TION OF GYNECOLOGIC LAP

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1 NEWS SCOPE THE NEWSLETTER OF THE AMERICAN ASSOCIATION OF GYNECOLOGIC LAPAROSCOPISTS JANUARY - MARCH 2002 VOL. 7, NO. 1 Expanding our Horizons T David L. Olive, M.D. President, AAGL he 2002 version of the AAGL is that of a strong, vibrant organization. We have elevated our position within academic medicine, our international 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 AAGL has functioned like a speedboat 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 pertinent issues was indeed a breath of fresh air. The mechanism 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 members or ex-members. 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 horizons 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 leadership of the organization. By opening up the committee membership to more rank-and-file members, particularly those from traditionally underrepresented groups, we encourage the association to evolve more in concert with the times. It also allows those who may feel somewhat disenfranchised to take a more active role in shaping the future of the organization. For these reasons, I would like to strongly request our members to contact the AAGL office regarding committees on which they might like to be considered. This See Horizons page 3 Turn up the Heat T in Miami D. Alan Johns, M.D. Scientific Program Chair he 31 st 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 problems 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 cancer 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 CALL FOR PAPERS Now Available Online Deadline for Abstracts: April 7 th found? What is the stateof-the art in diagnosis and therapeutic options? Does HRT really help prevent heart disease? 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 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 considerable 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. A. Borghi A. Borghi

2 F Y I Why Bother? C L I N I C A L O P I N I O N O N Avoiding the Peripheral Neuropathy Trap I Franklin D. Loffer, M.D. Executive Vice President / Medical Director, AAGL 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 reasons to bother to submit a scientific paper to the AAGL annual meeting. 1 I know many of our members have accumulated a wealth of clinical material. Some have not recognized 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 clinical 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 AAGL does 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 AAGL has historically found many of its leaders. References: 1. Loffer FD. Why Bother? - the 1986 AAGL Presidential Address. J Rep Med 21: , 1987 C C. Paul Perry, M.D. 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 complaints 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 peripheral neuropathies as an etiology of CPP may avoid inappropriate surgery. Error in diagnosis and treatment may lead to unhelpful surgery and poor treatment results. Somatic pain generation can be from isolated trigger points or from the entire peripheral 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 exacerbated if the abdominal wall is tensed (head raise test) and may duplicate the patients complaint. 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 dorsal horn transmission cell sensitivity. Differential nerve blocks that provide complete relief, albeit temporary, are the sine qua non for establishing this diagnosis. General principles of treatment include alleviation of compression, rehabilitation and the use of medications 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 transversus 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 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 )] 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. Executive Director Linda Michels Marketing Coordinator/Graphic Design Clifford K. Chu Editorial Assistant Rebecca Shoudt POSTMASTER: Send address changes to News Scope at the following address: East Florence Avenue, Santa Fe Springs, CA USA Tel (562) , (800) , Fax (562) , publications@aagl.com Web Site: 2 January - March 2002 News Scope

3 NEUROPATHY TRAP continued from previous page and becomes cutaneous in the anterior abdominal wall approximately 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 sensory 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 variable distance above the inguinal ligament, the nerve divides into genital and femoral branches. The genital 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 retroperitoneum lateral to the iliac vessels. The nerve passes under the iliopubic 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 afferent neuropathy that manifests as CPP. The sacral motor neuropathy produces abnormal bladder and bowel function, but this will not be discussed here. Conclusion Peripheral neuropathies should be ruled out in all patients suffering from chronic pelvic pain. To learn more about these potential pitfalls, see resources available at 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 educate 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, Howard FM. Taking a history. In Pelvic Pain: Diagnosis and Treatment, Edited by FM Howard, CP Perry, JE Carter and AM El-Minawi. Philadelphia, Lippincott Williams & Wilkins, 2000, pp Rogers RM: Basic pelvic neuroanatomy. In Chronic Pelvic Pain: An Integrated Approach, Edited by JF Steege, DA Metzger, and BS Levy. Philadelphia, WB Saunders, 1998, pp M AAGL/SRS One Year Fellowships in Endoscopy Joseph S. Sanfilippo, M.D. 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 laparoscopic and hysteroscopic advanced training. A committee composed of representatives from both the AAGL and the American Society for Reproductive Medicine- Society of Reproductive Surgeons coordinates the program. Currently, 10 fellowship training programs are available, nationwide. They include: 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 For more information on the AAGL/SRS fellowship training programs please visit and click on the Resident s site. HORIZONS continued from page 1 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, committee 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 contribute 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. News Scope January - March

