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Operative Laparoscopy Revisited
Editorial
Operative Laparoscopy Revisited In 1992, Dr. Roy Pitkin, the editor of Obstetrics & Gynecology, wrote an editorial entitled ‘‘Operative Laparoscopy: Surgical Advance or Technical Gimmick?’’ [1]. In the text, he posed 5 related questions. The first had to do with technical feasibility vs therapeutic appropriateness. This question can be best answered by randomized clinical studies with comparison to what was at the time the standard of care, namely, laparotomy. However, speaking from personal experience, it was not easy in the early days to have one’s research efforts in this area published. The negative bias of the academic community toward laparoscopy and its proponents was intense. We were called ‘‘cowboys,’’ a derogatory term then but perhaps less so now. I would rather be a cowboy than an investment banker; the pay is less but the public image is better. The second point raised was one of quality assurance because laparoscopic procedures had begun to be performed in free-standing surgicenters outside the inspection of the Joint Commission on Accreditation of Healthcare Organizations, although many of these centers did subscribe to quality control programs. The third of Dr. Pitkin’s questions is one that every revolutionary change in medicine faces, that is, ‘‘How can appropriate credentialing be established for procedures not taught in residency and for which no present member of the medical staff can claim experience?’’ Certainly over time the necessary experience and expertise to identify those capable of teaching the new procedure can be established; however, this seems like a weak answer at best, and organized medicine continues to struggle with this issue. The fourth question involved the participation of the institutional review boards, and the issue of true informed consent when the treatment is experimental or, at the least, nonstandard. This problem, too, has remained a sticking point. The fifth question was directed toward the ethics of charging a fee for a nonstandard service. In March 2010, Dr. Pitkin’s second editorial, co-authored by Dr. William Parker, entitled ‘‘Operative Laparoscopy: A Second Look After 18 Years,’’ was published [2]. The authors opine that there now is sufficient evidence to conclude that ‘‘many if not most gynecologic operations traditionally done by laparotomy are amenable to a laparoscopic approach. Further, the studies are consistent in indicating that operative laparoscopy confers unequivocal advantages over older surgical approaches including tubal pregnancy surgery, 1553-4650/$ - see front matter Ó 2010 AAGL. All rights reserved. doi:10.1016/j.jmig.2010.06.001
that is, salpingectomy or salpingostomy; myomectomy; hysterectomy, especially when vaginal hysterectomy is not feasible by itself; ovarian cyst surgery; and certain gynecologic cancer operations including lymph node dissection. The benefits of the laparoscopic approach include less pain and shorter postoperative convalescence, both in-hospital and after discharge.’’ Further, the authors state that ‘‘If a ‘societal cost’ that included financial results from early return to work or full home activity were calculated, the advantage of endoscopic surgery would be even greater’’ [2]. One could argue that it should not have taken 18 years to reach this conclusion, but that’s not the rub. In the recent editorial, Dr. George H. Wendel, Chair of the Resident Review Committee for Obstetrics-Gynecology, is credited with supplying the information that residents completing training in 2009 averaged 23 laparoscopic hysterectomies as the lead surgeon, but the 10th and 90th percentiles were 6 and 47, respectively, compared with 74 abdominal and 24 vaginal hysterectomies [2]. Fig. 1, used by Dr. Charles Miller in his 2008 AAGL presidential address [3], clearly demonstrates the low adoption rate of gynecologic laparoscopy. Although surgeons lagged behind gynecologists in adopting laparoscopy by more than a decade, they have surpassed us in routine use of endoscopy for commonly performed operations The main indictment for this disappointing situation, I believe, should be directed toward those councils and committees charged with formulating and overseeing gynecologic resident education in the United States. Reading the most recent document of the Council on Resident Education in Obstetrics and Gynecology [4] is frustrating because it includes many statements indicating that laparoscopic procedures are something residents should ‘‘understand’’ rather than ‘‘understand and perform.’’ Recognizing the need for a competency evaluation tool, in 2005, the American College of Surgeons partnered with the Society of American Gastrointestinal and Endoscopic Surgeons, which had initiated the ‘‘Fundamentals of Laparoscopic Surgery.’’ This specific approach to resident requirements and training in laparoscopic surgery includes a didactic and skills program be completed before resident graduation. In its present format, the educational module consists of a Web-based multimedia presentation of didactic content and ‘‘watch and do’’ exercises that focus on manual
Journal of Minimally Invasive Gynecology, Vol 17, No 4, July/August 2010
406
Minimally Invasive Gynecologic Surgery MIS Adoption 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1998 1999 Hysterectomy
2000
2001 2002
Appendectomy
2003 2004 Bariatric
2005
2006 2007
Cholecystectomy
Sources: 2004 –2007
Fig. 1. Percentage of common operations performed laparoscopically. MIS = minimally invasive surgery. From [3]. Used with permission.
