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Sponsored by AAGL Advancing 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

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Sponsored by

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

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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.   

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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 

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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

3

• 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

4

• 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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7 8

9 10

11 12

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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

learner

learner

learner

learner

learnerlearner

learner

learner

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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