Sponsored by

AAGLAdvancing Minimally Invasive Gynecology Worldwide

Single Port Laparoscopic Surgery,

Mini Laparoscopy and Robotics – Safe and

Appropriate Adoption into Your Practice

MODERATOR

Anthony Siow, MD

FACULTY

Stephanie A. King, MD & Anna Fagotti, MD

Professional Education Information   Target Audience This educational activity is developed to meet the needs of residents, fellows and new minimally invasive specialists in the field of gynecology.  Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.  The AAGL designates this live activity for a maximum of 1.0 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  Single Port Laparoscopic Surgery, Mini Laparoscopy and Robotics – Safe and Appropriate Adoption  into Your Practice A. Fagotti ....................................................................................................................................................... 3  Single Port Laparoscopic Surgery, Mini Laparoscopy and Robotics – Safe and Appropriate Adoption  into Your Practice A. Fagotti, S.A. King  ...................................................................................................................................... 9  Cultural and Linguistics Competency  ......................................................................................................... 16 

 

Surgical Tutorial 5 Single Port Laparoscopic Surgery, Mini Laparoscopy and Robotics –

Safe and Appropriate Adoption into Your Practice

Moderator: Anthony Siow

Anna Fagotti & Stephanie A. King

This course is designed to help you navigate the growing field of reduced port surgery. Single port surgery, mini laparoscopy and robotics all have something to offer as we move forward in laparoscopic gynecology. We will demonstrate surgical procedures, from routine oophorectomy and hysterectomies to radical gynecologic oncologic surgery, using these new techniques and video presentations. Advantages and disadvantages of the various platforms, instruments and techniques available will be presented. Learning Objectives: At the conclusion of this course, the participant will be able to: 1) Explain the advantages and disadvantages of the various platforms available for single port laparoscopic surgery; 2) use the learning process to communicate effectively to patients and OR staff the appropriate use of reduced port surgical platforms; and 3) integrate the reduced port surgical platforms into their surgical practices.

1

PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop and have no conflict of interest to disclose (in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Viviane F. Connor Consultant: Conceptus Incorporated Kimberly A. Kho* Frank D. Loffer, Executive Vice President/Medical Director, AAGL* Linda Michels, Executive Director, AAGL* M. Jonathan Solnik* Johnny Yi*

SCIENTIFIC PROGRAM COMMITTEE Ceana H. Nezhat Consultant: Ethicon Endo-Surgery, Lumenis, Karl Storz Other: Medical Advisor: Plasma Surgical Other: Scientific Advisory Board: SurgiQuest Arnold P. Advincula Consultant: Blue Endo, CooperSurgical, Covidien, Intuitive Surgical, SurgiQuest Other: Royalties: CooperSurgical Linda D. Bradley* Victor Gomel* Keith B. Isaacson* Grace M. Janik Grants/Research Support: Hologic Consultant: Karl Storz C.Y. Liu* Javier F. Magrina* Andrew I. Sokol* 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). Anna Fagotti* Stephanie A. King Speakers Bureau: Karl Storz Consultant: Spouse: Merck, Olympus Speakers Bureau: Spouse: Karl Storz Anthony Siow* Asterisk (*) denotes no financial relationships to disclose.

Single Port Laparoscopic Surgery, Mini Laparoscopy and 

Robotics – Safe and Appropriate Adoption into Your Practice

Anna Fagotti

Assistant Professor

Minimally Invasive Gynecology – Department of Surgery

St. Maria Hospital, University of Perugia ‐ Terni, Italy

anna.fagotti@unipg.it

No financial relationships to disclose

• Learn advantages and disadvantages of the variousplatform available for single port laparoscopic surgery

• Use the learning process to comunicate effectively topatients and OR staff the appropriate use of reducedport surgical platforms

• Integrate the reduced port surgical platforms intosurgical practicies

LPSΜ-LPS/3 mm

LESSROBOTICS

LESS OPERATING ROOM

S‐LPS LESS

45°

3

Moving beyond simple proceduresRIGHT SIDELEFT SIDE

PILOT

BBBAAA

Fader, Amanda‐N M.D.

Division of Gynecologic Oncology 

Johns Hopkins, Baltimore, MD, USA 

Boruta, David II M.D.

Division of Gynecologic Oncology

Massachusetts General Hospital, Boston, MA, USA

Escobar, Pedro M.D.