skills training. The ‘‘Fundamentals of Laparoscopic Surgery’’ assessment includes 2 components, a computer-based cognitive assessment and a performance-based manual skills assessment. To provide a similar training program specific to gynecology, the AAGL is currently constructing an educational module for minimally invasive gynecologic procedures that includes laparoscopy and hysteroscopy. This contains a cognitive portion and a validated skills assessment applicable from the resident and fellow level to those in practice. The Fellowship in Minimally Invasive Gynecologic Surgery initiated in 2001 by the AAGL and the Society of Reproductive Surgeons, an affiliate society of the American Society of Reproductive Medicine, requires that fellows perform specific endoscopic procedures. The fellowship now has nearly 100 graduates and is offered at 32 approved sites. These graduates are actively practicing minimally invasive gynecology, and many have pursued academic careers and are in position to train the next generation of gynecologists. To ensure the quality of minimally invasive gynecology, the AAGL pioneered the Council for Gynecologic Endoscopy. Its purpose is two-fold: to review the performance of physicians and designate their level of practice and to review hospitals and designate those that are centers of excellence.
I realize that most of you reading this editorial comprise the choir to whom I am preaching and that you are as frustrated as I am at the slow adoption of a technique so valuable to patients. Since the original editorial was published [1], substantial progress has been made, and with continued commitment by the AAGL, we may reach the point where this valuable technique becomes the standard of care. Stephen L. Corson, MD Editor-in Chief Thomas Jefferson University Medical School Department of Obstetrics and Gynecology Philadelphia, Pennsylvania References 1. Pitkin R. Operative laparoscopy: surgical advance or technical gimmick? [editorial]. Obstet Gynecol. 1992;79:441–442. 2. Pitkin R, Parker W. Operative laparoscopy: a second look after 18 years [editorial]. Obstet Gynecol. 2010;115:890–891. 3. Miller C. Training in minimally invasive surgery: you say you want a revolution? J Minim Invasive Gynecol. 2009;16:113–120. 4. Council on Resident Education in Obstetrics and Gynecology. CREOG’s Educational Objectives: A Core Curriculum in Obstetrics and Gynecology. 9th ed. Washington, DC: American College of Obstetrics and Gynecology; 2009.
Operative Laparoscopy Revisited In 1992, Dr. Roy Pitkin, the editor of Obstetrics & Gynecology, wrote an editorial entitled ‘‘Operative Laparoscopy: Surgical Advance or Technical Gimmick?’’ [1]. In the text, he posed 5 related questions. The first had to do with technical feasibility vs therapeutic appropriateness. This question can be best answered by randomized clinical studies with comparison to what was at the time the standard of care, namely, laparotomy. However, speaking from personal experience, it was not easy in the early days to have one’s research efforts in this area published. The negative bias of the academic community toward laparoscopy and its proponents was intense. We were called ‘‘cowboys,’’ a derogatory term then but perhaps less so now. I would rather be a cowboy than an investment banker; the pay is less but the public image is better. The second point raised was one of quality assurance because laparoscopic procedures had begun to be performed in free-standing surgicenters outside the inspection of the Joint Commission on Accreditation of Healthcare Organizations, although many of these centers did subscribe to quality control programs. The third of Dr. Pitkin’s questions is one that every revolutionary change in medicine faces, that is, ‘‘How can appropriate credentialing be established for procedures not taught in residency and for which no present member of the medical staff can claim experience?’’ Certainly over time the necessary experience and expertise to identify those capable of teaching the new procedure can be established; however, this seems like a weak answer at best, and organized medicine continues to struggle with this issue. The fourth question involved the participation of the institutional review boards, and the issue of true informed consent when the treatment is experimental or, at the least, nonstandard. This problem, too, has remained a sticking point. The fifth question was directed toward the ethics of charging a fee for a nonstandard service. In March 2010, Dr. Pitkin’s second editorial, co-authored by Dr. William Parker, entitled ‘‘Operative Laparoscopy: A Second Look After 18 Years,’’ was published [2]. The authors opine that there now is sufficient evidence to conclude that ‘‘many if not most gynecologic operations traditionally done by laparotomy are amenable to a laparoscopic approach. Further, the studies are consistent in indicating that operative laparoscopy confers unequivocal advantages over older surgical approaches including tubal pregnancy surgery, 1553-4650/$ - see front matter Ó 2010 AAGL. All rights reserved. doi:10.1016/j.jmig.2010.06.001
