SYLLABUS - AAGLDepartment of Obstetrics & Gynecology Royal Columbian Hospital November 12, 2019...

Be a Surgical “Multiplier” in MIGS Inspire Brilliance Through Teamwork

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Scientific Program ChairJubilee Brown, MD

Honorary ChairBarbara S. Levy, MD

PresidentMarie Fidela R. Paraiso, MD

SYLLABUSSURGICAL TUTORIAL 3:

TLH-Everyone Is Doing It, But We Make It Look Good!!

Professional Education Information

Target Audience This educational activity is developed to meet the needs of surgical gynecologists in practice and in training, as well as other healthcare professionals in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 1.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Disclosure of Relevant Financial Relationships As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME. Anti-Harassment Statement AAGL encourages its members to interact with each other for the purposes of professional development and scholarly interchange so that all members may learn, network, and enjoy the company of colleagues in a professional atmosphere. Consequently, it is the policy of the AAGL to provide an environment free from all forms of discrimination, harassment, and retaliation to its members and guests at all regional educational meetings or courses, the annual global congress (i.e. annual meeting), and AAGL-hosted social events (AAGL sponsored activities). Every individual associated with the AAGL has a duty to maintain this environment free of harassment and intimidation. AAGL encourages reporting all perceived incidents of harassment, discrimination, or retaliation. Any individual covered by this policy who believes that he or she has been subjected to such an inappropriate incident has two (2) options for reporting:

1. By toll free phone to AAGL’s confidential 3rd party hotline: (833) 995-AAGL (2245) during the AAGL Annual or Regional Meetings.

2. By email or phone to: The Executive Director, Linda Michels, at [email protected] or (714) 503-6200.

All persons who witness potential harassment, discrimination, or other harmful behavior during AAGL sponsored activities may report the incident and be proactive in helping to mitigate or avoid that harm and to alert appropriate authorities if someone is in imminent physical danger. For more information or to view the policy please go to: https://www.aagl.org/wp-content/uploads/2018/02/AAGL-Anti-Harassment-Policy.pdf

https://www.aagl.org/wp-content/uploads/2018/02/AAGL-Anti-Harassment-Policy.pdf

Table of Contents Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 2 Optimizing Ergonomics in the Operating Room M. Wesa ........................................................................................................................................................ 3 Total Laparoscopic Hysterectomy-Surgical Steps for a Safe and Successful Outcome R.T. O'Shea .................................................................................................................................................... 8 Simplifying the Difficult Hysterectomy S.M. Mansuria ............................................................................................................................................. 16 Training Our Trainers for TLH D. I. Eisenstein ......................................................................................................................................... UNA Cultural and Linguistics Competency .......................................................................................................... 22

Surgical Tutorial 3: TLH-Everyone Is Doing It, But We Make It Look Good!!

Chair: Suketu M. Mansuria Faculty: David I. Eisenstein, Robert T. O'Shea, Mina Wesa

Course Description This course is designed to provide the attendee with a systematic and comprehensive overview of laparoscopic hysterectomy from leading experts in the field. We will focus on practical skills that will help surgeons become safer and more efficient. In addition, we will discuss surgical strategies to tackle more difficult cases (e.g., scarred bladder flaps, obliterated posterior cul-de-sac, etc.) without conversion. The course will emphasize education through the heavy use of surgical videos to enhance the applicability of the techniques taught and will show real world utilization of these methods. Attendees will bridge the gap that separates novice from expert surgeons through a thoughtful overview of correct surgical technique, retroperitoneal anatomy, complication avoidance and management, appropriate OR set up, and proper ergonomics. There will also be a focus on reviewing the methodology of how to train others and teach TLH. Any surgeon wishing to refine their techniques should not miss this course!

Course Objectives At the conclusion of this activity, the participant will be able to: 1) Describe proper OR set up for laparoscopy and explain best practice to improve operating room ergonomics; 2) develop the proficiency to utilize retroperitoneal anatomy and identification of the uterine artery from its origin to complete difficult cases and minimize conversion to laparotomy; 3) employ time-tested tips and tricks to improve surgical efficiency and patient outcomes; and 4) review techniques on how to train others in TLH.