Division of Gynecologic Oncology

Women's Health Institute, Cleveland Clinic, OH, USA

HIMA‐San Pablo, Caguas, PR, USA.

LESS in Gynecology:  an international group

Kim, Tae‐Joong M.D. Division of Gynecologic OncologySamsung Medical CenterSungkyunkwan University School of Medicine, South Korea

King, Stephanie M.D. 

Division of Gynecologic Oncology 

Fox Chase Cancer Center, Philadelphia, PA, USA

Fagotti, Anna M.D. 

Division of Gynecologic Oncology 

S. Maria Hospital, Terni, Italy

Scambia, Giovanni M.D. 

Division of Gynecologic Oncology 

Gemelli Hospital, Rome, Italy

PASSED AND ONGOING LESS CONFERENCE IN 2013

LIVE SURGERY

SURGICAL COURSE

SATELLITE SYMPOSIUM

MAIN SESSION

SIGO/ESGEMAIN SESSION

• LESS is associated with significantly lesspostoperative pain compared with conventional LPS, thus leading to better patient comfort.

• A statistically significant patient’s higher satisfaction rate was observed in the LESS than in the conventional LPS group.

Moving Beyond Simple Procedures:more than 200 LESS procedures over 3 yrs

2009-10Adnexal path 2010-11

Hysterectomy

2011-12Pelvic lymph 2012-13

RH

LESS procedures in GYO

Tumor LESS procedure

Ovarian cancerBorder‐line Ovarian Tumor staging and prophylactic adnexectomy

Endometrial cancer Simple hysterectomy (+/‐lymphadenectomy)

Cervical cancerSimple and radical hysterectomy (+/‐lymphadenectomy)

4

LESS experience on adnexal surgery at UCSC‐Rome

2009

2009

2010

2010

2011

2011

RCT

CASE‐CONTROL

PILOT

PILOT

CASE REPORT2012

3  YEAR EXPERIENCE 

BOT STAGING

2010

JMIG, 2012

PROCEDURES 125

Cystectomy (%) 42 (33.6)

Adnexectomy (%) 79 (63.2)

Staging BOT (%) 4 (3.2)

Reply to: “Some criticism about LESS in gynecological surgery for benign and malignant diseases”.

Respect of patient’s body image in case of: - BRCA-positive women- any woman with cancer who needs ovarian tissue for freezing, before undergoing RT/CT - models, whose physicality is their means of financial support- pediatric patients- patients asking for reassignment of sex

Fagotti et al, F&S 2011

Tumor LESS procedure

Ovarian cancerBorder‐line Ovarian Tumor staging and prophylactic adnexectomy

Endometrial cancer Simple hysterectomy (+/‐lymphadenectomy)

Cervical cancerSimple and radical hysterectomy (+/‐lymphadenectomy)

LESS procedures in GYO

LESS experience on hysterectomy at UCSC‐Rome

2009

2010

2012

2012

2013

PROPSECTIVE OBSERVATIONAL3‐mm,S‐LPS, LESS

MULTICENTRIC

PILOT

CASE REPORT

ROBOT‐LESS

LESS‐RH

2013

5

2010

2012LESS procedures in GYO

Tumor LESS procedure

Ovarian cancerBorder‐line Ovarian Tumor staging and prophylactic adnexectomy

Endometrial cancer Simple hysterectomy (+/‐lymphadenectomy)

Cervical cancerSimple and radical hysterectomy (+/‐lymphadenectomy)

LESS RH: the first report on LESS type III hysterectomy involves a woman with cervical cancer.

Boruta DM, AJOG, 2012

LESS RH for the treatment of early stage cervical cancer.

Fader AN, Gyn Onc 2013

FIRST CASE‐REPORTS ON LESS RH

Laparoendoscopic single‐site radical hysterectomy with pelvic lymphadenectomy: initial multi‐institutional experience for treatment of invasive cervical cancer

David M. Boruta, Anna Fagotti, Leslie S. Bradford, Pedro Escobar, Giovanni Scambia, Christina L. Kushnir, Chad M. Michener, Amanda Nickles Fader

Submitted

6

THE ERA OF COMPARISONLPSΜ-LPS/3 mm

LESSROBOTICS

2012

LESS vs. ROBOTICS

2013

LESS vs. 3‐mm

Minimally invasive surgery

LPSΜ-LPS/3 mm

LESSROBOTICS

LESS‐ROBOTICS

2013

LESS vs. RSS

7

LESS HYSTERECTOMY IN OBESE PATIENTS: DOES THE BMI INFLUENCE THE SUCCESSFUL

RATE ? A MULTICENTRIC EVALUATION

Rome, Boston, Baltimore

< 3030‐35>35

Fanfani et al, submitted

[1] Escobar PF, Starks D, Fader AN, et al. Laparoendoscopic single-site and natural orifice surgery in gynecology. Fertil Steril. 2010;94:2497-2502.

