPA) laparoscopic surgery in gynecology:a surgeon’s experience with an initial 200 cases. Eur J Obstet Gynecol Reprod Biol, 2011, 154, 81-4

Song T, Kim TJ, et al. What is the learning curve for single-port access laparoscopoic-assisted vaginal hysterectomy? Eur J Obstet Gynecol Reprod Biol, 2011, 158, 93-96

Yoon A, Kim TJ, et al. Single Port Access Laparoscopic Staging operation for Borderline Ovarian Tumor. J Gynecol Oncol, 2011, 22, 127-13

Song T, Kim TJ, et al. Single-port access laparoscopic surgery using a novel laparoscopic port (Octo-port). Taiwan J Obstet Gynecol, 2011, 50, 436-40

Kim TJ, Lee YY, et al. Does single-port access (SPA) laparoscopy mean reduced pain? A retrospective cohort analysis between SPA and conventional laparoscopy. Eur J Obstet Gynecol Reprod Biol, 2012, May;162(1):71-4.

Song T, Kim TJ, et al. Learning curves for single-site laparoscopic ovarian surgery. J Minim Invasive Gynecol. 2012;19(3):344-9.

Song T, Kim TJ, et al. Cosmesis and body image after single-port access surgery for gynaecologic disease. Aust N Z J Obstet Gynaecol. 2012 Oct;52(5):465-9.

References

Song T, Cho J, Kim TJ, et al. Cosmetic Outcomes of Laparoendoscopic Single-Site Hysterectomy Compared With Multi-Port Surgery: Randomized Controlled Trial. J Minim Invasive Gynecol. 2013 Mar 26.

Jo EJ, Kim TJ, et al. Laparoendoscopic single-site surgery with hysterectomy in patients with prior cesarean section: comparison of surgical outcomes with bladder dissection techniques. J Minim Invasive Gynecol. 2013 Mar;20(2):160-5.

Park JY, Kim TJ, et al. Laparoendoscopic single site (LESS) surgery in benign gynecology: perioperative and late complications of 515 cases. Eur J Obstet Gynecol Reprod Biol. 2013 Apr;167(2):215-8.

Yoon A, Kim TJ, et al. Laparoendoscopic single-site (LESS) myomectomy: characteristics of the appropriate myoma. Eur J Obstet Gynecol Reprod Biol. 2014 Apr;175:58-61.

Kim TJ, Song T, et al. Comparison of laparoendoscopic single-site hysterectomies: laparoscopic hysterectomy with some vaginal component versus laparoscopically assisted vaginal hysterectomy. J Laparoendosc Adv Surg Tech A. 2014 Apr;24(4):254-9.

Song T, Kim TJ, et al. Comparison of barbed suture versus traditional suture in laparoendoscopic single-site myomectomy. Eur J Obstet Gynecol Reprod Biol. 2015 Feb,185:99-102.

Yoon A, Kim TJ, et al. Robotic Single-port Hysterectomy, Adnexectomy, and Lymphadenectomy in Endometrial Cancer. J Minim Invasive Gynecol. 2015 Mar-Apr;22(3):322.

Yoo HN, Kim TJ, et al. Single-site robotic surgery in gynecologic cancer: a pilot study. J Gynecol Oncol. 2015 Jan;26(1):62-7.

Kim TJ, Kim TH, Cho CH, Kwon SH, Shin SJ, Sung S, Song T, Hur S, Kim YM, Lee SW, Kim YT, Nam E, Kim YB, Lee JR, Roh HJ, Chung H. Multi-Institution, prospective randomized trial to compare the success rates of single-port versus multi-port laparoscopic hysterectomy for the treatment of uterine myoma or adenomyosis. J Minim Invasive Gynecol. 2015 Mar 7.

Kim TH, Kim TJ, et al. Is laparoendoscopic single-site surgery (LESS) retroperitoneal hysterectomy feasible?: Surgical outcomes of the initial 27 cases. Taiwan J Obstet Gynecol. 2015 Apr;54(2):150-4.

Song T, Park JY, Kim TJ, et al. A prospective comparative study of cosmetic satisfaction for three different surgical approaches. Eur J Obstet Gynecol Reprod Biol. 2015;190:48-51.

Song T, Kim TJ, et al. Laparoendoscopic single-site myomectomy compared with conventional laparoscopic myomectomy: a multicenter, randomized, controlled trial. Fertil Steril. 2015 Aug 8.

Choi HJ, Kim TJ, et al. Laparo-endoscopic single site paraaortic lymphadenectomy facilitated by a newarticulating vessel sealing device. Gynecol Oncol. 2015 Nov;139(2):385-6.

Kim TH, Kim TJ, et al. Single-port retroperitoneal hysterectomy with EnSeal. J Laparoendosc Adv Surg Tech A.2016

Kim TH, Kim TJ, et al. Retroperitoneal Approach in Single-Port Laparoscopic Hysterectomy. JSLS. 2016 Apr-Jun;20(2).

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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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