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Didactic: Pelvic Anatomy Directed to the Prevention and Management of Complications

PROGRAM CHAIR

Javier F. Magrina, MD

Marcello Ceccaroni, MD, PhD Paul M. Magtibay, MD Paul P.G., 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 (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

Navigating through the Pelvic Wall: Opening Spaces to Control Bleeding (Uterine and Hypogastric Artery Ligation) and Prevent Nerve Injury J.F. Magrina ................................................................................................................................................... 3

Presacral Space: Important Anatomy to Prevent Hemorrhage, Safe Dissection, Management of Presacral Bleeding, from Mild to Severe P.M. Magtibay ............................................................................................................................................... 8

Sigmoidorectal Anatomy: Blood Supply, Layers of the Bowel, and Importance for Closure of injuries; Is Bowel Prep necessary? What to Do Differently with Colon vs. Small Bowel Injury P. P.G. ......................................................................................................................................................... 11

How to Find and Preserve Pelvic Autonomic Nerves Resecting Endometriosis; Consequences of Transection of Sympathetic vs. Parasympathetic Innervation M. Ceccaroni .............................................................................................................................................. 14

The Difficult Parametrial Ureter Made Easy; Anatomy of the Parametrial Tunnel, from Easy to Difficult J.F. Magrina ................................................................................................................................................ 19

A Must for All Gynecologists: Bladder Anatomy: Blood Supply, Layers of the Bladder Wall and Importance for Closure; Prevention and Repair of Bladder and Ureteral Injuries; How to Perform Cystoscopy and Ureteral Stents P. P.G. .......................................................................................................................................................... 24

Vascular Disasters: The Large Pelvic Vessels: How to Avoid at Entry and during Surgery, What to Do and Not to Do; Handling of Vascular Injuries to Prevent Major Blood Loss and Death P.M. Magtibay ............................................................................................................................................ 30

Identification and Preservation of Pelvic Somatic and Sensory Nerves in Course of Pelvic Surgery: How to

Prevent Severe Neural Injuries

M. Ceccaroni .............................................................................................................................................. 33

Cultural and Linguistics Competency ......................................................................................................... 38

ANAT‐607: Didactic:

Pelvic Anatomy Directed to the Prevention and Management of Complications

Javier F. Magrina, Chair

Faculty: Marcello Ceccaroni, Paul M. Magtibay, Paul P.G. This course provides a review of the intraperitoneal and retroperitoneal pelvic anatomy applied to

minimally invasive gynecologic surgery with emphasis on preventing and correcting injuries. The

discussion on retroperitoneal anatomy will focus on opening lateral spaces for the prevention of

ureteral injury by demonstrating ureteral dissection (from easy to difficult), prevention and control of

severe pelvic hemorrhage (large vessels and presacral area), preservation of pelvic autonomic nerves

during resection of endometriosis, and prevention of motor nerve injury. In addition, anatomy applied

for the management of urologic and bowel injuries will be demonstrated.

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

pelvic spaces and the ureters; 2) identify the different retroperitoneal vessels and nerves; and 3) apply

the principles of prevention and management of urologic (bladder and ureter) and intestinal (small

bowel and sigmoidorectal) injuries.

Course Outline

7:00 Welcome, Introductions and Course Overview J.F. Magrina

7:05 Navigating through the Pelvic Wall: Opening Spaces to Control Bleeding (Uterine and Hypogastric Artery Ligation) and Prevent Nerve Injury J.F. Magrina

7:30 Presacral Space: Important Anatomy to Prevent Hemorrhage, Safe

Dissection, Management of Presacral Bleeding, from Mild to Severe P.M. Magtibay

7:55 Sigmoidorectal Anatomy: Blood Supply, Layers of the Bowel, and

Importance for Closure of injuries; Is Bowel Prep necessary?

What to Do Differently with Colon vs. Small Bowel Injury P. P.G.

8:20 How to Find and Preserve Pelvic Autonomic Nerves Resecting Endometriosis;

Consequences of Transection of Sympathetic vs. Parasympathetic Innervation

and New Nerve‐Sparing Approaches M. Ceccaroni

8:45 Questions & Answers All Faculty

8:55 Break

9:10 The Difficult Parametrial Ureter Made Easy; Anatomy of the Parametrial

Tunnel, from Easy to Difficult J.F. Magrina

9:35 A Must for All Gynecologists: Bladder Anatomy: Blood Supply, Layers of

the Bladder Wall and Importance for Closure; Prevention and Repair of Bladder

and Ureteral Injuries; How to Perform Cystoscopy and Ureteral Stents P. P.G.

10:00 Vascular Disasters: The Large Pelvic Vessels: How to Avoid at Entry and

during Surgery, What to Do and Not to Do; Handling of Vascular Injuries

to Prevent Major Blood Loss and Death P.M. Magtibay

10:25 Identification and Preservation of Pelvic Somatic and Sensory Nerves in

Course of Pelvic Surgery: How to Prevent Severe Neural Injuries M. Ceccaroni

10:50 Questions & Answers All Faculty

11:00 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* Javier F. Magrina* Suketu Mansuria Speakers Bureau: Covidien Linda Michels, Executive Director, AAGL* 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). Marcello Ceccaroni* Javier F. Magrina* Paul M. Magtibay* Paul P.G. Other: Honorarium for lecture: Ethicon Women’s Health & Urology Content Reviewer has no relationships. Asterisk (*) denotes no financial relationships to disclose.

2

Navigating through the Pelvic Wall: Opening Spaces to Control Bleeding (Uterine and Hypogastric Artery Ligation) and Prevent Nerve Injury

Javier F Magrina, MDMayo Clinic Arizona

Disclosures

• I have no financial relationships to disclose

Objectives

Discuss how to navigate and safely identify:

Lateral spaces

Vessels

Nerves

Enemies

• external and common iliac art.