Course Outline

11:00 Welcome, Introductions, and Course Overview S.M. Mansuria11:05 Optimizing Ergonomics in the Operating Room M. Wesa11:25 Total Laparoscopic Hysterectomy-Surgical Steps for a Safe and

Successful Outcome R.T. O'Shea

11:45 Simplifying the Difficult Hysterectomy S.M. Mansuria12:05 Training Our Trainers for TLH D. I. Eisenstein12:25 Questions & Answers All Faculty12:45 Adjourn

Page 1

PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop (listed in alphabetical order by last name). Art Arellano, Professional Education Director, AAGL* Linda D. Bradley, Medical Director, AAGL* Erin T. Carey Consultant: MedIQ Mark W. Dassel Contracted Research: Myovant Sciences Erica Dun* Adi Katz* Linda Michels, Executive Director, AAGL* Erinn M. Myers Speakers Bureau: Laborie Medical Technologies, Teleflex Medical Other: Unrestricted educational grant to support NC FPMRS Fellow Cadaver Lab: Boston Scientific Corp. Inc. Amy Park* Grace Phan, Professional Education Specialist, AAGL* Harold Y. Wu* Linda C. Yang Other: Ownership Interest: KLAAS LLC Suketu M. Mansuria Speakers Bureau: Medtronic, Olympus SCIENTIFIC PROGRAM COMMITTEE Linda D. Bradley, Medical Director, AAGL* Jubilee Brown* Nichole Mahnert* Shanti Indira Mohling* Fariba Mohtashami Consultant: Hologic Marie Fidela R. Paraiso* Shailesh P. Puntambekar* Matthew T. Siedhoff Consultant: Applied Medical, Caldera Medical, CooperSurgical, Olympus Amanda C. Yunker Consultant: Olympus Linda Michels, Executive Director, AAGL*

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). Suketu M. Mansuria Speakers Bureau: Medtronic, Olympus David I. Eisenstein Consultant: Accesa Health Speakers Bureau: AbbVie Robert T. O'Shea* Mina Wesa* Content Reviewer has nothing to disclose. Asterisk (*) denotes no financial relationships to disclose.

Page 2

Optimizing the OR Environment: Ergonomics and Team Collaboration

Dr. Mina Wesa, MD, FRCS(C) Department of Obstetrics & Gynecology

Royal Columbian Hospital

November 12, 2019

Disclosure(s)

• I have no financial relationships to disclose

Objective

Improve safety and efficiency in the MIS OR by:

• Optimal room set‐up

• Surgeon stance, patient positioning

• Team based approach

• Surgeon preparation

“In all things success depends on previous preparation, and without such previous preparation there is sure to be failure.”

‐ Confucius

Optimal Room Set Up

• Get to room early!

• Ensure critical equipment present, working

• Optimize set‐up for best surgeon ergonomics

• Set up recording

• Help position patient

Audience Response:

After a long day in the OR doing laparoscopic cases, what hurts the most?

A: Neck / shoulders

B: Arms / hands

C: Lower back

D: Legs / feet

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Optimal Table Height

• Goal is to minimize strain and fatigue

• Instrument handles at elbow level to minimize upper arm and shoulder work

• Adjust bed, utilize steps to attain desired height

21 surgeons, 2‐handed circle‐cutting task at varying instrument heights

• Measured surgeon discomfort, task difficulty

• EMG readings at deltoid, trapezius

An ergonomic study of the optimum operating table height for laparoscopic surgeryR. Berquer, W.D. Smith, S. DavisSurg Endosc 2002









Video Screens

Three Monitors…

Video ScreensRecommendations:• Monitor straight ahead

• In line with the forearm – instrument motor axis

• Avoid axial rotation of spine

• Positioned lower than eye level to avoid neck extension

– Optimal angle is 15 degrees downward

Optimal ergonomics for laparoscopic surgery in minimally invasive surgery suites: a review and guidelinesM.J. van Det et alSurgical Endoscopy, June 2009, Vol 23, Issue 6, pp1279‐1285

