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MIS privileges, training and  and videoregistration remains a debated subject.

Maurice K Chung started the discussion by asking : I have some questions. I am in the process of recommending the Delineation of Privileges of MIS in my institution. I want to know what are CCBL requirement for Robotics &/or advanced laparoscopic procedures?  What is the policy for a General Gynecologist who want to apply for Robotic privilege? After He/she has obtained the Robotic privilege what procedures can they perform?  When she/he has never performed a Robotic Colposacralpexy in training, and once she obtains the Robotic privilege eventhough she could perform a RTLH, can she perform the Colposacralpexy? Tubal re anastomoses, etc. If not, how many cases she has to be proctored?

Dr. Maurice K. Chung, RPh. MD.,Chairman, The Global Society of Endometriosis, Pelvic and Pain Surgeons (GSEPS).President 2012, The Society of Laparoendoscopic Surgeons (SLS).President 2011, International Pelvic Pain Society (IPPS).Board Member, International Society of Gynecology Endoscopy (ISGE).Clinical Associate Professor,Dept. OBG, University of ToledoSchool of Medicine, Ohio.

Date: Mon, 14 Jan 2013 19:24:33 -0500 answer by  Philippe R Koninckx and Anastasia Ussia 

MIS privileges, accreditation and training remain a difficult topic with very different opinions and several country specific aspects. Bottom line however is how to judge and to define quality of surgery.
- Quality of surgery obviously comprises the indication. A perfectly performed bowel resection for endometriosis in a women who does not have endometriosis can hardly be regarded as quality surgery.
- Complications and accidents of an individual intervention cannot be judged without videoregistration of the entire intervention. Clearly the overall published rates do not give information on the individual intervention or surgeon. As an example, ureter lesions during hysterectomy are known to range around 1%. Years ago I was involved in a law suit where the gynecologist was acquitted for having cut 1 ureter during LAVH, which is “acceptable” ; reality was that he did cut 6 ureters during the first 10 cases.
- It is very difficult to judge surgery itself since we lack criteria. Is duration of surgery a criterion knowing that adhesion formation increases with duration ? Or blood loss ?
- Is technique of surgery a criterion or is this the freedom of the individual gynecologist.

In Europe we had -and still have- discussions about specialties and subspecialties. It is unclear whether a gynecologist can do laparoscopic bowel resections or ureter reanastomes. Reality is that in many places only the gynecologist has the skill to do this by laparoscopy, a reason for which we claimed (F&S, 2011) that the lower part of the ureter should become part of gynecology. The levels/difficulty of endoscopic surgery do not fit with the subspecialties. Especially reproductive medecine often does not have the patient load to do deep endometriosis surgery. The same holds true for oncology. For this reason we and others are suggesting “pelvic surgery” as a subspecialty.

Endoscopic surgery did change our concept of training and accreditation, albeit because to the classic training in open and vaginal surgery, we added training in endoscopic surgery, ……..and laser and robots. The training and learning curve became longer, but the number of patients remained unchanged. In addition, and this is specific for OBGYN, our discipline progressively incorporated innovation as ultrasound, IVF, hormone replacement etc. Today in many countries the sheer number of interventions is hardly enough for most gynecologists to do surgery during half of a day per week. Lastly the duration of training in OBGYN in Europe remained unchanged to 5 years, which is way insufficient to become fully trained in all aspects of our discipline. Most fundamental in most training programs I know is that training is judged by the number of years spend in training. In some countries a theoretical exam is added but it is extremely rare that technical skills are evaluated. Periodical reavaluation is non existent. This concept is the cornerstone of most accreditation programs I am aware of.

Considering the difficulties and the fact that without videoregistration it is impossible to judge the individual intervention, I suggested (LMIG) that videoregistration of entire interventions should become mandatory for the
following reasons
- it can solve some discussions on indication
- it can solve any discussion between stupid accidents, acceptable complications and “unacceptable” complications.
- it could be used for accreditation.
- in addition the mere fact of videoregistration being performed will have some self regulatory aspect on the surgery performed.

For these reasons we strongly suggest to replace the eternal discussions on training, acrreditation and medicolegal issues by a simple criterion ” every gynecologist is permitted to do everything provided he shows what he
does” . The only remaining difficulty is “who is going to judge”. Since only we gynecologists can judge, this should be organized by us. If we do not the judge will continue to rely on non organized “expert witnesses” Philippe R. Koninckx* and Anastasia Ussia** *em Prof OBGYN and *,** Gruppo Italo Belga


Date: Tue, 15 Jan 2013 20:32:11 -0500   From: Hubert Fornalik

Obligatory videotaping sounds like a great idea from eductational/credentialing perspective. Unfortunately in legal environment in USA it would immediately become a tool used more often by lawyers than doctors. Ultimately it would actually shut down development of specialty. (Gynecologic Oncologist,  Indianapolis, USA)

John Marlow MD, Washington DC

First, my complements to Philippe Koninckx and Anastasia Assia for their well written blog concerning the complex issue of accreditation and training of gynecologic surgeons. Our AAGL Exchange blog site is an
appropriate site to explore this very difficult topic. AAGL is global, representing multiple health care delivery systems, presented in real time (almost) to anyone with access to the Internet, available to ivory tower
surgeon and foot soldier surgeon alike, without editorial revisions, free to reader and writer (almost again), and finally transparent in the true sense of the word.

As surgeons we have all learned our surgery from other surgeons. Many of us are asked to pass judgment on other surgeons competence. Methods to help us have been presented on this Exchange, including peer OR
monitorinng, video record reviews, medical record audits, including readmissions and complications. Many difficulties remain to this still unsolved credentialing goal:

Who will do the recredentialing? There are many volunteers for this. Do you need to review an entire video of the surgery including the audio tract? This may take hours and hours. Are their legal issues? Who has
access to the records? In the US this is an important question. How many cases are needed? What about virtual cases? The airline pilots use virtual jets. What about the loss of competence due to aging or low volume
experience? What about recertification? How often? Should a surgeon in a small remote town in Idaho (like my hometown) be judged the same as down town Washington? How can new overlapping areas in surgery be integrated
as far as certification is concerned? This is important for us to consider inasmuch as AAGL is renowned for introducing new surgical procedures. Examples of today’s overlapping interests are: cosmetic/gynecologic,
urologic/gynecologic, oncology/fertility, general surgical/gynecologic, obstetrical (including fetal) surgery/gynecologic surgery. Should OB and GYN surgery be kept united or separate? How many cases does it take to
make a competent surgeon? How long do we have? Age limits, I am told, are now close to 120 years. What about recertification? Should their be international training centers? International standards of practice? Or
should this remain local ?

….Whoa…Time Out!    Perhaps these are topics for a global summit at our next AAGL meeting

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