• obturator nerve

• lumbosacral trunk

• ureters

Friends

• Superior vesical artery

• Uterine artery

• Internal iliac artery

3

Practical branching of internal iliac artery

• Anterior: superior vesical, uterine

• Lateral: int. pudendal, inf. gluteal

• Posterior: superior gluteal

Which internal iliac branch has the most different origins?

obturator artery

Ashley FL, Anson BJ. Am J Phys Anthropol28:381, 1941

Which internal iliac branch has the largest diameter?

4

• Which internal iliac branch has the largest diameter?

Superior gluteal (known as posterior branch)

5 mm diameter

2.7 cm distal to common iliac bifurcation

Posterior trunk right side

Internal iliac branches right side Internal iliac branches right side

Internal iliac artery identification

5

Uterine artery divisionWhy do you need to know pelvic

nerve anatomy?

6

R superior hypogastric plexus

Pelvic autonomic nerves

References

• Ashley FL, Anson BJ. Am J Phys Anthropol 28:381, 1941

Thank you

7

©2016 MFMER | slide-1

Presacral Space: Important Anatomy to Prevent Hemorrhage, Safe Dissection, Management of Presacral Bleeding, from Mild to Severe

Paul M Magtibay, MDMayo Clinic ArizonaNovember 14, 2016


I have no financial relationship to disclose.


Objectives

• Define the vascular anatomy and anatomic borders of the presacral space

• Discuss reasons for dissection of the space

• Discuss management of presacral bleeding*

• Demonstrate the dissection of the presacral space


• Boarders & Vasculature• Sacral Venous

Plexus• 2Lateral / 1Middle

• Internal Vertebral• Basivertebral

• Presacral Venous Plexus

• Retraction• Valveless system Harrison; Dis Colon Rectum 2003


Presacral Bleeding (1)

–Prevention• Know anatomic landmarks• Practice developing the space• Be smart

–Sacrocolpopexy–Rectal resection: benign versus malignant

versus presacral tumors–Use available technology: sealing devices–Be aware of hemostatic agents available



• Preparation & Stabilization• Pressure• IV access• Massive Transfusion Protocol• Suction x 2 or x 3• Hands / Help

8



• Control• Pressure ***• Electrocautery• Suture: caution



• Control• Topical hemostatic agents:

• Floseal (bovine gelatin/human thrombin), Collagen hemostat (instat, avitene), Oxidized cellulose (surgicel, oxycel), Gelatin foam/sponge (gelfoam, surgifoam), Vasopressin (soaked packing), Fibrin glue, Thrombin, Arista

• Thumb tacks: nope• Bone wax: nope


Harrison; Dis Colon Rectum 2003

• 4 x 2 cm segment of rectus abdominis muscle

• Hold over bleeding with forceps

• Cautery at 100 Hz

• Vigorous suctioning

• Fragment may not “stick”




• Control• Tightly pack• Leave abdomen open• ICU

• Correct DIC• Bring back when more stable


Videos


9


Videos



References

• Harrison JL, Hooks VH, Pearl RK, et al; Muscle Fragment Welding for Control of Massive Presacral Bleeding During Rectal Mobilization: A Review of Eight Cases; Dis Colon Rectum 2003


Evaluation Question

• What is the best first move when you encounter a significant presacral bleed?

1. Utilize the muscle fragment welding technique

2. Place additional large bore IV’s

3. Apply direct pressure to bleeding site

4. Apply topical hemostatic agents

5. Utilize thumb tacks or bone wax

10

Sigmoidorectal Anatomy

Paul PG.MBBS,DGO

Paul’s Hospital, Kochi, India

Other: Honorarium for lecture: Ethicon Women’s Health & Urology

Objectives

Review the anatomy of sigmoid colon & rectum

Discuss the closure of large bowel & small bowel injuries

Describe the differences

Discuss the role of Bowel preparation

Sigmoid

S‐shaped distal portion of colon about 40 cm long

Definite mesentery

inferior mesenteric vessels(IMA), superior hypogastric plexus ,nerves & lymph nodes

Opening mesosigmoid window

fundamental surgical step of colorectal surgery

Rectum

Extends from S3 to upper limit of anal canal(10-15 cm) Proximal third intraperitoneal

Middle third covered by peritoneum continuous with POD

Distal third retroperitoneal

Rectum expands to rectal ampulla under Cul de sac

Blood supply

Sigmoid Sigmoid arteries (2-4) - branches of IMA

Rectum Superior rectal (branch of IMA) Middle rectal ( branch of hypogastric artery)

- anastomose with superior rectalMiddle rectal ‐minor blood supply‐ compromise of IMA blood supply (rectal dissection )‐ leakage at the colorectal anastomosis*

*Patricio J etal 1988

11

Blood supply

Small intestine Branches of superior mesenteric artery

Anastomose to form a series of arcades

Each branch of arcade supplies a small segment of intestine with little overlap of blood supply

Layers of colon

4 layers – mucosa, submucosa, muscularis and serosa

Submucosa contains blood vessels & Meissner plexus

Muscularis ‐ inner circular, outer longitudinal muscles and myenteric (Auerbach)nerve plexus

Teniae coli are formed by outer longitudinal muscles. 3 Teniaecoli coalesce to form complete longitudinal layer over rectum

Layers of small bowel

2 layers of muscle oriented at right angles Thin continuous longitudinal layer

Thicker circular inner layer

This 2 layer muscular arrangement provides safe guard against small perforating injuries (Muscular contraction seals off)

Closure of Small bowel injuries

Trocar injuries - check for through and through perforation

Repaired in 2 layers transversely to minimize stenosis

Laceration > half diameter - resection ,anastomosis

If mesenteric blood supply is interrupted - resection is done regardless the size of laceration*

*DeCherny AH 1988

Small bowel Trocar Injury Closure of small bowel injury

12

Rectosigmoid injury Is bowel prep necessary?

Mechnical bowel preparation prior to colorectal surgery Lower the risk of contamination - fewer infectious complications* Recent Cochrane review(4599 patients - majority open surgeries)** Patients who did not undergo bowel preparation , there was no difference in

rates of anastomotic leakage, mortality, peritonitis, reoperation, or wound infection.

