Surgical Tutorial 6: Tips and Tricks for Avoiding ... · Surgical Tutorial 6: Tips and Tricks for Avoiding Complications in Laparoscopy . R. Wendell Naumann, Chair . Faculty: Ted

Sponsored by

AAGLAdvancing Minimally Invasive Gynecology Worldwide

Surgical Tutorial 6: Tips and Tricks for Avoiding Complications

in Laparoscopy

PROGRAM CHAIR

R. Wendell Naumann, MD

Ted L. Anderson, MD, PhD John R. Miklos, MD Amanda Nickles Fader, MD

Professional Education Information Target Audience This educational activity is developed to meet the needs of residents, fellows and new minimally invasive specialists in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.

Table of Contents

Course Description ........................................................................................................................................ 1

Disclosure ...................................................................................................................................................... 2

Did I Really Agree to Do Laparoscopy in This Woman?! T.L. Anderson ............................................................................................................................................... 3

The Retroperitoneal Space: The Solution To Difficult Laparoscopic Surgery R.W. Naumann ............................................................................................................................................. 7

Stuck Between a Bladder and a Hard Place

A. Nickles Fader ................................................................................................................................. 1

I’m in Trouble and the Urologist Can’t Fix It Without a Robot! J.R. Miklos .................................................................................................................................................. 11

Cultural and Linguistics Competency .......................................................................................................... 15

Surgical Tutorial 6: Tips and Tricks for Avoiding Complications in Laparoscopy

R. Wendell Naumann, Chair

Faculty: Ted L. Anderson, John R. Miklos, Amanda Nickles Fader This session provides ways to approach the most common problems encountered during laparoscopic

hysterectomy. This will include difficult abdominal entry due to previous surgery or obesity, and ways to

prevent ureteral and bladder injury in the face of difficult anatomy or multiple previous C/S, and

describe methods for opening the retroperitoneal space for location of ureters, dealing with difficult

bleeding during hysterectomy, and ways to evaluate, manage and repair complications.

Learning Objectives: At the conclusion of this course, the participant will be able to: 1) Reduce the risk of

causing or missing complications during difficult laparoscopic hysterectomy.

Course Outline

12:10 Welcome, Introductions and Course Overview R.W. Naumann

12:15 Did I Really Agree to Do Laparoscopy in This Woman?! T.L. Anderson

12:25 The Retroperitoneal Space: The Solution To Difficult

Laparoscopic Surgery R.W. Naumann

12:35 Stuck Between a Bladder and a Hard Place A. Nickles Fader

12:45 I’m in Trouble and the Urologist Can’t Fix It Without a Robot! J.R. Miklos

12:55 Questions & Answers All Faculty

1:10 Adjourn

1

PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop (listed in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* R. Edward Betcher* Amber Bradshaw Speakers Bureau: Myriad Genetics Lab Other: Proctor: Intuitive Surgical Sarah L. Cohen Consultant: Olympus Erica Dun* Joseph (Jay) L. Hudgens Contracted Research: Gynesonics Frank D. Loffer, Medical Director, AAGL* Suketu Mansuria Speakers Bureau: Covidien Linda Michels, Executive Director, AAGL* R. Wendel Naumann Consultant: AstraZeneca, Clovis, Janssen Karen C. Wang* Johnny Yi* SCIENTIFIC PROGRAM COMMITTEE Sawsan As-Sanie Consultant: Myriad Genetics Lab Jubilee Brown* Aarathi Cholkeri-Singh Consultant: Smith & Nephew Endoscopy Speakers Bureau: Bayer Healthcare Corp., DySIS Medical, Hologic Other: Advisory Board: Bayer Healthcare Corp., Hologic Jon I. Einarsson* Suketu Mansuria Speakers Bureau: Covidien Andrew I. Sokol* Kevin J.E. Stepp Consultant: CONMED Corporation, Teleflex Stock Ownership: Titan Medical Karen C. Wang* FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Ted L. Anderson* John R. Miklos Consultant: Coloplast, CooperSurgical, Gyrus ACMI (Olympus) Contracted Research: Olympus R. Wendel Naumann Consultant: AstraZeneca, Clovis, Janssen Amanda Nickles Fader Other: Honorarium: Apple Medical Corporation Content Reviewer has no relationships.

