TION OF GYNECOLOGIC LAP

Heat

Miami

vibrant organization. We have elevated our posi-tion within academic medicine, our internaposi-tional reach has never been stronger, and our journal’s influence has reached an all-time high. Despite these association gains, however, certain glaring deficiencies remain apparent within our infrastructure. The chief shortcoming, and the one I wish to address in this column, is that of broad representation.

Traditionally, the AAGLhas functioned like a speed-boat surrounded by barges when maneuvering among the other Ob/Gyn organizations. While others made definitive policies and took concrete actions only slowly and irregularly, the AAGL’s rapid response time to per-tinent issues was indeed a breath of fresh air. The mech-anism by which this was accomplished, however, was via a concentration of relatively few decision-makers at the organizational pinnacle. Thus, not only was the Board of Trustees granted substantial authority, in addition most of the committees were composed of Board mem-bers or ex-memmem-bers. This structure allowed

for flexibility and rapid action items; the price, however, was a lack of diversity in viewpoint. Slowly, this has begun to change. Two international members now sit on the Board of Trustees, allowing greater representation from this previously underrepresented aspect of our membership. Yet much more needs to be done if we are truly to “open up” this organization.

An ideal venue for expanding our hori-zons lies in the committee structure.

Standing and ad-hoc committees can serve as nodes for initiating input into the organizational hierarchy. They also can serve as training grounds for the future leader-ship of the organization. By opening up the committee membership to more rank-and-file members, particu-larly those from traditionally underrepresented groups, we encourage the association to evolve more in concert with the times. It also allows those who may feel some-what disenfranchised to take a more active role in shap-ing the future of the organization.

For these reasons, I would like to strongly request our members to contact the AAGLoffice regarding com-mittees on which they might like to be considered. This

NEWS

SCOPE

JANUAR

Y - MARCH 2002 VOL. 7, NO. 1

THE NEWSLETTER OF THE AMERICAN ASSOCIA

TION OF GYNECOLOGIC LAP

AROSCOPISTS

D. Alan Johns, M.D. Scientific Program Chair

he 31st_{annual meeting will begin a new era in the} AAGL. Our organization is widely recognized for innovation in endoscopy, presenting new ideas every year. It is a dynamic and progressive society dedicated to the needs of gynecologists all over the world. This year (without abandoning our traditional feast of endoscopic material) we will expand our focus to topics outside the realm of laparoscopy and hysteroscopy, including prob-lems and situations we encounter every day in our offices.

After their successful minimally invasive surgical procedure, patients are very concerned about “hot button” topics such as breast can-cer and postmenopausal hormone replacement therapy. When and how should they be screened for breast cancer and osteoporosis? What should we do when an abnormality is found? What is the state-of-the art in diagnosis and therapeutic options? Does HRT really help prevent heart disease? Does estrogen cause breast cancer? What about sentinel nodes? These and many other questions will be answered.

Our panels and debates will be particularly timely and entertaining. “Don't Touch My Cyst!” and “Economic Survival” panels should provoke consider-able discussion. Once again, “live” cadaveric dissection and telesurgery round out what will be one of the most comprehensive programs ever presented.

Miami Beach, Florida is a particularly exciting venue for the meeting. If we fail, and you are bored, the worst that can happen is you go to a beautiful beach and relax. Either way, it will be

a few days well spent. I'm looking forward to seeing you in Miami. ■

T

T

President, AAGL

See Horizonspage 3

CALL FOR PAPERS

Now Available Online

You can now submit your abstracts or the AAGL’s 31st annual meeting via the internet. Its quick and simple. For more information, please visit www.aagl.com.

Expanding

our

Horizons

Turn up the

Heat

AAGL Statement of Vision

To develop and promote the safe, practical, and skilled application of endoscopic techniques in treating gynecologic conditions through the establishment of standards, education, research, and dialogue.