Laparoscopy - effect of gravity on fecal matter within the bowel may provide a better surgical view***

*Hughes 1972**Guenega etal 2011***Bucher P etal 2005

Is bowel prep necessary?

Bowel without fecal and gaseous contents are easier to handle.

In deep endometriosis where bowel surgery is indicated an enema the night before is recommended

An additional enema 2-3 hours before surgery( colorectal surgeons*

*Fernandez R etal 2016

References

1. Bucher P,GervazP,SaroviaC etal.Randomized clinical trial of mechanical bowel preperationversus no preperation before elective left sided colorectal surgery.Br.J Surg2005;92:409-41

2. DeCherny AH. Laparoscopy with unexpected viscus penetration. In Nicholas DH ed.Clinical Problems, injuries and complications of gynecologic surgery. Baltimore:Williams & Wilkins, 1988:62-3

3. Guenega KF,Matos D,Wille-Jorensen P.Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev 2011.CD 0001544

4. Fernandez R et al. Exposure in laparoscopic surgery. In Jon Einarsson ed.Minimallyinvasivegyncologic surgery. London. JP Medical publishers,2016:9-15

5. Patricio J etal.Surgical anatomy of the arterial blood-supply of the human rectum. SurgRadiol Anat.1988;10(1):71-5Hughes ESR. Asepsis in large –bowel surgery.Ann R CollSurg Engl 1972;51:347-356

13

Marcello Ceccaroni, M.D., Ph.D.

“How to find and preserve pelvic and autonomic nerves resecting endometriosis;consequences of transection of sympathetic VS parasympathetic innervation”

Director, Department of Obstetrics & Gynecology,Gynecologic Oncology and

Minimally-Invasive Pelvic Surgery Sacred Heart Hospital – Negrar (Verona), Italy

International School of Surgical Anatomy

[email protected] www.issaschool.com

The author of this presentation declares to have no conflict of

interest or financial relationships to disclose

ObjectivesReview the surgical anatomy of the visceral innervation of the female pelvis

Discuss operative technique to avoid damages to these structures during endometriosis surgery

WHAT CHANGED IN THE LAST CENTURYLaparoscopic/RoboticOncologic Surgery

Radical Surgery for Deep Endometriosis

and Cancer

Nerve Sparing Techniques

New and ModernRadical Pelvic Surgery

New anatomical studies(cadavers, human living models)

New anatomical nerve sparing landmarks (Middle Rectal Artery, Deep Uterine Vein,Superior Vesical Vein)

Laparoscopic/RoboticMagnification

Pelvic Neuro-NavigationImprovement of Electric surgery

Endometriotic foci sorrounding a nerve

CD10 highlights the endometriotic stroma

S100 positive nerve fibers

Severe Endometriosis andnerves-involvement

Radical surgery for Genital Cancer and Deep Infiltrating Endometriosis:an “onco-mimetic” surgery

(Ceccaroni M. et al, 2006)

Visceral resections:Ovarian Cancer

Parametrial resections:Cervical Cancer

Cancer Endometriosis

14

Laparoscopic dissection of left lateral and medial para-vesical space in DIE Laparoscopic dissection of left medial and lateral para-rectal space in DIE

Lympho-Vascular and Parametrial tissues of female pelvis

Anterior Parametrium

Uterus

Bladder

Ureter

Posterior ParametriumLateral Parametrium

Anterior Parametrium

Cranialportion of VUL

Caudalportion of VUL

Ceccaroni M., et al. CIC ed., 2006.

Recto-Vaginalligament

Uterus Bladder

Ureter

Promontorium

Cardinalligament

Postero-lateral parametrium:Recto-vaginal ligaments, Lateral Rectal Ligaments,

Cardinal ligament/Paracervix

(Ceccaroni M et al, 2006, 2013)

“..the so-called rectal pillar(otherwise referred to as dorsal or posterior parametrium) is defined after surgical opening of the rectovaginal septum and pararectal spaces. The rectal pillarcorresponds to the uterosacral ligament plus the rectouterine and rectovaginal ligament.It can be separated surgically from the hypogastric nerve that runs lateral to it..”

D. Querleu, C.P. Morrow,Lancet Oncol 2008; 9: 297–303

“..the so-called rectal pillar(otherwise referred to as dorsal or posterior parametrium) is defined after surgical opening of the rectovaginal septum and pararectal spaces. The rectal pillarcorresponds to the uterosacral ligament plus the rectouterine and rectovaginal ligament.It can be separated surgically from the hypogastric nerve that runs lateral to it..”

D. Querleu, C.P. Morrow,Lancet Oncol 2008; 9: 297–303

Laparoscopic surgical anatomy of Autonomic visceral pelvic nerves

(Ceccaroni M et al, 2006)

SHP

HN

RLLR

SB

WHeHe

IMP

IMV

A SB

SHP

HN HN

WHe

PSN PP LLR

R

IV

RVL

RVL

IV

IV

IV

R

IVPM

PM

Ceccaroni M, et al. “Neuro-anatomy of posterior parametrium and surgical considerations for a nerve-sparing approach in radical pelvic surgery”; Surg Endosc. 2013

Postero-lateral parametrium and its ligaments

15

R

V

SB

RLLR

O

PR

U

USRVL

LLR

LLR

W

CB

CB

U

UR

US

RVLLLR

R

D

PSN

PP

CL

ASB

PSNSR

PP

LLR

SB

Ur


M

SHP

SB

HN

HN

WR

He

LLR

PSN

PP

PP

HePSN

He

UR MRA

R

DUV RVL

LLR

M

M

U B

R

US

LLR

RVL

US

Ceccaroni M, et al. “Neuro-anatomy of posteriorparametrium and surgical considerations for a

nerve-sparing approach in radical pelvic surgery”;Surg Endosc. 2013

CL


Classical Technique for DSELaparoscopic surgical anatomy recto-vaginal space

www.issaschool.com

Nerve-Sparing Technique for DSE Sparing visceral innervationin radical pelvic surgery