[2] Fader AN, Escobar PF. Laparoendoscopic single-site surgery (LESS) in gynaecologic oncology: technique and initial report. Gynecol Oncol. 2009;114:157-161.

[3] Escobar PF, Fader AN, Paraiso MF, et al. Robotic-assisted laparoendoscopic single-site surgery in gynecology: initial report and technique. J Minim Invasive Gynecol. 2009; 16:589-591.

[4] Fagotti A, Fanfani F, Marocco F, et al. Laparoendoscopic single-site surgery (LESS) for ovarian cyst enucleation: report of first 3 cases. Fertil Steril. 2009;92. 1168.e13-16.

[5] Marocco F, Fanfani F, Rossitto C, Gallotta V, Scambia G, Fagotti A. Laparoendoscopic single-site surgery for fertility-sparing staging of border line ovarian tumors: initial experience. Surg LaparoscEndosc Percutan Tech. 2010 Oct;20(5):e172-5.

[6] Escobar PF, Starks DC, Fader AN, et al. Single-port risk-reducing salpingo-oophorectomy with and without hysterectomy: surgical outcomes and learning curve analysis. Gynecol Oncol.2010;119:43-47.

[7] Fagotti A, Fanfani F, Rossitto C, et al. Laparoendoscopic single-site surgery for the treatment of benign adnexal disease: a prospective trial. Diagn Ther Endosc. 2010:e1-4.

[8] Fagotti A, Fanfani F, Marocco F, et al. Laparoendoscopic single-site surgery for the treatment of benign adnexal diseases: a pilot study. Surg Endosc. 2011;25:1215-1221.

[9] Fagotti A, Bottoni C, Vizzielli G, Rossitto C, Tortorella L, Monterossi G, Fanfani F, Scambia G. Laparoendoscopic single-site surgery (LESS) for treatment of benign adnexal disease: single-center experience over 3-years. J Minim Invasive Gynecol. 2012 Nov-Dec;19(6):695-700

[10] Fagotti A, Boruta DM 2nd, Scambia G, Fanfani F, Paglia A, Escobar PF. First 100 early endometrial cancer cases treated with laparoendoscopic single-site surgery: a multicentricretrospective study. Am J Obstet Gynecol. 2012 Apr;206(4):353.e1-6.

[11] Fagotti A, Rossitto C, Marocco F, et al. Perioperative outcomes of laparoendoscopic single-site surgery (LESS) versus conventional laparoscopy for adnexal disease: a case-control study. SurgInnov. 2011;18:29-33.

[12] Fagotti A, Bottoni C, Vizzielli G, et al. Postoperative pain after conventional laparoscopy and laparoendoscopic single-site surgery (LESS) for benign adnexal disease: a randomized trial. FertilSteril. 2011;96(1):255-259.e2.

[13] Fanfani F, Fagotti A, Scambia G. Laparoendoscopic single-site surgery for total hysterectomy. Int J Gynaecol Obstet. 2010;109:76-7.

[14] Fanfani F, Rossitto C, Gagliardi ML, et al. Total laparoendoscopic single-site surgery (LESS) hysterectomy in low-risk early endometrial cancer: a pilot study. Surg Endosc. 2012;26(1):41-6.

[15] Fanfani F, Gagliardi ML, Zannoni GF, et al.Total laparoscopic hysterectomy in early-stageendometrial cancer using an intrauterine manipulator: is it a bias for frozen section analysis? Case-control study. J Minim Invasive Gynecol. 2011;18(2):184-188.

[16] Fagotti A, Corrado G, Fanfani F, Mancini M, Paglia A, Vizzielli G, Sindico S, Scambia G, Vizza E. Robotic single-site hysterectomy (RSS-H) vs. laparoendoscopic single-site hysterectomy (LESS-H) in early endometrial cancer: a double-institution case-control study. Gynecol Oncol. 2013 Jul;130(1):219-23.