4 L E G A L I S S U E S Risk Management A PLAINTIFF S PREPARATION FOR A LAVH MALPRACTICE CLAIM Richard M. Soderstrom, M.D., F.A.C.O.G 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. I. Training Claim Defendant Smith failed to be adequately and properly trained and experienced 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) considered 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 proposed 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 important 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? See RISK MANAGEMENT page 7 4 January - March 2002 News Scope

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6 I N T E R N A T I O N A L N E W S Highlighting the The Japanese Society of Gynecologic and Obstetric Endoscopy (JSGOE) The Japanese Society of Gynecologic and Obstetric Endoscopy is the newest affiliated society of the AAGL. It roots date back to 1973 and it currently has 1,116 members. The AAGL has had many excellent contributors over the years from members of the Japanese Society. Their members have frequently presented at the annual meeting and published articles in the Journal of the AAGL. The 42 nd 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 Franklin D. Loffer, M.D., Executive Vice President/Medical Director NewsScope: When was the JSGOE established? 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 gynecologic 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 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 Society s journal at no charge. Participation in the annual meeting and training courses for endoscopic techniques, and presentation of research achievements during the meeting. N/S: What kinds of problems specific to physicians in Japan does your association address? JSGOE: How to elevate the technical skill of its members. How to avoid accidental malpractice in daily clinical work. For further information please contact JSGOE President, Kazuo Satoh, M.D., Professor, Research Institute of Medical Science, Nihon University, c/o Medical Supply Japan Ltd., Natsume Building, 4th Floor, Yushima Bunkyo-ku, Tokyo, Japan Tel , Fax , kazuosatoh@aol.com New Codes Go Before RBRVS in April Barbara S. Levy, M.D, Member, ACOG Nomenclature Committee W Vincent Lucente, M.D., AAGL Representative, ACOG Nomenclature Commitee e have been representing the AAGL for coding and nomenclature issues facing our society. The AAGL, working jointly with the ACOG, developed and brought new codes before the CPT editorial panel. They must now undergo a survey process for detemining the work RVUs in preparation for our presentation to the RBRVS update 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. Advanced Workshop on Unembalmed Female Cadavers The AAGL will be hosting a 2-day advanced workshop on gynecologic laparoscopic anatomy and surgery in Louisville, Kentucky on May 31 June 2, 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 AAGL is excited to be offering this popular course, which will be featuring new topics and faculty. Early registration is encouraged, as space is limited. To sign up for this course, please contact the AAGL office at (562) or (800) 554-AAGL. 6 January - March 2002 News Scope

7 RISK MANAGEMENT continued from page 4 - Did you discuss and/or present vaginal hysterectomy as an alternative to Jane? - What, if any, complications did you discuss with Jane concerning vaginal hysterectomies, abdominal 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 procedure 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 procedure? 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-insufflate 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 contents, 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? I M E M B E R N E W S In Rememberance of Joel M. Childers, M.D t is with sorrow that we announce the passing of Joel M. Childers, who died on February 14 th, several hours after a motorcycle 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 donations 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) ; or send donations to 2545 N. Woodland Road, Tucson, Arizona 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 facility 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? News Scope January - March

8 News Scope East Florence Avenue Santa Fe Springs, California Tel Fax Web site PERIODICALS POSTAGE PAID SANTA FE SPRINGS CA F U T U R E M E E T I N G S 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 AAGL 31 th 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 AAGL 32nd Annual Meeting November 19 22, 2003 (Registration begins evening November 18, 2003) Paris Las Vegas Las Vegas, Nevada

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