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Surgeon Stance

• Feet flat– Rubber pads to stand on, one

foot up on step stool

• Hips level– Avoid tilting / leaning

• Shoulders down and relaxed

• Arms by sides, elbows 90 degrees

• Spine straight ahead, facing monitor

• Neck neutral, not pushed forward

• Gaze slightly down

Patient Positioning

Anti‐skid devices

• Pads, foam, bean bag

• Prevent patient slipping during steep T‐berg

• Avoid shoulder braces or chest wall strapping

Patient Positioning

• Neurologically neutral low lithotomy

• Candy canes: little support, allow uncontrolled hip abduction and rotation

• Boot stirrups: adjustable, minimize pressure on lateral and posterior calf– Yellofin® stirrups

Optimal Patient Positioning

• Neutral, padded positioning

• Knee, umbilicus, contralateral shoulder in line

Patient Positioning

Tucking arms military style with padding

• Sleighs, toboggans, sheet tuck

• Provides unrestricted mobility for surgeon

– Prevents surgeon from “sitting” on patient’s arm

• Prevents arm from being dislodged from arm board

• Avoids ulnar nerve injury, protects hand

1. 2.

3. 4.

Teamwork

Audience Response:

Do you have a dedicated OR team for your procedures:

A: Yes (core group of staff)

B: No (different people depending on the day)

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Teamwork

• Learn from aviation, crew resource management

• Highly functioning team is key to patient safety– Decreased surgical errors (e.g. wrong site surgery), SSI

– Efficiency– Specific to certain procedures, techniques

Teamwork

• What to do if you don’t have a team?– Seek out interested nurses, staff

– Provide training, in‐services

– Discuss with administration – safety and efficiency data!

• Other ways to optimize team– Simulation

– Enhance communication• Update preference cards, alert to specific case needs

• Time outs / debriefs

• Safety checklists

Surgeon Preparation

Audience Response:

What, if any, personal preparation do you do before a case?

A: None (does coffee count?)

B: Review patient history

C: Discuss the case with colleagues

D: Review videos

E: Mental imagery exercise

Surgeon Preparation

• Mental Imagery: “the symbolic rehearsal of a physical activity in the absence of any gross muscular movements”

• Produces cognitive blue prints for movement patterns

• Mental rehearsal of these blueprints allows movements to become automatic

Richardson A. Mental practice: a review and discussion, part I. Res Q 1967; 38:95‐107.

**Borrowed from the world of sports psychology

Surgeon Preparation

• 66 residents with limited experience in cystoscopy• Imagery group had <20 minute guided session to envision the procedure

• Control group read textbook chapter• Surgery assessment scores 15.9% higher in imagery group

Surgeon Preparation

Also from sports world:

• Record your cases, review your performance

Make use of your colleagues

• Brainstorm about difficult / unique cases

• Ask for help / collaborate

Surgery is a team sport!!

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Final Tips

• Get to room early• Set things up the same way every

time• Be aware of your stance• Know all equipment better than

anyone• Optimize your team• Update preference cards• Record cases often• Consider mental imagery exercises• Observe other high‐performing

surgeons

Questions…???

“Real knowledge is to know the extent of one’s ignorance”

‐ Confucius

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TOTAL LAPAROSCOPIC HYSTERECTOMY

Surgical Steps for a Safe and Successful Outcome

Robert O’Shea

Flinders EndogynaecologyFlinders University & Flinders Medical Centre

Adelaide, Australia

Head of Unit

No financial relationships to disclose

• I have no financial relationships to disclose.