Asterisk (*) denotes no financial relationships to disclose.

2

Did I Really Agree To Do Laparoscopy in This Woman?!

Ted L. Anderson, MD, PhD, FACOG, FACSBetty and Lonnie S. Burnett Professor

Vice Chair for Gynecology

Department of Obstetrics & Gynecology

Vanderbilt University Medical Center, Nashville, TN

[email protected]

Surgical Tutorial 6: Tips and Tricks for Avoiding Complications in Laparoscopy

AAGL Global Congress on MIGSOrlando, FL November 2016

Tips and Tricks for Avoiding Complications in Laparoscopy

Disclosures

I have no financial relationships to disclose

2



OBJECTIVES The participant will be able to:

1. Mitigate nerve and abdominal wall injury during laparoscopic surgery in patients with extremes of size

2. Describe techniques for safe laparoscopic entry in patients with multiple prior operations.

3. Mitigate the downstream consequences of intraoperative injury during laparoscopic procedures

DESIRED OUTCOME That laparoscopists understand techniques to maximize safe patinetpositioning and abdominal cavity entry during laparosospic surgery

3AAGL Global Congress on MIGSOrlando, FL November 2016


Challenges to Safe Laparoscopy

• Extremes of patient size• Patient positioning

• Patient stability

• Nerve injury

• Trocar placement

• Abdominal adhesions• Site and method of entry

• Trocar injuries• Vascular

• Bowel



The Morbidly Obese Patient

• First concern is to prevent slipping

• Second concern is to prevent nerve injury

• Third concern is appropriate trocar placement



Obese Patient Positioning

Scheib S et al. Laparoscopy in the Morbidly Obese: Physiologic Considerations and Surgical Techniques to Optimize Success. J Minim Invasive Gynecol (2014) 21:182–195.

3



Obese Patient Positioning• Patient slipping

• Bean bag best overall support• Secure arms with expenders• Secure patient to table

• Nerve Injury• Exaggerated effect of angles• Attention to limb position • Adequate limb padding

• Peroneal ‐ foot drop• Femoral ‐ decreased

sensation anterior thigh, difficult extension

• Obturator – decreased sensation medial thigh, adductor weakness

• Sciatic – loss of sensation calf/foot and hamstring / calf weakness with loss of flexion

Scheib S et al. Laparoscopy in the Morbidly Obese: Physiologic Considerations and Surgical Techniques to Optimize Success. J Minim Invasive Gynecol (2014) 21:182–195.Barnett JC et al. Laparoscopic positioning and nerve injuries. J Minim Invasive Gynecol (2007) 14:664 – 672.



Trocar Placement

• xxx

www.mgmunro.yourmd.com

45o 90o



Trocar Placement

Avoid insertion in Trendelenberg’s positionConsider LUQ insertion first

Scheib S et al. Laparoscopy in the Morbidly Obese: Physiologic Considerations and Surgical Techniques to Optimize Success. J Minim Invasive Gynecol (2014) 21:182–195.



Trocar Types

• Blunt and optical trocars do NOT prevent injuries



Avoid Soft Tissue Dystocia

11www.mgmunro.yourmd.com

D = 10mm C = 20mm = 2R = D20mm = 3.14 x D

20/3.14 = 6.36 mm = D

C = 2R = DC = 3.14 x 10 mm

C = 31.4 mm

C = 20mm C = 31.4 mm

D = 15.7 mm



Adhesive Disease• Veress Needle

• Opening pressure most sensitive for free placement

• LUQ trocar insertion• Palmer’s point• 3cm below costal margin• mid‐clavicular line• No longer as valid in the era of

bariatric surgery

• Hasson Open Entry• No evidence this approach is

superior or inferior to other entry techniques

• No evidence of reduced incidence of injuries

• Increased number of procedures equals increased risk

Palmer R. Safety in laparoscopy. J Reprod Med (1974) 13:1–5.Vilos GA et al. Laparoscopic Entry: A review of techniques, technologies, and complications. SOGC Clinical Practice Guideline (2007) JOGC 193:433‐447.