[17] Vizza E, Corrado G, Mancini E, Baiocco E, Patrizi L, Fabrizi L, Colantonio L, Cimino M, SindicoS, Forastiere E. Robotic single-site hysterectomy in low risk endometrial cancer: a pilot study. Ann Surg Oncol. 2013 Aug;20(8):2759-64.

[18] Escobar PF, Haber GP, Kaouk J, Kroh M, Chalikonda S, Falcone T. Single-port surgery: laboratory experience with the daVinci single-site platform. JSLS. 2011 Apr-Jun;15(2):136-41

[19] Cela V, Freschi L, Simi G, Ruggiero M, Tana R, Pluchino N. Robotic single-site hysterectomy: feasibility, learning curve and surgical outcome. Surg Endosc. 2013 Jul;27(7):2638-43.

[20] Fanfani F, Fagotti A, Gagliardi ML, Monterossi G, Rossitto C, Costantini B, Gueli Alletti S, Vizzielli G, Ercoli A, Scambia G. Minilaparoscopic versus single-port total hysterectomy: a randomized trial. J Minim Invasive Gynecol. 2013 Mar;20(2):192-7

[21] Fagotti A, Gagliardi ML, Fanfani F, Salerno MG, Ercoli A, D'Asta M, Tortorella L, Turco LC, Escobar P, Scambia G. Perioperative outcomes of total laparoendoscopic single-site hysterectomyversus total robotic hysterectomy in endometrial cancer patients: a multicentre study. GynecolOncol. 2012 Jun;125(3):552-5

8

“PATIENCE,TIME,

EXPERIENCE

Reduced Port Surgery

Stephanie A. King, M.D.

Director, Minimally Invasive Gynecologic Surgery and Postgraduate Training 

Dept of Surgical Oncology

Fox Chase Cancer Center,  Philadelphia

Reducing scars,learning curves and cost

Consultant: Merck, Olympus 

Speakers Bureau: Karl Storz

At the conclusion of this course, the participant will be able to:

Explain the advantages and disadvantages of the various platforms available for single port laparoscopic surgery

use the learning process to communicate effectively to patients and OR staff the appropriate use of reduced port surgical platforms, their risks and benefits

integrate the reduced port surgical platforms into their surgical practices safely and cost effectively

Gynecology  (1969 – 1992)• Wheeless Single Incision BTL• Pelosi        Single Incision TAH BSO, Appy

General Surgery (1997)• Navarra, Cuesta   Single Incision Cholecystectomy

Working together  (April 2007)• Urology and General Surgery (together) Rao and Rao One Port Umbilical Cholecystectomy

• Gynecology and General Surgery (together) Curcillo & King Single Port Access Surgery

Flaps raised to

widen incision

(widen ellipse)

Lateral 5 mm Trocar Site

Lateral 5mm Trocar Site

Camera Trocar Site

Initial Camera (5mm) Trocar Site

Umbilical Incision(1.5cm)

pgc/sak ‘08

9

• Cholecystectomy• Gastric • Liver • Pancreas• Small Bowel• Meckels• Colon and Rectum• Spleen• Adrenal• Ventral Hernia Repair• Hysterectomy• Oophorectomy• Bladder• Kidney• Prostate

• General Surgery

• Gynecology

• Pediatric Surgery

• Urology

• Veterinary Surgery

• And now …Plastic Surgery

Simple

Allow easy instrument exchanges

Cost Effective

Reasonable  incision size

Minimize hand/instrument/trocar clashing

Minimize air leaks

Allow smoke evacuation

Allow easy specimen extraction/anastomosis

• Cosmetic  +

• Shorter Stay  +/‐

• Less Pain  +/‐

• Faster Recovery  +/‐

• Safety– so far, so good  ??