News Scope [Library of Congress Cataloging in Publication Data, Main entry under News Scope, Vol. 7, No. 1; (ISSN 1094–4672)] is published

quarterly by the American Association of Gynecologic Laparoscopists for five dollars, paid from member’s dues. Periodicals Postage Paid at Santa Fe Springs, California. Copyright © 2002 American Association of Gynecologic Laparoscopists.

POSTMASTER: Send address changes to News Scope at the following address: 13021 East Florence Avenue, Santa Fe Springs, CA 90670-4505 USA

Tel (562) 946-8774, (800) 554-2245, Fax (562) 946-0073, E-mail: publications@aagl.com Web Site: www.aagl.com

Executive Director Linda Michels

Marketing Coordinator/Graphic Design Clifford K. Chu

Editorial Assistant Rebecca Shoudt

January - March 2002 NewsScope 2

C L I N I C A L

O P I N I O N

O N

am frequently asked by members how they can be more active in the AAGL. I chose this title for my column for two reasons. First, it allows me to cite my 1986 Presidential Address, “Why Bother” - probably for the first time by anyone! Second and more importantly, it allows me to add to what Dr. Olive said in his President’s message. It is my suggested “roadmap” for being more involved with the AAGL.

The thesis of my 1986 presidential address was that there were several good rea-sons to “bother” to submit a scientific paper to the AAGLannual meeting.1_{I know many} of our members have accumulated a wealth of clinical material. Some have not recog-nized the value and some have not bothered to organize and share it with others.

One reason to bother is that physicians who take the time to document their clin-ical experience and areas of special interest and expertise will increase the enjoyment of their practice of medicine by developing an avocation within their vocation. Another reason is, in addition to basic research, that clinical observations and the reporting of individual series that help our specialty accumulate its core knowledge. I pointed this out in the address and would again emphasize that the AAGLdoes not require an academic position to participate. Many of our landmark presentations have come out of clinical practices. And, finally, it is out of those who contribute academically, that the AAGLhas historically found many of its leaders. ■

References:

1. Loffer FD. Why Bother? - the 1986 AAGL Pres-idential Address. J Rep Med

21:729-731, 1987

F Y I

Franklin D. Loffer, M.D. Executive Vice President / Medical Director, AAGL

Avoiding the

Peripheral Neuropathy Trap

I

hronic pelvic pain is usually assumed visceral in origin by patient and physician alike. It is not uncommon for patients with low lateral pain to present with the chief com-plaints of “my ovary hurts,” or “my endometriosis is back.” Often, however, it may be impossible to distinguish between visceral and somatic nerve pain generation without a meticulous history, physical exam and differential nerve blocks.1 _{An awareness of} periph-eral neuropathies as an etiology of CPP may avoid inappropriate surgery. Error in diag-nosis and treatment may lead to unhelpful surgery and poor treatment results.

Somatic pain generation can be from isolated “trigger points” or from the entire periph-eral nerve branch. Careful abdominal wall examination to look for “trigger points” should be routinely performed before bimanual examination. Trigger points will manifest as areas of discrete hyperalgesia. When palpated with fingertip pressure, they elicit sharp pain that can refer to distant dermatomes. Patients will often jump or their muscle twitches when a trigger point is palpated by single digit pressure (positive jump sign). The pain is exac-erbated if the abdominal wall is tensed (head raise test) and may duplicate the patients com-plaint.2

These isolated neuro-motor units, which produce trigger points, differ in presentation and etiology from peripheral neuropathy that can involve the total distribution of the involved peripheral nerve. There are five somatic nerves that often mimic visceral nerve stimulation. They include the iliohypogastric, the ilioinguinal, genitofemoral, lateral femoral cutaneous, and the pudendal nerves. Their pain perception overlaps visceral pain because of shared dorsal horn receptor cells in the spinal cord. They include dermatomes at the T12-L3 and S2-4. Except for the Iliohypogastric and pudendal nerves, these nerves are afferent (sensory) with no significant efferent (motor) component in females.3_Somatic neuropathic pain originating from these nerves can have multiple etiologies. Nerve injury has been reported from: 1) Stretching 2) Blunt trauma 3) Compression with hypoxia 4) Fibrosis with entrapment or 5) Suture ligature.1