Discuss the surgical steps to complete a safe Laparoscopic Hysterectomy. Abdominal

Hysterectomy8498 50%

Vaginal Hysterectomy

6015 35%

Laparoscopic Hysterectomy

2594 15%

2000-2001 2013-2014 2016-2017 2017-2018

Abdominal Hysterectomy

50% (8498) 29% (4680) 16%(2180) 22% (3260)


35% (6015) 32% (5090) 28% (3887) 23% (3432)

LaparoscopicHysterectomy

15% (2594) 39% (6276) 56% (7862) 55% (8321)

Total 17,107 16,046 13,929 15,013(↓12%)

2000-2001 2013-2014 2016-2017 2017-2018


50% (8498) 29% (4680) 16% (2180) 22% (3260)


35% (6015) 32% (5090) 28% (3887) 23% (3432)


15% (2594) 39% (6276) 56% (7862) 55% (8321)

Total 17,107 16,046 13,929 15,013(↓12%)

Page 8

2000-2001 2013-2014 2016-2017 2017-2018


50% (8498) 29% (4680) 16% (2180) 22% (3260)


35% (6015) 32% (5090) 28% (3887) 23% (3432)


15% (2594) 39% (6276) 56% (7862) 55% (8321)

Total 17,107 16,046 13,929 15,013(↓12%)

2000-2001 2013-2014 2016-2017 2017-2018


50% (8498) 29% (4680) 16% (2180) 22% (3260)


35% (6015) 32% (5090) 28% (3887) 23% (3432)


15% (2594) 39% (6276) 56% (7862) 55% (8321)

Total 17,107 16,046 13,929 15,013(↓12%)

2017-2018National

2017-2018SouthAustralia


22% (3260) 31% (360)


23% (3432) 15% (180)


55% (8321) 54% (635)

Total 15,013 (↓12%)

1,175

Port Configuration

Generally progression LAVH → TLH

EquipmentConfidenceCompetence

Equipment I1. Uterine manipulator - Valchev

+ tenaculum - Pelosi- Clermont- Koh

2. Bipolar Diathermy - ? Lyons3. Unipolar Diathermy- scissors / mini shears

/ spoon diathermy

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Equipment II

4. Laparoscopic Suturing Set- Needle driver- Needle receiver- Knot pusher

5. Vaginal Tube – Reich (Wolf)- Koh manipulator/tube- Clermont manipulator- McCartney tube

Combination tube and manipulatorClermont manipulator Koh colpotomizer

Advantages/Disadvantages

Step I - Ureteric/bladder dissection Step II - Upper pedicles (L) Step III - Uterine vessels (L) Step IV - Upper pedicles (R) Step V - Uterine vessels (R) Step V1 - Colpotomy Step V11 - Vault closure/suspension Step V111 - Cystoscopy

Step I - Ureteric/bladder dissection

Page 10

Step II - Upper pedicles (L)

Electrosurgery

UnipolarBipolarSuture

Step III - Uterine vessels (L)Dissection/ligation

BipolarSutureVascular clip

Step IV - Upper pedicles (R)

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Step V - Uterine vessels (R)

Dissection/ligation

Step V1 - Colpotomy

Colpotomy

Laparoscopic TenaculumMcCartney tube1. Elevates uterus2. Shelf for bladder dissection3. Delineates uterines for ligation

Colpotomy

4. Presents vagina for colpotomy5. Tamponades vagina6. Pericervical ring preserved

Colpotomy - diathermy scissors- spoon diathermy- harmonic scalpel

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Step V11 - Vault closure/suspension

Vault Closure - Absorbable- 2 mattress sutures (Figure 8)- 1 monocryl

Prophylactic vault suspension (Ethibond)

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Step V111 - Cystoscopy

Step 1,II,IV - No problem

Step V - Elevation/manipulation- Difficult initially- Safe!

Step VII - Suturing skills required- ? Closure vagina (diff)

Step III,V - main problem

- Uterine demarcation- Full bladder dissection- McCartney tube / tenaculum- Uterine vessel dissection & ligation above

tube

Page 14

“Success is not final, failure is not fatal. It is the courage to continue that counts.”

Winston Churchill

Laparoscopic Hysterectomy

Now the standard!• Laparoscopic hysterectomy increasing popularity (55%) 2018

• Vaginal hysterectomy decreasing popularity (23%) 2018

• Abdominal hysterectomy decreasing popularity (22%) 2018

• Training in laparoscopic surgery - major issue (? streaming)

• TLH should replace abdominal hysterectomy and LAVH

• Confidence and competence

• TLH – signature procedure for gynaecologists

• Connoisseur’s procedure – elegant and anatomical

46

Flinders Endogynaecology Fellows (1997-2019)

47

AGES Fellowship 2018

Page 15

Simplifying the Difficult Hysterectomy

Suketu Mansuria, M.D.