Multi Trocar Techniques• Single Port Access (SPA)

• Multiple trocars through one skin incision, separate fascial defects

• Minilaparoscopy

• Needle Laparoscopy

• Standard Instrumentation

• Transvaginal

• Single Port Device Techniques• SILS

TM, LESS, SSL, S‐Portal 

(Device driven)

• Multiple Instruments through one fascial defect

• Articulating, bent or curved instruments

Melissa S. Phillips, Eric M. Pauli, Jeffrey M. Marks, Roberto Tacchino, Kurt Roberts, Raymond Onders, George DeNoto, Paraskeva Parskevas, Homero Rivas, Arsalla 

Islam, Nathaniel Soper, Alexander Rosemurgy, Sajani Shah

University Hospitals Case Medical Center, Cleveland, OhioUniversity of Tennessee, Knoxville, Tennessee

SINGLE PORT DEVICETECHNIQUESACS 2011

‐ HOMERO RIVAS4PLC SILC p value

Wound Complications (total)* 2.5% 8.4% 0.13

Erythema 0% 3.4% 0.15

Cellulitis 0% 1.7% 0.52

Postoperative wound infection 2.5% 1.7% 1.00

Suture-related complication 0% 1.7% 0.52

Seroma 0% 0.8% 1.00

Postoperative Hernia Incidence 1.2% 8.4% 0.05

Retained Choledocholithiasis 1.3% 0.8% 1.00

Bile Duct Injury or Bile Leak 0% 0% 1.00

Total adverse events p=0.46                                                          4PLC 37% SILC 43%

ACS 2011‐ HOMERO RIVAS

10

Trocar Size and Hernia Formation

5mm < 10mm < 15mmPuncture  < Hassan (open)

Azurin DJ, Go LS, Arroyo LR, Kirkland ML  Am Surg. 1995Plaus WJ J Laparoendosc Surg. 1993

Sanz‐Lopez R, Martinez‐Ramos C, Nunez‐Pena JR et al  Surg Endosc. 1999Fitzgibbons RJ Jr, Annibali R, Litke BS  Am J Surg. 1993Wagner M, Farley GE WMJ, Bender E, Sell H  SurgeryFreedman AN, Sigman HH J Laparoendosc Surg. 1995

Boughey JC, Nottingham JM, Walls AC Surg Laparosc Endosc Percutan Tech

Trocar Site and Hernia FormationPara‐umbilical > Lateral

Umbilicus is a weakened area

Lateral ‐Multiple muscle layers

Duron JJ, Hay JM, Msika S, Arch Surg. 2000

Callery MP, Strasberg SM, Soper NJ. Gastrointest Endosc Clin N Am. 1996

Azurin DJ, Go LS, Arroyo LR, Kirkland ML.. Am Surg. 1995

Fear RE. Obstet Gynecol. 1968

Plaus WJ. J Laparoendosc Surg. 1993

Rabinerson D, Avrech O, Neri A, Schoenfeld A. Obstet Gynecol Surv. 1997

Sanz‐Lopez R, Martinez‐Ramos C, Nunez‐Pena JR et al Surg Endosc. 1999

Bowrey DJ, Blom D, Crookes PF, et al.. Surg Endosc. 2001

Multi Trocar Techniques• Single Port Access (SPA)

• Multiple trocars through one skin incision, separate fascial defects

• Minilaparoscopy

• Needle Laparoscopy

• Standard Instrumentation

• Transvaginal

• No new Instruments

• No Crossing

• No Endowrist/Articulating

• Decreased COSTS

• Disadvantages ??

• Training• Stepwise

• Adoptable

• Adaptable

Every Minimally Invasive Procedure ….

Starts out as Single Port

Wu AS, Podolsky ER, King SA, Curcillo PGSingle Port Access (SPA) Surgery: A Novel Technique for Minimal Access Surgery

(Video) Surgical EndoscopyDOI 10.1007/s00464-009-0752-4 12/09 June 2010

• Reduction in pain

• Reduction in recovery time

• Reduction in port/entry sites size and number

• Reduction in instrument exchange

• Reduction in errors/complications

• Reduction in Costs (Economic and Ecologic)

This is where Single Port Needs to take us ……

11

• Reduction in the number of trocars …

• Single Port Access

• Two trocar procedures

• …or the size of the Trocars

• Needlescopic / Minilaparoscopy

• Thinner “5mm” trocars ‐When is 5mm not 5mm ?

• Single Port Rescue ‐ Safety

• A “hidden” port site ?

• A “smaller” port site ?

• A “second”  or “third” port site ?

When is Single Port not “Single Port ?”

When it doesn’t make sense and is safer

2012 –SPA EXENT WITH RECTUS FLAP – PATEL, KING, CURCILLO (PHILA, PA)

• Access

• Need “versatile answer”•Don’t make the decision before the operation

•Make it after you see what your up against

•Reduced Heads•Reduced Footprint (when is 5mm not 5mm ?)