IIAP

Rectum

Hypogastric Nerves

UreterSHP

HN

SHP

PSN

IHP

(Ceccaroni M, et al, J Spinal Disord Tech. 2011; Ceccaroni M, et al. JMIG 2010, Ceccaroni M, et al. AJOG 2010; Ceccaroni M, et al, Surg Rad Anat 2010; Landi S, Ceccaroni M, et al. Hum Reprod 2006; Ceccaroni M, et al, Eur J Ob & Gyn Reprod Biol.2010; Volpi E, et al, Surg Endosc 2004; Possover M, et al, Obstet Gynecol 2000, Kavallaris A., et al, Arch Gynecol Obstet 2010, Ceccaroni M et al, Surg Endosc 2012)

16

(Nerve Sparing Technique) (“Classical” Technique)

www.issaschool.com

Relationships btw fasciae and planes: Heald’s “Holy Plane”,Recto-Sacral space and Waldeyer’s fascia

Ercoli A, Delmas V, Fanfani F, Gadonneix P, Ceccaroni M, Fagotti A, Mancuso S, Scambia G. Am J Ob & Gyn, 193(4):1565-73, October 2005

Rectum-mesorectum wrapped

into fascia recti

(M. Ceccaroni, A. Maggioni, Paris 2008)

(Ceccaroni M. et al, 2006)

Surgical parametrial steps and sites at higher risk of denervation during

Radical Pelvic Surgery

D) Separation of the lateral sheet of the presacral Visceral Pelvic Fasciawhich contains the nerve structures, from the deep portions of recto-vaginal and vesico-uterine ligaments fibers

B) Identification of nerve roots and fibers

F) Functional cartography of Pelvic Plexus

A) Development of real and virtualavascular spaces and fascial planes

I) Know-how/nerve-sparing “Good Manners”

G) Selective neuro-ablation

E) Identification of nerve-sparingSurgical Landmarks(Middle Rectal Artery, Deep Uterine Vein, Superior Vesical Vein)

C) Knowledge of anatomy of pelvicneural pathways

(Ceccaroni M, et al, 2006)

Principles and tricks forNerve-Sparing Radical Pelvic Surgery

H) Tailoring the level of resection/colpectomy

« The Negrar Method »: Nerve-Sparing laparoscopic radical excision of deep endometriosis with

segmental rectal and parametrial resection

(Ceccaroni M, et al, J Spinal Disord Tech. 2011; Ceccaroni M, et al, Eur J Ob & Gyn Reprod Biol.2010; Ceccaroni M, et al. JMIG 2010; Ceccaroni M, et al. AJOG 2010;

Ceccaroni M, et al, Surg Rad Anat 2010; Landi S, Ceccaroni M, et al. Hum Reprod 2006; Volpi E, et al, Surg Endosc 2004; Possover M, et al, Obstet Gynecol 2000, Kavallaris

A., et al, Arch Gynecol Obstet 2010, Ceccaroni M et al, Surg Endosc 2012)

17

Laparoscopic retroperitoneal dissection of visceral innervationof the pelvis in pre-sacral space

Laparoscopic retroperitoneal dissection of visceral innervationof the pelvis in pre-sacral space

“The Negrar Method”: Nerve-Sparing laparoscopic radical excision of deep endometriosis with segmental rectal and parametrial resection

“The Negrar Method”: Nerve-Sparing laparoscopic radical excision of deep endometriosis with segmental rectal and parametrial resection

THANK YOU

Aknowledgements:

Dr. R. Clarizia, Dr. G. Roviglione,

Dr. F. Bruni,Dr. M. Mabrouk,

Dr. M. Lamanuzzi,Dr. C. Kiefert

Prof. L. Bovicelli

18

Tunnel, from Easy to Difficult

Javier F Magrina, MDMayo Clinic Arizona

The Difficult Parametrial Ureter Made Easy;Anatomy of the ParametrialTunnel, from Easy to Difficult

Disclosures

I have no financial relationships to disclose

Objectives

• Parametrial ureteral anatomy

• Prevention of injury at endoscopic hysterectomy

• Ureterolysis: mild, severe, impossible

\

The incidence of ureteral injuries in gynecologic laparoscopic surgery during the past 15 years has:

• A. decreased

• B. remained the same

• C. increased

• D. don’t know

Laparoscopic ureteral injuriesYear %

2002 0.03‐0.5* (1.7)

2009 0.03‐0.7** (1.6)

2014 0.02‐0.4***

*Clin Obstet Gynecol 45: 469, 2002

**Clin Obstet Gynecol 52:201, 2009

***JMIG 21:558, 2014 (only hyst)

Open + vaginal hyst 1984‐90 0.3‐1.5%

Complex robotic hyst 1.7% Obstet Gynecol 114:585, 2009

URETERAL INJURIES IN GYNECOLOGIC SURGERY 1939‐98

No. %

Post‐operative 107,068 0.1

Intra‐operative 3,235 0.6

1939-9829 studiesObstet Gynecol, 1999; 94:883

19

Intra vs postoperative diagnosis of ureteral injury : is there a difference for the necessity of surgical repair?

intraop dx : 14 % 9 %

postop dx : 86 % 61%

N=157 Lit review

JMIG 2014; 21:558

Parametrial ureter

How close can the ureter be to the cervix?

• A. < 0.5 cm

• B. 1 cm

• C. 1.5 cm

• D. 2.0 cm

20

How close are the ureters to the cervix?