4



Risk of Postoperative Adhesions

• ObGyn – specific surgery (varies by incision)• Midline incision for gyn procedure (57%)

• Pfannensteil for gyn procedure (27%)

• All incisions for OB procedure (22%)

Okabayashi K et al. Adhesions after abdominal surgery: a systematic review of the incidence, distribution and severity. Surg Today (2014) 44:405‐420.Odd Langbach et al. Adhesions to Mesh after Ventral Hernia Mesh Repair Are Detected by MRI but Are Not a Cause of Long Term Chronic Abdominal Pain. Gastroenterology Research and Practice. (2016) Article ID 2631598, 7 pages. http://dx.doi.org/10.1155/2016/2631598.Brill AI et al. The incidence of adhesions after prior laparotomy: a laparoscopic appraisal. Obstet Gynecol (1995) 85:269‐272.Menzies D, Ellis H. Intestinal Obstruction from Adhesions‐‐How Big Is the Problem? Ann Royal Coll Surg (1990) 72: 60‐63.

• All abdominal surgery ‐ 54%• Gastrointestinal surgery – 66%

• Hernia repair with mesh placement – 60%

• Ob/Gyn surgery – 51%

• Urologic surgery – 22%

• No history of surgery – 10%



Risk of Postoperative Adhesions

• Placement of 1st port • Results in bowel injury 7 /10,000 operations

• Results in 2.5 ‐ 5% risk of death

• Use of surgical scars to choose entry site• were correct 88% of the time

• Use of ultrasound to choose entry site• Visceral slide test

• Correct 99.5% of the time

Minaker S et al. Can general surgeons evaluate visceral slide with transabdominal ultrasound to predict safe sites for primary laparoscopic port placement? A prospective study of sonographically naïve operators at a tertiary center. Am J Surg (2015) 209:804‐809.Larciprete G et al. Ultrasound detection of the "sliding viscera" sign promotes safer laparoscopy. J Minim Invasive Gynecol. (2009) 16(4):445‐459.



Visceral Slide Test

Minaker S et al. Can general surgeons evaluate visceral slide with transabdominal ultrasound to predict safe sites for primary laparoscopic port placement? A prospective study of sonographically naïve operators at a tertiary center. Am J Surg (2015) 209:804‐809.Larciprete G et al. Ultrasound detection of the "sliding viscera" sign promotes safer laparoscopy. J Minim Invasive Gynecol. (2009) 16(4):445‐459.



Bowel Injury

• Incidence up to about 0.5% of surgery

• Entry (lacertions) vs intraop (thermal)

• Up to 50% unrecognized

• Leave trocar in place

• Evaluate via alternative port site

• Isolate and repair

• Laparoscopy

• Laparotomy

• Run the bowel

• General surgery consultation

Intraopertive Injury

Berker B et al. Complications of Laparoscopic Gynecologic Surgery. Chapter 60 in: Prevention and Management of Laparoendoscopic Surgical Complications, Third Edition (Wetter PA et al, eds). Society of Laparoendoscopic Surgeons (2010). http://laparoscopy.blogs.com/prevention_management_3/2010/07/complications‐of‐laparoscopic‐gynecologic‐surgery.html



Bladder Injury

• Incidence 0.2% – 8.3% of surgery

• Most during hysterectomies

• Up to 90% at dome

• Over 95% recognized at time of surgery

• Stents vs no stents

• Multi‐layer closure

• Foley decompression

• Laparoscopy

• Laparotomy

• Check for leaks

• Urology consultation





Vascular Injury

• Abdominal Wall

• Balloon vs Balloon trocar vs Suture

• Intraperitoneal• Between 0.04% ‐ 0.5%

• If major vessels involved, about 20% mortality rate

• If small venous and no growing hematoma, pressure may stop

• If arterial or venous and major vessel, call for help, open ASAP, add pressure



5





References

• Barnett JC et al. Laparoscopic positioning and nerve injuries. J Minim Invasive Gynecol (2007) 14:664 – 672.