Associate Professor

University of Pittsburgh Medical Center

Disclosures

Speakers Bureau: Medtronic, Olympus

Objectives

• Discuss various surgical strategies to accomplish difficult hysterectomies

• Discuss techniques to minimize conversion to laparotomy and minimize complications

• Review pelvic sidewall/retropertionealanatomy to help in safely completing difficult hysterectomies

– Identify the uterine artery from its origin to facilitate difficult cases

Uterine Manipulators

• Most important assistant is the uterine manipulator

– I prefer the Pelosi manipulator

• Heavy duty

• Great anteversion/retroversion and lateral deflection

• Different size tips

Pelosi Manipulator Difficult Hysterectomies

• Ureteral Stents

– Helps with identification of the course of the ureter along the pelvic sidewall

– Helpful when visualization of the ureters may be compromised due to low fibroids and endometriosis (and obesity!)

– Placement of stents does NOT absolve the surgeon from needing to know where the uretersare‐it just makes finding them easier

– Can aide in ureterolysis

• Ureters more rigid and more easily bluntly dissected out of harm’s way

Page 16

Port Placement• Port Placement

– Rarely does the port placement need to be modified for large uteri less than 24 weeks size (larger than that may require the optical port to be placed more cephalad)

• Keep in mind that 90% of the case is securing the blood supply

– Upper pedicles‐even in large uteri the upper pedicles are rarely much above the level of the pelvic brim

– Lower pedicles‐often the more difficult pedicles to secure and even in larger uteri the lower pedicles are still deep in the pelvis. Therefore if the ports are positioned too cephalad, this may compromise access to the deep pelvis (where the majority of the case will be performed)

Port Placement

5 mm

10 mm

Pelvic Sidewall Anatomy

• Why is retroperitoneal anatomy important?– Important structures in the retroperitoneum:

• Uterine artery‐control of the uterine blood supply is 75% of a hysterectomy

• Ureter‐knowledge of its retroperitoneal course will minimize ureteral injury

– Very rarely does pelvic pathology affect the retroperitoneal anatomy

• Adhesions• Endometriosis• Fibroids

– Allows you to accomplish difficult cases• Scarred bladder flaps• Obliterated posterior cul‐de‐sac/endometriosis• When a ureterolysis is necessary

Difficult Hysterectomies

• Securing the lower pedicles (ie. uterine arteries)

– Securing the uterine artery at its origin off the hypogastric (internal iliac) can be helpful when dealing with fibroids:

• Easier to control large vessels (ie. decreased bleeding)

– Able to “get around” the whole vessel

• Often sidewall exposure is better than at the traditional coagulation point

• Sidewall anatomy often less distorted

• Able to control uterine blood supply before performing myomectomies to aide in hysterectomy

Difficult Hysterectomies

• Securing the lower blood supply (ie. uterine arteries)

– Securing the uterine artery at its origin off the hypogastric (internal iliac) can be helpful when dealing with a scarred bladder flap or obliterated cul‐de‐sac:

• Sidewall anatomy often less distorted

• Able to control the uterine blood supply when bowel or bladder is in close proximity to the traditional coagulation point

• Once the uterus is devascularized, able to perform adhesiolysis with less bleeding (thereby improving visualization and decreasing the risk of bowel/bladder injury)

• “Do the easy stuff first, and the hard stuff becomes easy!”