The pain will often have a burning quality. Some patients will complain of shooting or lancinating pain. The pain will usually become constant and more intense with time. It is usually aggravated by activity. Menstruation may aggravate the pain due to peri-neural edema, hormone-induced increased neurotransmitters, and dysmenorrhea producing dor-sal horn transmission cell sensitivity. Differential nerve blocks that provide complete relief, albeit temporary, are the sine qua non for establishing this diagnosis. General prin-ciples of treatment include alleviation of compression, rehabilitation and the use of med-ications with demonstrated effectiveness for neuropathic analgesia.1

Iliohypogastric neuropathy

The iliohypogastric nerve (T12-L1) is the highest branch of somatic pelvic nerves and shares dorsal horn dermatomes with the ovary and distal tube. It passes through the psoas muscle, extending diagonally along the anterior surface of the quadratus lumborum. From there, it continues through the transversus abdominis, extending between the trans-versus and the internal oblique and continuing medially deep to the aponeurosis of the internal oblique at the level of the anterosuperior iliac crest. The nerve then divides into its anterior and lateral cutaneous branches. The anterior branch extends horizontally below the aponeurosis to the external oblique _{See NEUROPATHY TRAP page 3}

C

C. Paul Perry, M.D.

Why

Bother?

3 and becomes cutaneous in the anterior abdominal wall

approxi-mately 1 cm superior to the superficial inguinal ring and 2 cm medial to the anterosuperior iliac crest. This nerve serves as motor innervation to the transversus abdominis and the internal oblique muscles. Its sensory distribution is the groin and the symphysis pubis region. This distribution is overlapping with the ilioinguinal and genitofemoral nerves.3

Ilioinguinal Neuropathy

The ilioinguinal nerve (L1-2) shares dorsal horn transmission cells with the proximal fallopian tubes and uterine fundus. It enters the inguinal canal about 2 cm medial to the anterior superior iliac spine and then courses just beneath the anterior leaf of the inguinal canal. Here it exits out the superficial inguinal ring or pierces at the ring to become a sensory nerve to the overlying skin. It supplies sen-sory innervation to the groin, mons, labia, and inner thigh.

Genitofemoral Neuropathy

The genitofemoral nerve (L1-2) shares dorsal horn transmission cells with the proximal fallopian tube and uterine fundus. It runs through the substance of the psoas muscle and emerges near its medial border opposite the third and fourth lumbar vertebrae. It descends retroperitoneally and crosses behind the ureter. At a vari-able distance above the inguinal ligament, the nerve divides into gen-ital and femoral branches. The gengen-ital branch crosses the lower end of the external iliac artery and enters the inguinal canal through the deep inguinal ring together with the round ligament. The femoral branch descends lateral to the external iliac artery, behind the inguinal ligament, and through the fascia lata into the femoral sheath. The genital branch supplies the skin of the mons pubis and labium majus. The femoral branch supplies the skin of the femoral triangle.

Lateral Femoral Cutaneous Neuropathy

The lateral femoral cutaneous nerve (L2-3) shares dorsal horn transmission cells with the uterine fundus and lower uterine segment. It runs inferolaterally on the iliacus muscle. It traverses the retroperi-toneum lateral to the iliac vessels. The nerve passes under the iliop-ubic tract and inguinal ligament. It may pass behind or through the ligament making this area vulnerable to compression injury.

Pudendal Neuropathy

The pudendal nerve (S2-4) shares the dorsal horn transmission cells with the cervix, uterosacral, and vulvovaginal areas. The pudendal nerve is a mixed sensory and motor nerve. The efferent (motor) neuropathic symptoms will usually accompany the affer-ent neuropathy that manifests as CPP. The sacral motor neuropa-thy produces abnormal bladder and bowel function, but this will not be discussed here.