• Berker B et al. Complications of Laparoscopic Gynecologic Surgery. Chapter 60 in: Prevention and Management of Laparoendoscopic Surgical Complications, Third Edition (Wetter PA et al, eds). Society of Laparoendoscopic Surgeons (2010). http://laparoscopy.blogs.com/ prevention_management_3/2010/07/complications‐of‐laparoscopic‐gynecologic‐surgery.html

• Larciprete G et al. Ultrasound detection of the "sliding viscera" sign promotes safer laparoscopy. J Minim Invasive Gynecol. (2009) 16(4):445‐459.

• Minaker S et al. Can general surgeons evaluate visceral slide with transabdominal ultrasound to predict safe sites for primary laparoscopic port placement? A prospective study of sonographically naïve operators at a tertiary center. Am J Surg (2015) 209:804‐809.

• Palmer R. Safety in laparoscopy. J Reprod Med (1974) 13:1–5.• Scheib S et al. Laparoscopy in the Morbidly Obese: Physiologic Considerations and Surgical

Techniques to Optimize Success. J Minim Invasive Gynecol (2014) 21:182–195.• Vilos GA et al. Laparoscopic Entry: A review of techniques, technologies, and complications.

SOGC Clinical Practice Guideline (2007) JOGC 193:433‐447.

Questions?

Ted L. Anderson, MD, PhD, FACOG, FACSBetty and Lonnie S. Burnett Professor

Vice Chair for Gynecology

Department of Obstetrics & Gynecology

Vanderbilt University Medical Center, Nashville, TN

[email protected]

6

The Retroperitoneal Space:The Solution to Difficult Surgery

R. Wendel Naumann, MD

Levine Cancer InstituteCarolinas Medical Center

Charlotte, NC

Disclosures

Consultant: AstraZeneca, Clovis, Janssen

Explain how to utilize the retroperitoneal space to prevent

complications

OBJECTIVE Paravesical and Pararectal Spaces

Branching of the Uterine Artery Common Sites of Ureteral Injury

DANGERZONES!

42%

33%

25%

Naumann RW, and Stepp KJ. Urologic Complications of Laparoscopic Gynecologic Surgery in Nezhat's Operative Gynecologic Laparoscopy & Hysteroscopy, 2nd Ed, 2013

7

Finding the UreterCross Sectional Anatomy

GU Injury during TLH

Brummer THI, Human Reproduction 23(4):840, 2008

Cross Sectional Anatomy

Blood Supply to Uterus/VaginaLigation of Uterine Artery

8

Uterine Arteries Isolating the Ovarian Vessels

Ureteral Stents

Ureteral Injury at the Cuff

Naumann RW, and Stepp KJ. Urologic Complications of Laparoscopic Gynecologic Surgery in Nezhat's Operative Gynecologic Laparoscopy & Hysteroscopy, 2nd Ed, 2013

Brummer THI, Human Reproduction 23(4):840, 2008

9

What is the most common site of ureteral injury

A. Renal pelvis

B. Pelvic brim

C. Passing under uterine artery

D. Vaginal cuff

E. Ureterovesical junction

Correct answer: B

10

I’m in Trouble and the Urologist Can’t Fix It Without a Robot!

I’m in Trouble and the Urologist Can’t Fix It Without a Robot!