12% of ureters are within 0.5 cm

=

1 in 8 patients

Obstet Gynecol 184:336, 2001

Identifiying ureter at cardinal lig

Identifiying ureter at cardinal lig

21

R ureter at colpotomy R ureter at colpotomy

Blocked L ureter vaginal cuff

Laparoscopic ureteral injuriesNeed for ureteral

surgery

intraop dx : 14 % 9 %

postop dx : 86 % 61%

N=157 Lit review

JMIG 2014; 21:558

Your patient has low urinary output and flank pain after

hysterectomyOptions to check for ureteral obstruction

• Serum creatinine

• Renal ultrasound

• Retrograde ureteral stent

• Antegrade ureteral stent

22

Parametrial ureteral dissection

References

Clin Obstet Gynecol 45: 469, 2002

Clin Obstet Gynecol 52:201, 2009

JMIG 21:558, 2014



Thank you

23

A Must For All GynaecologistsBladder Anatomy

Paul PG. MBBS,DGO

Paul’s Hospital, Kochi, India

Other: Honorarium for lecture: Ethicon Women’s Health & Urology

Objectives

To review Bladder anatomy

Discuss methods for Prevention of Bladder & ureter injuries

Video demonstration of repair of bladder& ureteric injuries

Video demonstration of Cystoscopy & insertion of ureteral stents

Bladder – Muscle layers

Dome (β cholinergic)& Base (α adrenergic) Detrusor – Mesh work of intertwining muscle bundles Internal longitudinal Median circular External longitudinal

Base – Trigone & U shaped band of musculature(Detrusor Loop)

Trigone is made of muscle that arises from ureters & continues as vesical neck & urethra

Blood supply

Superior vesical artery from non obliterated portion of

umbilical artery

Supply Dome of bladder

Inferior vesical artery Branch of Internal iliac

Supply Base & Trigone

Bladder InjuriesRisk Factors

Placement of suprapubic trocars full bladder, Previous caesarean

During adhesiolysis

LAVH Inadequate dissection of bladder & Vaginal closure*

Total Lap hysterectomy

Previous caesarean ***Kadar Netal1994 **Rooney CM, 2005

24

Trocar Injury Prevention

Empty bladder before suprapubic trocars

identify the upper border of bladder

Bladder to be displaced 2-3cm beyond colpotomy site(LAVH/TLH)

PP

Prevention

Identifying Bladder Margins Distend bladder with 200 ml with or without dye stained lactated

Ringers solution

Limiting blunt dissection*

Sheth’s uterocervical broad ligament space for previous caesarean**

*Utrie JW Jr. 1998

**Sheth SS.2005

Bladder dissection‐Previous Cesareanuterocervical broad ligament space

Recognition

Gas in the urinary bag

Retrograde instillation of dye

Cystoscopy Only 35% are recognized during hysterectomy before

cystoscopy*

*Vakili B etal2005,

Bladder Diathermy injuryprevious caesarean section

25

Slide 8

PP1 Paul PG, 9/10/2016

PP2 Paul PG, 9/10/2016

26

Repair

Delineation of injury Trigone, ureters vaginal cuff proximity

Laparoscopic closure Water tight full thickness closure 2-0/3-0 vicryl continuous or interrupted sutures 1-2 cm apart Avoiding mucosa is difficult & unnecessary* 2 Layer closure demonstrate decreased rate of vesicovaginal

fistula in animal model***Wohlrab KJ 2011**Sokol AI2004

Bladder injuryPelvic abscess

Other considerations

Injuries close to other suture lines Increased chance of fistula

Omental graft / peritoneal imbrication

Fibrin sealants more inflammation & poor strength*

EndoGIA stapler,Lapra-Ty,Barbed sutures Not recommended

*Borin JF2008

Postoperative management

Continuous bladder drainage Foley’s catheter -2 weeks or less*

Prophylactic antibiotics ?

Role of cystography before removal

Wohlrab etal.2011

Ureteral InjuriesPrevention

Common sites of injury

80% occur at the ureteral jn with uterine artery*

Risk factors

Previous pelvic surgery

Adhesions ,endometriosis

Enlarged uterus, cervical/broad ligament fibroids,

Urinary tract Anomalies

*Ibeanu OA 2009

Ureteral InjuriesPrevention

Identification Visual identification, ureterolysis in extensive pelvic disease Ureteral stents –No significant differences in incidence of

surgery*

cephalad pressure with Cervical cup of uterine manipulator.

Careful closure of vaginal cuff – Avoid anchoring stitch lateral to cuff margin

*Chou MT 2009

27

Ureteric transection Ureteric repair

Standard TreatmentLaparotomy - Ureter implantation with or without Boari Flap Intraoperative recognition – immediate Postoperative recognition Ureteral stents if partial Reapiar 6 wks later with percutaneous nephrostomy tube if not fit

Mode of Repair Upper third – ureteroureterostomy Middle third –ureteroureterostomy with or without Boari Flap Pelvic ureter - Ureteroneocystostomy with psoas hitch

Laparoscopic Anastomosis

Laparoscopic ureteral repair is comparable to open repair*

Laparoscopic reanastomosis of 29 women with ureteral transection was succesful in all. Laparoscopic management could become the prefered first line of mangement**

*Cholkeri-Singh A etal2007

**Cicco CD etal.2009

Laparoscopic ureteric anastomosis

Cystoscopy - Instrumentation

Diagnostic hysteroscopy instrumentation

Distention medium - Normal Saline

Full bladder survey - Bladder dome & base

Ureteric orifices for urine reflux Intravenous indigo carmine / Methylene blue / None

Cystoscopy

28

Universal cystoscopy

Detection of urinary tract injury 25.6% to 97.4% after universal cystoscopy*

Negative cystoscopy doers not guarantee lack of injury –partial obstruction**

Recommended when bladder or ureters may be injured****Ibeanu OA etal 2009

**Dandolu V etal 2003

***ACOG Committee Opinion 2007

Ureteral stenting

References1. ACOG Committee Opinion #372. The role of cystourethroscopy in the generalist obstetrician-

gynecologist practice. Obstet Gynecol. 2007;110:221–224.

2. Borin JF, Deane LA, Sala LG, et al. Comparison of healing after cystotomy and repair with fibrin glue and sutured closure in the porcine model. J Endourol. 2008;22:145–150

3. Cholkeri-Singh A, Narepalem N, Miller CE. Laparoscopic ureteral injury and repair: case reviews and clinical update. J Minim Invasive Gynecol. 2007;14: 356-361.

4. Cicco CD etal. Laparoscopic mangement of ureteral lesions in gynecology.Fertl Sterl 2009;92:1424-7

5. Chou MT, Wang CJ, Lien RC. Prophylactic ureteral catheterization in gynecologic surgery: a 12- year randomized trial in a community hospital. Int Urogynecol J Pelvic Floor Dysfunct. 2009;20(6):689-693.