Conclusion

Peripheral neuropathies should be ruled out in all patients suf-fering from chronic pelvic pain. To learn more about these poten-tial pitfalls, see resources available at www.pelvicpain.org. The International Pelvic Pain Society is a sister organization of the AAGL. Our goals are to educate health care professionals on the proper diagnosis and treatment of chronic pelvic pain and to edu-cate the public on how to receive help for their suffering. ■

References:

1. Perry CP: Peripheral neuropathies causing chronic pelvic pain. J Am Assoc Gynecol Laparosc 7(2):281–87, 2000

2. Howard FM. Taking a history. In Pelvic Pain: Diagnosis and Treatment, Edit-ed by FM Howard, CP Perry, JE Carter and AM El-Minawi. Philadelphia, Lippincott Williams & Wilkins, 2000, pp26–42

3. Rogers RM: Basic pelvic neuroanatomy. In Chronic Pelvic Pain: An Inte-grated Approach, Edited by JF Steege, DA Metzger, and BS Levy. Philadel-phia, WB Saunders, 1998, pp 31–58

inimally Invasive Surgery reached one more milestone with the development of training programs following completion of an Ob/Gyn residency. Each fellowship program is a one-year focused educational experience in both laparo-scopic and hysterolaparo-scopic advanced training.

A committee composed of representatives from both the AAGLand the American Society for Reproductive Medicine-Society of Reproductive Surgeons coordinates the program. Currently, 10 fellowship training programs are available, nation-wide. They include:

For more information on the AAGL/SRSfellowship training pro-grams please visit www.aagl.com and click on the Resident’s site.

AAGL/SRS One Year Fellowships in Endoscopy

is particularly true for female members, fellows, and residents, each of whom is traditionally underrepresented on committees and within the leadership. For those who respond rapidly, com-mittee positions are still available for 2002, and for those who wish to be more contemplative, the 2003 committees await. Please let us know how you would like to be involved. Your addition will con-tribute mightily to the growth and success of the future AAGL.

Standing Committees Ad Hoc Committees

AGLOR Affiliated Society

Bylaws Annual Scientific Program

CME Coding

Editorial Ethics

Finance Fellowship

International Advisory Industrial Relations

Membership Long Range Planning

National Advisory Membership Recruitment

Nominating Practice Web Site

Please send your letter of interest to generalmail@aagl.com. ■ Joseph S. Sanfilippo, M.D.

HORIZONScontinued from page 1

NEUROPATHY TRAP continued from previous page

M

Andrew I. Brill. M.D.,University of Illinois, Chicago, Illinois

Grace M. Janik, M.D., Charles H.Koh, M.D.,

Reproductive Specialty Center, Milwaukee, Wisconsin

C.Y.Liu, M.D.,Chattanooga Women’s Laser Center Chattanooga, Tennessee

Eberhard C. Lotze, M.D.,The Women’s Hospital of Texas Houston,Texas

Thomas L. Lyons, M.D.,Center for Women’s Care & Reproductive Surgery, Atlanta, Georgia

Michael L. Moore, M.D.,Advanced Women’s Health Institute, Denver, Colorado

Camran R. Nezhat, M.D., Stanford Endoscopy Center for Training and Endoscopy, Palo Alto, California

James Ross, M.D., Ph.D.,Salinas, CA

Joseph S. Sanfilippo, M.D.,University of Pittsburgh Pittsburgh, Pennsylvania

Jaime M.Vasquez, M.D.,Center for Reproductive Health, Nashville, Tennessee

4 January - March 2002 NewsScope I. Training

Claim

Defendant Smith failed to be adequately and properly trained and expe-rienced in the surgical procedure he performed on the plaintiff, known as the LAVH.