that is, salpingectomy or salpingostomy; myomectomy; hysterectomy, especially when vaginal hysterectomy is not feasible by itself; ovarian cyst surgery; and certain gynecologic cancer operations including lymph node dissection. The benefits of the laparoscopic approach include less pain and shorter postoperative convalescence, both in-hospital and after discharge.’’ Further, the authors state that ‘‘If a ‘societal cost’ that included financial results from early return to work or full home activity were calculated, the advantage of endoscopic surgery would be even greater’’ [2]. One could argue that it should not have taken 18 years to reach this conclusion, but that’s not the rub. In the recent editorial, Dr. George H. Wendel, Chair of the Resident Review Committee for Obstetrics-Gynecology, is credited with supplying the information that residents completing training in 2009 averaged 23 laparoscopic hysterectomies as the lead surgeon, but the 10th and 90th percentiles were 6 and 47, respectively, compared with 74 abdominal and 24 vaginal hysterectomies [2]. Fig. 1, used by Dr. Charles Miller in his 2008 AAGL presidential address [3], clearly demonstrates the low adoption rate of gynecologic laparoscopy. Although surgeons lagged behind gynecologists in adopting laparoscopy by more than a decade, they have surpassed us in routine use of endoscopy for commonly performed operations The main indictment for this disappointing situation, I believe, should be directed toward those councils and committees charged with formulating and overseeing gynecologic resident education in the United States. Reading the most recent document of the Council on Resident Education in Obstetrics and Gynecology [4] is frustrating because it includes many statements indicating that laparoscopic procedures are something residents should ‘‘understand’’ rather than ‘‘understand and perform.’’ Recognizing the need for a competency evaluation tool, in 2005, the American College of Surgeons partnered with the Society of American Gastrointestinal and Endoscopic Surgeons, which had initiated the ‘‘Fundamentals of Laparoscopic Surgery.’’ This specific approach to resident requirements and training in laparoscopic surgery includes a didactic and skills program be completed before resident graduation. In its present format, the educational module consists of a Web-based multimedia presentation of didactic content and ‘‘watch and do’’ exercises that focus on manual
Journal of Minimally Invasive Gynecology, Vol 17, No 4, July/August 2010
406
Minimally Invasive Gynecologic Surgery MIS Adoption 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1998 1999 Hysterectomy
2000
2001 2002
Appendectomy
2003 2004 Bariatric
2005
2006 2007
Cholecystectomy
Sources: 2004 –2007
Fig. 1. Percentage of common operations performed laparoscopically. MIS = minimally invasive surgery. From [3]. Used with permission.
skills training. The ‘‘Fundamentals of Laparoscopic Surgery’’ assessment includes 2 components, a computer-based cognitive assessment and a performance-based manual skills assessment. To provide a similar training program specific to gynecology, the AAGL is currently constructing an educational module for minimally invasive gynecologic procedures that includes laparoscopy and hysteroscopy. This contains a cognitive portion and a validated skills assessment applicable from the resident and fellow level to those in practice. The Fellowship in Minimally Invasive Gynecologic Surgery initiated in 2001 by the AAGL and the Society of Reproductive Surgeons, an affiliate society of the American Society of Reproductive Medicine, requires that fellows perform specific endoscopic procedures. The fellowship now has nearly 100 graduates and is offered at 32 approved sites. These graduates are actively practicing minimally invasive gynecology, and many have pursued academic careers and are in position to train the next generation of gynecologists. To ensure the quality of minimally invasive gynecology, the AAGL pioneered the Council for Gynecologic Endoscopy. Its purpose is two-fold: to review the performance of physicians and designate their level of practice and to review hospitals and designate those that are centers of excellence.
I realize that most of you reading this editorial comprise the choir to whom I am preaching and that you are as frustrated as I am at the slow adoption of a technique so valuable to patients. Since the original editorial was published [1], substantial progress has been made, and with continued commitment by the AAGL, we may reach the point where this valuable technique becomes the standard of care. Stephen L. Corson, MD Editor-in Chief Thomas Jefferson University Medical School Department of Obstetrics and Gynecology Philadelphia, Pennsylvania References 1. Pitkin R. Operative laparoscopy: surgical advance or technical gimmick? [editorial]. Obstet Gynecol. 1992;79:441–442. 2. Pitkin R, Parker W. Operative laparoscopy: a second look after 18 years [editorial]. Obstet Gynecol. 2010;115:890–891. 3. Miller C. Training in minimally invasive surgery: you say you want a revolution? J Minim Invasive Gynecol. 2009;16:113–120. 4. Council on Resident Education in Obstetrics and Gynecology. CREOG’s Educational Objectives: A Core Curriculum in Obstetrics and Gynecology. 9th ed. Washington, DC: American College of Obstetrics and Gynecology; 2009.