6. Dandolu V, Mathai E, Chatwani A, et al. Accuracy of cystoscopy in the diagnosis of ureteral injury in benign gynecologic surgery. Int Urogynecol J Pelvic Floor Dysfunct.

7. Ibeanu OA, Chesson RR, Echols KT, Nieves M, Busangu F, Nolan TE. Urinary tract injury during hysterectomy based on universal cystoscopy. Obstet Gynecol. 2009;113(1):6-10

8. Kadar N, Lemmerling L. Urinary tract injuries during laparoscopically assisted hysterectomy: causes and prevention. Am J Obstet Gynecol. 1994;170:47–48

References

7. Rooney CM, Crawford AT, Vassallo BJ, et al. Is previous cesarean section a risk for incidental cystotomy at the time of hysterectomy? A case-controlled study. Am J Obstet Gynecol. 2005;193:2041–2044

8. Sokol AI, Paraiso MF, Cogan SL, et al. Prevention of vesicovaginal fistulas after laparoscopic hysterectomy with electrosurgical cystotomy in female mongrel dogs. Am J Obstet Gynecol. 2004;190:628–633.

9. Utrie JW Jr. Bladder and ureteral injury: prevention and management. Clin Obstet Gynecol. 1998;41(3):755‐763

10. Vakili B, Chesson RR, Kyle BL, et al. The incidence of urinary tract injury during hysterectomy: a prospective analysis based on universal cystoscopy. Am J Obstet Gynecol. 2005;192:1599–1604.

11. Wohlrab KJ , Sung VW, Rardin CR. Management of laparoscopic bladder injuries. JMIGS.2011;18:4‐8

29


Vascular Disasters: The Large Pelvic Vessels: How to Avoid at Entry & during Surgery, What to Do and Not to Do; Handling Vascular Injuries to Prevent Major Blood Loss & Death

Paul M Magtibay, MDMayo Clinic ArizonaNovember 14, 2016


I have no financial relationship to disclose.


Objectives

• Review pros of open technique versus closed laparoscopy

• Demonstrate the technique for open laparoscopy

• Identify important vascular anatomy of the pelvis

• Discuss management of vascular injuries

• Demonstrate some potential vascular catastrophes


How To Avoid Vascular Injury At Entry


Anatomy Clamente 3rd

edition


30

©2016 MFMER | slide-7 ©2016 MFMER | slide-8

Mayo DataLong 2008


Meta-analysisLarobina 2005

• 22,500 open versus 761,000 closed cases• Enterotomy rate same (0.049% versus 0.067%)• Vascular injuries

• 0% open versus 0.044% closed (p=0.003)• No fatal vascular injuries in open laparoscopy• Most litigation


Technique• Hasson Technique.mp4


What to Do and Not to Do


Vascular InjuryWhat to Do

• Direct pressure: sponge with suction

• Increase abdominal pressure: 20-25 mm Hg• Alert anesthesia, MTP, vascular surgery & tray

• If controlled, assess trocar placement• Clips (caution); suture with Lapra-Ty; bull dogs

or Satinsky; hemostatic agents

31


Vascular InjuryWhat to Do

• Low threshold to CONVERT to laparotomy• Keep pneumoperitoneum while opening• Exposure, pack, catch-up and calm down


Vascular InjuryWhat NOT to Do

• Panic

• Blindly cauterize or suture

• Use crushing clamps

• Slow to convert

• Not rehearse


Vascular InjuryWhat NOT to Do


References• Anatomy: A Regional Atlas of the Human Body. Clamente CD. 3rd

edition

• Long JB, Giles DL, Cornella JL et al: Open Laparoscopic Assessment Technique: Review of 2010 Patients. JSLS 2008; 12:372.

• Larobina M, Nottle P. Complete evidence regarding major vascular injuries during laparoscopic access. Surg Laparosc Endosc PercutanTech 2005; 15:119


32

Marcello Ceccaroni, M.D., Ph.D.

“Identification and preservation of pelvic somatic motor and sensory nerves in course of pelvic

surgery: how to prevent severe neural injuries”

Director, Department of Obstetrics & Gynecology,Gynecologic Oncology and

Minimally-Invasive Pelvic Surgery Sacred Heart Hospital – Negrar (Verona), Italy

International School of Surgical [email protected] www.issaschool.com

The author of this presentation declares to have no conflict of interest or financial

relationship to disclose

Objectives

Review the surgical anatomy of the somatic innervation of the female pelvis

Discuss operative technique to avoid damages to these structures during endometriosis surgery

Neurological complications

• NEUROABLATIVE DAMAGE (due to radicality)

• IATROGENIC DAMAGE (due to a mistake)

• TYPE OF DAMAGE: Visceral/Somatic/Mixed (due to the type of nerve), Functional/Anatomical

• Neurological complications can often be overlapped to pre-existing neurological dysfunctions related to disease and/or previous surgery

• Neuroablative and Iatrogenic damages can be associated

5

Vegetative visceral compartment

Somatic compartment

Inferior mesenteric plexus

Superior hypogastric plexus (SHP)

Hypogastric nerves (HN)

Ortosymphatetic lumbar chain

Pelvic splanchnic nerves

Inferior hypogastric plexus (IH) or pelvic plexus (PP)

Lumbar plexus

Sacral plexus

Lumbo-sacral trunk

Pudendal nerve

Obturator nerve

Genito-femoral nerve

Sciatic nerve

Femoral nerve

International School of Surgical Anatomy, 2009 International School of Surgical Anatomy, 2009

Nervous SystemNervous System Anatomical remarksAnatomical remarks Sacral PlexusNerve Segment Innervated muscles