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Ureterolysis

• Knowledge of retroperitoneal anatomy can help:

– Aide in the identification of the ureter

– Aide in ureterolysis

• Since the uterine artery crosses over the ureter, controlling the artery laterally allows the surgeon to completely dissect the ureter without encountering bleeding from inadvertant injury to the uterine artery

Pelvic Sidewall

• Two important structures in the pelvic sidewall/retroperitoneum

– Ureter‐ALWAYS found along the posterior leaf of the broad ligament

– Uterine Artery‐ALWAYS crosses above the ureter(water under the bridge)

Pelvic Sidewall

• Two Important Avascular Spaces

– Pararectal space

– Paravesical space

• Both spaces are triangles and share a common base – the uterine artery

• As long as you can identify one boundary of either space, you can develop both spaces and identify all the other boundaries

Pelvic Sidewall

UterusUA UA

Hypogastric/Int Illiac Hypogastric/Int Illiac

Bladder

Ureter Ureter

PRPR

PV PV

MUL MUL

Pelvic Sidewall

• Three main surgical approaches to identifying the uterine artery from its origin off the hypogastric artery

– Posterior approach

– Lateral approach

– Anterior approach

• Choice of approach will be determined by visualization and anatomy

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Pelvic Sidewall

• Posterior Approach– Make a peritoneal incision between the IP ligament and the ureter (If there is difficulty identifying the ureter, start at the pelvic brim)

– Extend the peritoneal incision from the pelvic brim towards the uterus‐have your assistant pull the peritoneum medially

– Develop the pararectal space

– Identify all borders of the pararectal space and use them to identify the paravesicle space

Pelvic Sidewall

• Lateral Approach‐the approach most familiar to most gynecologist

– Make a peritoneal incision from the round ligament parallel to the IP ligament

– Have your assistant pull the peritoneal edge medially

– Develop the pararectal space

– Identify all borders of the pararectal space and use them to identify the paravesicle space

Pelvic Sidewall

• Anterior Approach‐Used when the other two approaches are not possible (ie. obliterated cul‐de‐sac, very large and broad uterus)– The medial umbilical ligament is identified– The MUL is skeletonized and followed retrograde towards the uterine artery

• Concentrate dissection on the medial side of the ligament (the paravesicle space will be developed)

• Superior vesicle artery will be encountered before the uterine artery – SVA originates from the posterolateral aspect of the hypogastric artery and runs upwards to the bladder

– Once the uterine artery identified, use it to identify all other structures

Obliterated Posterior Cul de Sac

• When an obliterated posterior cul de sac is encountered:

– Devascularize the uterus (if performing a hyst)

– Develop the rectovaginal space

• Initiate the dissection in the perirectal space/Okabayashi Space

– The space between the uterosacral ligament and the rectum

• Identify the rectovaginal space below the obliteration

• Go from “known” to “unknown”

Difficult Bladder Flap

• When a difficult bladder flap is encountered, the approach can be broken down into discrete steps:

• Secure the blood supply

• Complete the rest of the hysterectomy

• Delineate borders of the bladder

• Initiate dissection laterally and inferiorly

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Difficult Bladder Flap

• Delineate the borders of the bladder

• Retrograde fill the bladder with 300‐400cc– I use my suction‐irrigator and connect it to the end of the foley and clamp the foley when the bladder is full

– Once the borders are delineated, dissection can continue safely

• Often when the uterus is adherent to the anterior abdominal wall, the bladder is not involved (Dissect the uterus off the anterior abdominal wall with impunity!!)

Bladder Flap

• Initiate the dissection laterally and inferiorly

• Why?

– The bladder is usually pulled up in the midline by scarring from previous cesarean sections

– When dealing with scar tissue, it is important to find the proper plane for dissection=endopelvicfascia

– By initiating the dissection inferiorly and laterally, the endopelvic fascia can more easily be identified

Uterus

Bladder

Uterus

Bladder

Uterus

Bladder

Uterus

Bladder

XXXX

Page 20

Uterus

Bladder

XXXX

Cross‐Section of Uterus

Uterus Cervix

Bladder


Uterus Cervix

Bladder


Uterus Cervix

Bladder

Thank You

Questions?

Evaluation Question

What two spaces should be developed to identify the uterine artery from it’s origin?

A. Presacral and retrorectal spaces

B. Pararectal and paravesicle spaces

C. Obturator and rectovaginal spaces

D. Pararectal and retrorectal spaces

E. Paravesicle and obturator spaces

Page 21

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%

Page 22

http://www.imq.org/

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

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

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

SYLLABUS - AAGLDepartment of Obstetrics & Gynecology Royal Columbian Hospital November 12, 2019...

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