John R Miklos MD, FPMRS, FACSMiklos & Moore Urogynecology

Atlanta ~ Beverly Hills ~ Dubai

45th AAGL Meeting

Orlando, FL – Nov. 14-18, 2016

John R Miklos MD, FPMRS, FACSMiklos & Moore Urogynecology

Atlanta ~ Beverly Hills ~ Dubai

45th AAGL Meeting

Orlando, FL – Nov. 14-18, 2016

DisclosureDisclosure

• Contracted ResearchOlympus

• Contracted ResearchOlympus

• ConsultantColoplast, CooperSurgical, Gyrus ACMI

• ConsultantColoplast, CooperSurgical, Gyrus ACMI

ObjectivesObjectives

• Evaluate and understand the management of bladder & ureteral injuries

• Discuss the placement and use of postoperative ureteral stents

• Evaluate and determine whether a patient has a bladder injury postoperatively

• Evaluate and understand the management of bladder & ureteral injuries

• Discuss the placement and use of postoperative ureteral stents

• Evaluate and determine whether a patient has a bladder injury postoperatively

Bladder & Ureteral InjuryIncidence


• True Rate - ????

• Bladder Injury Rate - 0.2% - 1.8%

• Ureteral Injury Rates - 0.03% - 1.5%

• # 1 reason - gynecologic of lawsuit

• True Rate - ????

• Bladder Injury Rate - 0.2% - 1.8%

• Ureteral Injury Rates - 0.03% - 1.5%

• # 1 reason - gynecologic of lawsuit



• Abdominal, Laparoscopic, Vaginal

• Cancer, Radiation, Endometriosis

• Hysterectomy ****

• Injury specific to procedure

• Abdominal, Laparoscopic, Vaginal

• Cancer, Radiation, Endometriosis

• Hysterectomy ****

• Injury specific to procedure

The Answer is : Abdominal HysterectomyThe Answer is : Abdominal Hysterectomy

• Leading cause of VVF in USA ?

• Leading cause of bladder injury during Gyn surgery?

• Leading cause of ureteral injuries during Gyn surgery?

• Leading cause of VVF in USA ?

• Leading cause of bladder injury during Gyn surgery?

• Leading cause of ureteral injuries during Gyn surgery?

• Are ureteric injuries more common in Vaginal or TAH?

• The #1 reason why gynsurgeons are sued for lower UT injury is during which surgery?

• Are ureteric injuries more common in Vaginal or TAH?

• The #1 reason why gynsurgeons are sued for lower UT injury is during which surgery?

11

Intraoperative Bladder InjuryIntraoperative Bladder Injury

• Gross Injury Bladder mucosa

Foley Bulb

Urine

• Foley Bag Blood

Gas

• Gross Injury Bladder mucosa

Foley Bulb

Urine

• Foley Bag Blood

Gas

Intraoperative Diagnosis - Bladder InjuryIntraoperative Diagnosis - Bladder Injury