Cutaneous branches

Superior gluteal L4-S1Gluteus mediusGluteus minimusTensor fasciae latae

Inferior gluteal L5-S2 Gluteus maximus

Posterior cutaneous femoral

S1-S3

Posterior cutaneous femoral • Inferior cluneal nerves• Perineal branches

Direct branches from plexus

• Piriformis S1-2 Piriformis

• Obturator internus

L5, S1-2Obturator internus and Superior gemellus

• Quadratus femoris

L4-5, S1Quadratus femoris and Inferior gemellus

Sciatic

Sciatic L4-S3

Semitendinosus (Tib)Semimembranosus (Tib)Biceps femoris• Long head (Tib)• Short head (Fib) Adductor magnus(medial part, Tib)

Common fibular L4-S2

Lateral sural cutaneousCommunicating fibular

• Superficial fibular

Peroneus longusPeroneus brevis

Medial dorsal cutaneousIntermediate dorsal cutaneous

• Deep fibular

Tibialis anteriorExtensor digitorum longusExtensor digitorum

Lateral cutaneous nerve of big toe

POSITION located on the border of piriformis muscle

33

7

Anatomical remarksAnatomical remarks

Somatic compartment

Lumbar plexus

Sacral plexus

Lumbo-sacral trunk

Pudendal nerve

Obturator nerve

Genito-femoral nerve

Sciatic nerve

Femoral nerve

Endometriosis and somatic nerves


• Endometriotic or fibrotic involvement of somatic nerves,sacral plexus and sacral roots are very common causes ofpelvic and ano-genital pain (39%)Nehme-Schuster et al., Lancet 2005; Possover et al., Fertil Steril 2007

• When endometriosis develops as parametrial diseaseextending to the pelvic wall, a frequent involvement ofsomatic nerves is found

•Possover et al., J Urol 2009, Ceccaroni et al., Surg Rad Anat 2010

• Often difficult differential diagnosis• Patients observed after years of disease’s progression without a

precise diagnosis• “Pilgrimage” between orthopaedics, neurosurgeons and

gynaecologists

•Often resistant pain, not healed by NSAIDs (FANS) or opioids

Robert et al., Eur Urol 2005; Possover et al., Min Invas Neurosurg 2007;

Ceccaroni, Clarizia et al., Surg Rad Anat 2010,

Ceccaroni, Clarizia et al., J Spin Disorders 2011,

Ceccaroni, Clarizia et al., Eur J Obst Gyn 2011

•Surgical decompression/neurolysis revealed to be effectivein pain relief, comparable to neuromodulation

DiagnosisDiagnosis

Endometriosis and somatic nervesEndometriosis and somatic nerves

Trans-perineal approach

Trans-gluteal approach

“Open” approach

Laparoscopic approach

Laparoscopic Neuro Navigation (LANN)

Sacral Neuromodulation



Surgical ApproachSurgical Approach

Ceccaroni M, Clarizia R, Cosma S, Pesci A, Pontrelli G, Minelli L.

Laparoscopic neurolisys for deep endometriosis infiltrating pelvic wall and somatic nerves: a retrospective study on 216 patients

Ceccaroni M. et al., WCE, San Paulo, May 2014

Laparoscopic neurolisys for deep endometriosis infiltrating pelvic wall and somatic nerves: a retrospective study on 216 patients

Ceccaroni M. et al., WCE, San Paulo, May 2014

EvidencesEvidences

ORIGIN Sacral plexus (S2‐S4)

TYPEmixed, sensitive and motor, somatic and visceral

COURSEGreat sciatic foramen, small sciatic foramen, Alcock canal, Perineum

FUNCTION

sensitive innervation to the perineum, external genitalia, anal region; motor innervation to the uro‐genital diaphragm muscles and clitoris; orgasm

LESIONSAlcock’s canal syndrome, ano‐genital pain, reduced sexual arousability/orgasm


PUDENDAL NERVE

34



Medial Approach

PARARECTAL AND

RETRORECTAL SPACES

LaparoscopicSurgical Approaches

LaparoscopicSurgical Approaches

Lateral approach

ILEOLUMBAR SPACE

Ceccaroni M., 2010 Ceccaroni M., 2011

(Right side-wall)

(Ceccaroni M, et al 2006)

(Ceccaroni M, et al. Surg Rad Anat, 2010)

(Right side-wall)

(Right side-wall)

(Possover M, et al. Minim Invas Neurosurg; Possover M, et al. FertilSteril 2007; Ceccaroni M, et al. Surg Rad Anat 2010;Ceccaroni M, et al, Eur J Ob & Gyn Reprod Biol.2010;Ceccaroni M, et al, J Spinal Disord Tech. 2010, in press; )

Laparoscopic Neurolysis of the Sacral Plexus and the Sciatic Nervefor extensive endometriosis of the pelvic wall


(Possover M, et al. Minim Invas Neurosurg; Possover M, et al. Fertil Steril 2007;Ceccaroni M, et al. Surg Rad Anat 2010; Ceccaroni M, et al, Eur J Ob &Gyn Reprod Biol.2010, Ceccaroni M, et al, J Spinal Disord Tech. 2010, in press;)

(Right side-wall)

(Leftt side-wall)


(Right side-wall)



(Possover M, et al. Minim Invas Neurosurg; Possover M, et al. Fertil Steril 2007;Ceccaroni M, et al. Surg Rad Anat 2010; Ceccaroni M, et al, Eur J Ob & Gyn ReprodBiol.2010, Ceccaroni M, et al, J Spinal Disord Tech. 2011)

www.issaschool.com




(Right side-wall)

17

ORIGIN L1‐L2 Roots

TYPE pure sensitive somatic

COURSEPsoas muscle genital branch inguinal canal femoral branch beneath inguinal ligament

FUNCTIONSsensitive innervation genital branch Mons Veneris, medial thighfemoral branch cranial and lateral thigh

LESIONS hypoaesthesiaCeccaroni M, Fanfani F, Ercoli A, Scambia G. Innervazione viscerale e somatica della

pelvi femminile. Testo-Atlante di anatomia chirurgica. CIC editore 2006.

