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
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”[email protected]
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.
15
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%
16