• Increase Versatility• Economic/Ecologic

• Separate very low profile trocars or “sleeves”

• Single Skin Incision

• Separate fascial incisions

• ~ $85 / case

12

TrocarsSmaller Head Design

(< 1.8cm)

Longer Shaft

Reduced Footprint (Steel)Re‐usableSingle Port, Minilaparoscopy, Transvaginal Access

“Sleeves”

Triangulation : 7-8cm spread internally

Mini Laparoscopy –Safer and More Versatile then Needles/Sutures

• Single Port Access Surgery – Results• Closing Fascial Defects and Hernia Formation

• General Surgery Procedures (PGC n = 222)

• Closed

• 2 Hernias in Colon Patients

• Gynecology Procedures (SAK n = 212)

• Not Closed

• No Access Site Hernias

King,  Podolsky,  Curcillo  ‐ submitted 2011

• Costs

• Reusable vs Disposable ?

•Economic

•Ecologic

SINGLE PORT SURGERY

• Costs• MPL $180

• Single Port Access < $80

• Single Port Device $ > 400

13

• Progressive reduction of port sites

• 4 to 3 to 2 to 1

• Transition to 3mm instruments when appropriate

3 Port

2 Port

SPA GynSPA Procedure

• Single Port Access

• Mini Laparoscopy

• NOTES

A New Platform  ??

• How to develop a Safe Procedure• Maintain Safe Standards

• Dissection

• Maintain Safe Outcomes

• Port Sites and Hernias

• Maintain Costs

• Economic and Ecologic

• Safe Training Platform

• The Benefits

• None proven except cosmetics

• Is this any better ?

14

Is this better then multiport ??

The bigger picture –‐ evolution and improvement

Please –

Instruments don’t cause injuries  –

Be Safe

Be Cautious

Single Port Rescue

Another Port Site

Mini Laparoscopy

“ALL GOOD THINGSNEED TODEVELOP ANDMATURE;START THEM FOR THEWRONGREASONS, RUSH INTO THEM

AND THEYNEVER REACH THEIR FULLEST POTENTIAL”PGC@curcillo.com

References:

King SA, Atogho A, Podolsky E, Curcillo, PG. Single Port Access (SPA) Bilateral Oopherectomy and Hysterectomy.Laparoscopy Today, Volume 7 / Number 2,  Fall 2008

Podolsky ER , Rottman SJ, Poblete H, King SA,  Curcillo PGSingle Port Access (SPATM) Cholecystectomy:  A Completely Transumbilical ApproachJournal of Laparoendoscopic & Advanced Surgical Techniques. April 2009, 19(2): 219‐222. doi:10.1089/lap.2008.0275

Podolsky ER, Curcillo PGC:Single Port Access (SPA) Surgery ‐ A 24 Month Experience –Jour Gastrointestinal Surgery  , Volume 14 Issue 5 May 2009,  DOI 10.1007/s11605‐009‐1081‐6

Curcillo PG, Wu AS,  Podolsky ER, Graybeal C, Katkhouda N et al:Single Port Access (SPA) Cholecystectomy: A Multi‐Institutional Report of the First 297 CasesSurgical Endoscopy DOI 10.1007/s00464‐009‐0856‐x  , Volume 24, Issue 8 (2010), Page 1854.

Wu A, Podolsky ER, Rottman SJ, Huneke R, Curcillo PG:Initial Surgeon Training for Single Port Access (SPA) Surgery – Our First Year ExperienceJour Soc of Laparoendoscopic Surgeons (JSLS)  2010;14(2):200‐204

XU J, Delvadia D, Curcillo PG, King SA, Kotlar E:Single Port Access (SPA) Laparoscopic Tubal OcclusionJournal of Gynecologic Surgery – Accepted  May 2010

Curcillo PG, Wu A, King SA:Reduced Port Surgery: Developing a SAFE Pathway to Single Port Access SurgeryDer Chirurg  ,2011 82:391‐397 DOI 10.1007/s00104‐010‐2003‐6

Curcillo PG, Podolsky ER, King SA –The Road to Reduced Port Surgery: From Single Big Incisions to Single Small Incisions, and BeyondWorld Journal of Surgery; DOI 10.1007/s00268‐011‐1099‐2 World J Surg. 2011 Jul;35(7):1526‐31.

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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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