GENITO-FEMORAL NERVE

Iatrogenic LesionsIatrogenic Lesions

Ceccaroni M., 2013

Obturator nerve repair after debulking surgery and neurolysis,by end end-to end anastomosis

Obturator nerve repair after debulking surgery and neurolysis,by end end-to end anastomosis

LESIONS Abductor hyposthenia; enlarged march

35

(Ceccaroni M, et al, 2006, 2009, 2010)

Iatrogenic lesions of visceral and somatic nerves: Sacral Plexus, Sacral roots, Pelvic Plexus and Pudendal nerve

Iatrogenic lesions of visceral and somatic nerves: Sacral Plexus, Sacral roots, Pelvic Plexus and Pudendal nerve

LESIONS

-Impaired flexo-extension of thigh/leg, sciatica, hypoaesthesia,-Chronic pain refractory to opioids-Impaired pelvic floor muscular functions/hypo-hyperthonus-Impaired bladder, rectal functions-Alcock’s canal syndrome, ano-genital pain, reduced sexual arousability/orgasm

ORIGIN Lumbo‐sacral plexus (L4‐S3)

TYPEmixed, sensitive and motor, somatic

COURSEgreat sciatic notch, buttock, thigh, leg, tibial/common peroneal

FUNCTIONS

sensitive innervation of buttock, thigh, leg, foot;motor innervation to the posterior thigh, leg and foot muscles.

LESIONSSciatica, hypoaesthesia, flexion defect of the leg


SCIATIC NERVE

21

ORIGIN Lumbar plexus, L2‐L4 roots

TYPEmixed somatic, sensitive and motor

COURSEPsoas dorsal margin; interior obturator muscle; obturator foramen

FUNCTIONSsensitive innervation medial thigh; motor innervation abtuctor muscles of the thigh

LESIONS Abductor hyposthenia; enlarged march

OBTURATOR NERVE


22

ORIGIN Lumbar plexus, L2‐L4 roots

TYPEmixed somatic, sensitive and motor

COURSEPsoas lateral margin; iinguinal ligament; Scarpa triangle; articular branches

FUNCTIONS

sensitive innervation anteromedial thigh; medial leg and footmotor innervation extension muscles of the knee (quadriceps femoralis), flexor muscles of the hip (pectineus, sartorius, iliacus)

LESIONS Leg extension deficit, knee flexor deficit


FEMORAL NERVE

Iatrogenic lesions of somatic nerves: Femoral nerve

Iatrogenic lesions of somatic nerves: Femoral nerve

LESIONS-Leg extension deficit,- Knee flexor deficit,- Impaired march

(Ceccaroni M et al, 2006)

www.issaschool.com

Laparoscopic surgical anatomy of Autonomic visceral pelvic nervesLaparoscopic surgical anatomy of Autonomic visceral pelvic nerves

36

(Ceccaroni M, et al, J Spinal Disord Tech. 2011;Ceccaroni M, et al, Eur J Ob & Gyn Reprod Biol.2010; Ceccaroni M, et al AJOG 2010;Ceccaroni M, et al, JMIG 2010;Ceccaroni M, et al, Surg Rad Anat 2010;Landi S, Ceccaroni M, et al, Hum Reprod 2006;Volpi E, et al, Surg Endosc 2004;Possover M, et al, Obstet Gynecol 2000)

Right Hypogastric nerve injury

Superior Hypogastric Plexus and Hypogastric nerves preservation

Iatrogenic and radicality-related lesions of visceral pelvic nervesIatrogenic and radicality-related lesions of visceral pelvic nerves

Laparoscopic rectal resection for DIE

(Classical Technique)

(Ceccaroni M, et al, J Spinal Disord Tech. 2011; Ceccaroni M, et al, Eur J Ob & Gyn Reprod Biol; Ceccaroni M. et al, JMIG 2010, Ceccaroni M. et al, Surg Rad Anat 2010; Ceccaroni M, et al, AJOG 2010; Landi S,Ceccaroni M, et al, Hum Reprod 2006)

(Ceccaroni M, et al, 2006)

Iatrogenic lesions ofvisceral nerves

Iatrogenic lesions ofvisceral nerves

The “dark side” of radical pelvic surgeryThe “dark side” of radical pelvic surgery

Unrecoverable neurologic damage,Sacral neuromodulation,

Psycho-social burden

Unrecoverable neurologic damage,Sacral neuromodulation,

Psycho-social burden

(Possover 2000, 2002, 2003, 2005, Volpi 2004, Darai 2005, Fanfani 2009, Landi 2006, Dubernard 2006, 2007, 2008, Deffieux 2007,

Ceccaroni , 2006, 2009, 2010, 2011, 2012, Roman , 2010, Kovoor, 2011)

Bladder Dysfunctions (0-20%)Ano-Rectal Dysfunctions (7-27%)

Sexual Dysfunctions (8-54%)

Bladder Dysfunctions (0-20%)Ano-Rectal Dysfunctions (7-27%)

Sexual Dysfunctions (8-54%)

ConclusionsConclusions

2) Anatomical knowledge is a key for a better know-how and for a safe endoscopic surgery, minimizing the risks of neurological complications

4) Laparoscopic approach is the less invasive and the more accurate and effective treatment offering p

7) Gynecologist is supposed to be the most indicated and expert specialist do diagnose/treat this condition and to offer the adequate care to these “orphan” patients

8) Considering that this kind of surgery requires uncommon surgical skills and anatomical knowledge, it should be performed only in selected reference centres

6) Involvement of somatic nerves in DIE is not an uncommon condition, undiagnosed or misdiagnosed in the majority of cases

5) Repair of some neurological damages is feasible by laparoscopy if promptly recognised

1) Neurological damage during laparoscopic pelvic surgery may lead to unrecoverable motoric/sensorial or functional impairment in young women treated also for benign conditions (i.e. DIE)

3) Nerve-Sparing procedures successfully treat the disease with an adequate radicality, offering good

Aknowledgements:Dr. R. Clarizia, Dr. G. Roviglione,

Dr. F. Bruni, Dr. M. Mabrouk,Dr. M. Lamanuzzi,Prof. L. Bovicelli

THANK YOU

37

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%

38

http://www.imq.org/

http://www.usdoj.gov/crt/cor/pubs.htm

http://www.usdoj.gov/crt/cor/13166.htm

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538

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