QUESTIONS:

- Describe your medical training?

- Are you certified by the American Board of Obstetrics and Gynecology?

- How many times did you take the exam? - When/where/how were you trained in LAVH?

- What, if any, instructional courses have you attended re: LAVH? - During your training did you ever work with animal models? - When did you perform your first LAVH?

- How many surgeries have you performed laparoscopically? - How many hysterectomies have you performed laparoscopically? - Of all the hysterectomies you have done in a given year, how many

were done laparoscopically?

- Do you agree that laparascopic hysterectomies “may be associated with serious complications and therefore need specific expertise?” - Is it recognized in your dept. of Ob/Gyn that “the learning phase

should be closely monitored by an experienced laparoscopist?” - What, if any, formal credentialing process was required by the

hospital before you could perform an LAVH?

- What, if any, experience do you have with operative laparoscopy (besides or other than LAVH)?

- How many total LAVH procedures have you performed? Solo? With more experienced laparoscopists?

- Do you have a judgement as to how many LAVH procedures you have performed that have been converted to a total abdominal hysterectomy?

- During the laparoscopic part of the surgery or during the vaginal part of the procedure?

- What was the reason for the conversion to total abdominal hysterectomy?

-In other words, how many LAVH procedures were converted to laparotomy due to poor access and how many were converted due to intraoperative complications?

- Can you agree that LAVH is a controversial procedure with concerns about inadequate training and improper credentialing of surgeons who perform LAVH?

II. Evaluation

Claim

Defendant:

1. Failed to properly screen the Plaintiff as an unsuitable candidate for LAVH

2. Failed to recognize that LAVH was contraindicated

3. Failed to adequately and properly inform and advise the Plaintiff of the risks and benefits known and associated with LAVH

QUESTIONS:

- Why was hysterectomy medically necessary?

- What was the diagnosis that prompted hysterectomy? - What were the indications for hysterectomy?

- How many vaginal hysterectomies did you perform in 1997? In 1996?

- How many abdominal hysterectomies did you perform in 1997? In1996?

- Do you have a judgement as to the complication rate for abdominal hysterectomies you have performed?

- Do you have a judgement as to the complication rate for vaginal hysterectomies you have performed?

- Do you have a judgement as to the complication rate for the LAVH procedures you have performed?

- What complications have occurred during the LAVH procedures you have performed?

- What is your understanding as to the complication rate generally for abdominal hysterectomies, vaginal hysterectomies and LAVHs? - What are the indications for laparoscopically assisted vaginal

hysterectomy?

- What were the indications in Jane’s case for LAVH? - Was Jane a candidate for VH in your judgement?

- Do you agree that the records don’t reflect whether a VH was 1)

con-sidered and 2) nor was any basis for not choosing VH?

- Prior to surgery, what was your judgement concerning the size of Jane’s

uterus?

- After surgery, what was your judgement of the size of Jane’s uterus?

- Did Jane have any of these conditions: 1) Large uterus 2) Difficult vaginal approach 3) Past history of pelvic surgery 4) Symptoms of ill-defined pelvic pain 5) The need for ovarian surgery

- Do you agree that because of its low morbidity, when possible, VH should be the procedure of choice?

- Do you agree that LAVH should be used to reduce the number of abdominal hysterectomies not the number of vaginal hysterectomies? - Do you agree with this statement? "Laparoscopic surgery is not an

alternative to vaginal surgery when the latter can be carried out under good conditions. Laparoscopic surgery should only be pro-posed as a means of making a difficult vaginal hysterectomy easier and/or to avoid laparotomy for the patient."

- Do you agree with this statement? “The selection of patients is impor-tant and patients should be aware of the risks involved.”

Informed Consent

- Tell EVERYTHING you told Jane prior to the surgery about the LAVH

- Did you discuss with Jane VH and/or AH?