• Laparoscopic Bladder mucosa

Foley Bulb

Ureteric Stents

• Cystoscopic

• Laparoscopic Bladder mucosa

Foley Bulb

Ureteric Stents

• Cystoscopic

Bladder Injury Management – Intra OpBladder Injury Management – Intra Op

• Bladder Dome• Extraperitoneal

• Baldder Dome Intraperitoneal

• Bladder Base

• Bladder Dome• Extraperitoneal

• Baldder Dome Intraperitoneal

• Bladder Base

Ureter Injury - IntraoperativeUreter Injury - Intraoperative

• No ureter efflux

• Ureter enlargement

• Intraperitoneal dye

• Gross ureteral damage

• No ureter efflux


• Intraperitoneal dye

• Gross ureteral damage

Ureter EvaluationUreter Evaluation

• Cystoscopy Indigo, Methylene blue

Fluorescein, Vit B, Pyridium


• Deflate bladder pressure

• Cystoscopy Indigo, Methylene blue

Fluorescein, Vit B, Pyridium


• Deflate bladder pressure

Ureter EvaluationUreter Evaluation

• Cystoscopy – 2nd time

• Ureteral Stent Visualize laparoscopically

• Blocked ureter Remove suture

• Cystoscopy – 2nd time

• Ureteral Stent Visualize laparoscopically

• Blocked ureter Remove suture

12

Ureter Injury Management - Intra OpCall for Help

Ureter Injury Management - Intra OpCall for Help

• Partial Thickness

• Kinking

• Crush Injury

• Ureterotomy

• Transection

• Partial Thickness

• Kinking

• Crush Injury

• Ureterotomy

• Transection

Bladder Injury – Post OpBladder Injury – Post Op

Signs & SymptomsSigns & Symptoms

• Hematuria

• Suprapubic Pain

• Peritoneal Sign

• Urine Output

• Distension

• Guarding

• Hematuria

• Suprapubic Pain

• Peritoneal Sign

• Urine Output

• Distension

• Guarding

DiagnosisDiagnosis

Bladder Injury – Work UpBladder Injury – Work Up

Labs and ImagingLabs and Imaging

• Creatinine

• CBC w/diff

• CT cystogram

• IV urogram

• Cystoscopy

• Creatinine

• CBC w/diff

• CT cystogram

• IV urogram

• Cystoscopy

IV UrogramIV Urogram

Ureteral Injury Post OpUreteral Injury Post Op

SymptomsSymptoms

• Flank Pain

• Fever

• Hematuria

• Abdominal distension

• Secondary hypertension

• Flank Pain

• Fever

• Hematuria

• Abdominal distension

• Secondary hypertension

PresentationPresentation

Ureteral Injury Post OpUreteral Injury Post Op

Labs & ImagingLabs & Imaging

• Intravenous Urogram

• CT w/ Contrast

• Retrograde Ureterogram

• Renal US

• CBC with differential

• Creatinine

• Intravenous Urogram

• CT w/ Contrast

• Retrograde Ureterogram

• Renal US

• CBC with differential

• Creatinine

IV urogramIV urogram

Bladder Injury –Catheter ManagementBladder Injury –Catheter Management

• Transurethral Foley 7-21 days

Stops draining?

• Suprapubic Catheter Relief Valve

14-21 days

• Transurethral Foley 7-21 days

Stops draining?


14-21 days

13

SupraPubic & Transurethral FoleySupraPubic & Transurethral Foley

• Transurethral Foley Hematuria clears

Catheter removed


14-21 days

• Transurethral Foley Hematuria clears

Catheter removed


14-21 days

Ureteral Injury –Stent Management Ureteral Injury –Stent Management

• Days – Months

• Severity of Injury Partial

Full

Transection

• Days – Months

• Severity of Injury Partial

Full

Transection

BibliographyBibliography

• Barbier HM, Smith MZ, Eto CU, Welgoss JA, Von Pechmann W, Horbach N, et al. Ureteral Compromise in Laparoscopic Versus Vaginal Uterosacral Ligament Suspension: A Retrospective Cohort. Female Pelvic Med Reconstr Surg. 2015 Nov-Dec. 21 (6):363-8.

• Adelman MR, Bardsley TR, Sharp HT. Urinary tract injuries in laparoscopic hysterectomy: a systematic review. J Minim Invasive Gynecol. 2014 Jul-Aug. 21(4):558-66

• Thompson JD. Operative injuries to the ureter: prevention, recognition, and management. Te Linde’s Operative Gynecology. 8th ed. 1997. 1135-73

• Barbier HM, Smith MZ, Eto CU, Welgoss JA, Von Pechmann W, Horbach N, et al. Ureteral Compromise in Laparoscopic Versus Vaginal Uterosacral Ligament Suspension: A Retrospective Cohort. Female Pelvic Med Reconstr Surg. 2015 Nov-Dec. 21 (6):363-8.

• Adelman MR, Bardsley TR, Sharp HT. Urinary tract injuries in laparoscopic hysterectomy: a systematic review. J Minim Invasive Gynecol. 2014 Jul-Aug. 21(4):558-66

• Thompson JD. Operative injuries to the ureter: prevention, recognition, and management. Te Linde’s Operative Gynecology. 8th ed. 1997. 1135-73

LAPAROSCOPIC REPAIR OF BLADDER INJURY

LAPAROSCOPIC REPAIR OF BLADDER INJURY

VIDEOVIDEO

14

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%

15

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

Documents

Surgical Tutorial 6: Tips and Tricks for Avoiding ... · Surgical Tutorial 6: Tips and Tricks for Avoiding Complications in Laparoscopy . R. Wendell Naumann, Chair . Faculty: Ted