Risk Management

L E G A L

I S S U E S

This is the second in a two-part series examining risk management and what to do when faced with a lawsuit. The first part of this series summarized the background and outcome of an actual lawsuit brought against a surgeon. The second part to this article, featured below, are the actual questions as prepared by the plaintiff ’s attorney. It displays how thorough many plaintiff ’s attorney’s can be when investigating a laparoscopic lawsuit. Many of the questions were prompted by the literature review. Should the reader have or know of a similar claim filed, the plaintiff ’s preparation and questions should be a valuable guide for one’s preparation.

A PLAINTIFF’S PREPARATION FOR A LAVH MALPRACTICE CLAIM

6 January - March 2002 NewsScope

The Japanese Society of Gynecologic and Obstetric Endoscopy is the newest affili-ated society of the AAGL. It roots date back to 1973 and it currently has 1,116 mem-bers. The AAGLhas had many excellent contributors over the years from members of the Japanese Society. Their members have frequently presented at the annual meet-ing and published articles in the Journal of the AAGL. The 42nd_{meeting of the}

Japanese Society will be held August 1–2, 2002 in Tokyo, Japan, with Professor M. Takayama as the meeting’s president. Further information can be obtained by visiting www.aagl.com.

—Franklin D. Loffer, M.D., Executive Vice President/Medical Director

NewsScope: When was the JSGOEestablished?

JSGOE: The Japanese Society of Gynecologic and Obstetric endoscopy was

established in 1984 after the society had started in 1973 as a research group of endoscopy, which was founded by scientists with the same interests in research and clinical application of endoscopy. The head of this group was Professor O. Sugimoto.

N/S: What is its mission statement?

JSGOE: The purpose of the Society is the development of research in

gyne-cologic and obstetric endoscopy, and the activiation of its clinical application.

N/S: Approximately how many members are there?

JSGOE: As of March 4, 2002, there are 1,116 members.

N/S: What are some of the benefits of membership?

JSGOE: Subscription to the

Society’s journal at no charge. Participation in the annual meeting and train-ing courses for endoscopic techniques, and presenta-tion of research achieve-ments during the meeting.

N/S: What kinds of

prob-lems specific to physicians in Japan does your associ-ation address?

JSGOE: How to elevate the technical skill of its members. How to avoid

acci-dental malpractice in daily clinical work. ■

For further information please contact JSGOEPresident, Kazuo Satoh, M.D., Professor, Research Institute of Medical Science, Nihon University, c/o Medical Supply Japan Ltd., Natsume Building, 4th Floor, Yushima 2-18-6 Bunkyo-ku, Tokyo, Japan 113-0034. Tel. 81-3-3818-2177, Fax. 81-3-3815-2644, E-mail: kazuosatoh@aol.com

Highlighting the

The Japanese Society of Gynecologic

and Obstetric Endoscopy (JSGOE)

I N T E R N A T I O N A L

N E W S

The Japanese Society of Gynecologic and Obstetric Endoscopy

Founded: 1984

No. of members: 1,116

President: Kazuo Satoh, M.D.

Treasurer: Kenichi Seki, M.D.

Secretary General: Toshio Matsuzaki, M.D

e have been representing the AAGLfor coding and nomenclature issues facing our society. The AAGL, working jointly with the ACOG, developed and brought new codes before the CPTeditorial panel. They must now undergo a survey process for detemining the work RVUs in preparation for our presentation to the RBRVSupdate committee in April. The survey is designed to assess the physician work associated with these six new and revised CPT codes. Findings from the survey will be used to assure that physicians are paid correctly for their services. The codes are:

• Laparoscopy, surgical, myomectomy, excision, fibroid tumor(s) of uterus; 1-4 intramural myomas with total weight of 250 grams or less and/or removal of surface myomas

• Laparoscopy, surgical, myomectomy, excision, fibroid tumor(s) of uterus; 5 or more intramural myomas and/or intramural myomas with total weight of greater than 250 grams

• Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 grams or less

• Laparoscopy, surgical, with vaginal hysterectomy, for uterus 250 grams or less; with removal of tube(s) and/or ovary(s)

• Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 grams

• Laparoscopy, surgical, with vaginal hysterectomy, for uterus greater than 250 grams; with removal of tube(s) and/or ovary(s)

Please take the time to complete these surveys if you receive them. Without your participation we cannot lobby for appropriate work values. ■

New Codes

Go Before RBRVS

in April

The AAGLwill be hosting a 2-day advanced workshop on gynecologic laparoscopic anatomy and surgery in Louisville, Kentucky on May 31–June 2, 2002. Unembalmed female cadavers will be used for the training of advanced procedures and laparoscopic techniques. Tommaso Falcone, M.D. from the Cleveland Clinic Foundation is the workshop’s Scientific Program Chair, and Ronald L. Levine, M.D., from the University of Louisville is the Co-chair.

The AAGLis excited to be offering this popular course, which will be featuring new topics and faculty. Early registration is encour-aged, as space is limited. To sign up for this course, please contact the AAGLoffice at (562) 946-8774 or (800) 554-AAGL.

Vincent Lucente, M.D., AAGL Representative, ACOG Nomenclature Commitee

Advanced Workshop on Unembalmed Female Cadavers

7 - Did you discuss and/or present vaginal hysterectomy as an

alterna-tive to Jane?

- What, if any, complications did you discuss with Jane concerning vagi-nal hysterectomies, abdomivagi-nal hysterectomies and LAVHs? - In discussing these procedures with Jane Brown, did you discuss with

her any complication rates for the various procedures?

- Did you take these steps prior to the procedure as recommended by ACOG: 1) Counseling of patient regarding the benefits of proce-dure versus the potential increased hazard of two separate operative procedures each with its own associated risks. 2) Document normal cervical cytology. 3) Evaluate abnormal uterine bleeding if indicated 4) Rule out pregnancy 5) Administer prophylactic antibiotics if indicated

III. Operative Procedure

Claim

Defendant:

1. Failed to adequately and properly perform a LAVH

2. Failed to use adequate and proper methods to avoid and/or present vessel laceration while performing a LAVH

QUESTIONS:

- Was the procedure videotaped? - Are any of your LAVHs videotaped?

- Describe the instruments used:trocar, manufacturer, type, size, shield ing? (or “self-guarding”), present location

- Do you claim that any defect in trocar led to the injuries suffered by Jane? - Did the instrument have a plastic safety sheath that was to jump out

instantaneously upon perforation of the abdominal wall? - Did the safety sheath jump out in this instance?

- Can we agree that there is tremendous variability among surgeons as to how much the operation is performed laparoscopically? - How much of the operation did you intend to perform laparoscopically? - How much of the operation did you actually perform laparoscopically? - Based on anesthesia record, anesthesia began at 8:10. Do you have judgement/documentation as to what time you started the proce-dure? Do you have judgement/documentation as to what time per foration occurred?

- Describe step-by-step the operative procedure you performed on Jane. Regarding Jane’s anatomy, was anything unusual? Do you claim that unusual anatomy led to injuries suffered by Jane?

- What method did you use of entering the cavity for introduction of the laparoscope?

- Before introducing the first entry trocar/cannula did you pre-insuf-flate the cavity with carbon dioxide with a Veress needle (or did you use a direct entry approach)?

- At what angle did you insert the trocar? Did you stay in the midline plane?

- Were you able to control the trocar’s descent

- Do you agree that it is vitally important that the abdomen be fully distended to provide the greatest clearance between the anterior abdominal wall peritoneal surface and both intra-abdominal con-tents, and most especially the posterior wall peritoneum and the great retroperitoneal blood vessels?

- What, if anything, was done to elevate or stabilize the abdominal wall? - What was the position of the patient/table during the initial trocar

insertion? Was Jane initially placed in (steep or moderate) Trendelenburg position with both legs supported in stirrups? - Was that position changed before you detected a problem? - After penetration, were Jane’s lower extremities discolored/pale? - What is your estimate of total blood loss? Is it documented?

- Was blood transfused? How many units?

- When did you first realize/appreciate that there was bleeding, i.e., what were signs of bleeding?

- From the size and shape of the external iliac defect, was it apparent that the wound was made with the trocar (or needle if one was used)? - How long was Jane “hemodynamically unstable?”

- Were vascular instruments available in OR?

IV. After Care

Claim

The LAVH should not be performed at Safe Haven Hospital. The facil-ity lacks the expertise and back up to safely and properly perform this procedure.

QUESTIONS:

- Did you call for assistance? When? At what point?

- Was a vascular surgeon available/on call at Safe Haven Hospital? - Why did you proceed with a hysterectomy and appendectomy? - Going into this surgery, what was your protocol, if any, to deal with

a major vascular injury?

V. Relationship with Hospital

A.) Contract

- Hired by whom? When? After what process? - Started?

- Present Relationship B.) Credentialing

-What, if any, formal credentialing process was required by Safe Haven Hospital before you could perform an LAVH? ■ t is with sorrow that we announce the passing of Joel M. Childers, who died on February 14th_{, several hours after a} motor-cycle accident. Dr. Childers was a long standing, well-respected member of the AAGL; he will be dearly missed.

Dr. Childers was affiliated with the Arizona Oncology Associates, Tuscon, Arizona. During his career he helped develop the use of laparoscopy in treating ovarian cancer, and was one of the first doctors in the United States to use this technology for that purpose.

Throughout his time with the AAGL, Dr. Childers was an active participant. He was a member of the National Advisory Committee, and an ad hoc reviewer for the Journal of the AAGL. In addition to this, he served as faculty for PG Courses on cancer, held during the annual meeting, and had participated as a faculty member in the panels and debates as well.

Dr. Childers is survived by his wife, Becky, and children Mick, 12; and Carly, 17. Arizona Oncology Associates is accepting dona-tions to go toward a building in Childers' name at the Sunstone Cancer Support Foundation. For more information on the project, call the foundation at (520) 794-1928; or send donations to 2545 N. Woodland Road, Tucson, Arizona 85749.

In Rememberance

o f

Joel M. Childers, M.D

RISK MANAGEMENT continued from page 4

I

F U T U R E

M E E T I N G S

PERIODICALS POSTAGE PAID SANTA FE SPRINGS CA

News

Scope

13021 East Florence Avenue

Santa Fe Springs, California 90670-4505

Tel562.946.8774 Fax562.946.9204

E-mailpublications@aagl.com

Web sitewww.aagl.com

Advanced Workshop on Gynecologic Laparoscopic Anatomy & Surgery Using

Unembalmed Female Cadavers

May 31–June 1, 2002 University of Louisville

Louisville, Kentucky

Pre-Congress Workshop on Advanced Gynecologic Anatomy on Unembalmed Female Cadavers

In affiliation with IMET

November 18–19, 2002 Miami Beach, Florida

Global Congress of Gynecologic Endoscopy

AAGL31th _{Annual Meeting}

November 20–24, 2002

(Registration begins evening November 19, 2002) Fontainebleau Hilton & Towers

Miami Beach, Florida

Strategies & Techniques for Advanced Laparoscopy and Hysteroscopy

Including live telesurgeries

Supported by an unrestricted educational grant from Gynecare, Inc., a division of Ethicon, Inc.

December 13–14, 2002 Endo-Surgery Institute

Cincinnati, Ohio

Workshop on Taking Your Laparoscopic Skills to the Next Level

February 2003 Arizona State University

Phoenix, Arizona

Global Congress of Gynecologic Endoscopy

AAGL32nd Annual Meeting

November 19–22, 2003

(Registration begins evening November 18, 2003) Paris Las Vegas