Accepted Manuscript Presidential address Javier F. Magrina, MD
PII:
S1553-4650(14)00052-1
DOI:
10.1016/j.jmig.2014.01.022
Reference:
JMIG 2244
To appear in:
The Journal of Minimally Invasive Gynecology
Received Date: 24 January 2014 Accepted Date: 25 January 2014
Please cite this article as: Magrina JF, Presidential address, The Journal of Minimally Invasive Gynecology (2014), doi: 10.1016/j.jmig.2014.01.022. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
RI PT
ACCEPTED MANUSCRIPT
42nd Annual Meeting of the AAGL
Javier F Magrina, MD
TE D
Mayo Clinic in Arizona
M AN U
Isn’t it time to separate the O from the G?
SC
Presidential address
Dear friends and colleagues, I want to share with you my views on the
EP
present training and practice of minimally invasive gynecologic surgery (MIGS). They are based on the evolution of our surgical specialty and the implications
AC C
resulting from this. As I present you with the evidence, the role of this association, AAGL, will be apparent. The rapidly expanding field of surgical technology has deeply impacted our specialty of Gynecology, a different and separate specialty from Obstetrics. I fail to see a common ground between the two specialties of Gynecology and Obstetrics other than patient’s gender. The diseases, ailments, conditions, and
ACCEPTED MANUSCRIPT
disorders of a pregnant woman have nothing in common with a woman with a
RI PT
gynecological malignancy, symptomatic fibroids, or advanced endometriosis.
In 1976, Dr Richard Symmonds, a key surgical mentor during my residency, addressed the need to develop a purely gynecologic surgical subspecialty, rather
SC
than in oncology alone (1). His rationale was that highly specialized, high volume surgeons, and in particular when practicing in dedicated centers, had improved
M AN U
outcomes and reduced costs as compared to unspecialized, low volume surgeons. There is now extensive published evidence confirming his early statements, embracing many surgical specialties. A few of the extensive evidence is referenced here (2-8). His coaching inspired me to abandon
TE D
obstetrics and to pursue a surgical career exclusively in Gynecologic Surgery and Oncology.
EP
Evolution
Gynecological surgery has evolved from a maximally invasive surgical
AC C
approach using abdominal incisions, to a minimally invasive specialty (MIS), using small stab wounds. I consider this a revolution more than an evolution. MIS is here to stay, to expand, and to dominate the surgical practice of gynecologic surgery. The advantages of reduced blood loss, shorter hospitalization, and faster recovery are common outcomes in practically all studies comparing laparotomy with MIS, either laparoscopy or robotics. Indeed, there should be a minimal use of laparotomy in gynecology, which should be almost a purely
ACCEPTED MANUSCRIPT
minimally invasive surgical specialty, what we are already addressing as MIGS:
RI PT
Minimally Invasive Gynecological Surgery. Here a major role for AAGL.
Implications
Many, if not most of us in this room learned two approaches to hysterectomy:
SC
vaginal and abdominal. Present day trainees are required to learn two more
M AN U
approaches to hysterectomy: laparoscopic and robotic, and the single incision technique for each one of them. They are also required to learn about primary care…and all in a shorter residency time.
TE D
Residency training hours have been limited to 80 hours a week. Considering that past residents would easily log 100 hours a week, it is a reduction of 20 hours of training per week. The cumulative result of the reduced hours over a
EP
period of four years, adds to 4,240 hours, which equals to180 days or the equivalent of 6 months. Yes, present day residents are required to learn more
AC C
surgical techniques and primary care with reduced training hours. Training
Have we evolved consequently in our training as our surgical field has embraced MIS techniques? The answer is simply no.
ACCEPTED MANUSCRIPT
In 2012, 1,221 graduates (9) were given certificates to practice Obstetrics and Gynecology, a license which allows them to practice the entire aspects of the specialty to all women, unless their request for specific surgical privileges is
RI PT
denied by the credentialing and privileging committee of the hospitals they are applying to. In 2012, obgyn residents graduated with an average of 59
abdominal hysterectomies, 38 laparoscopic hysterectomies, and 19 vaginal
SC
hysterectomies (9). Considering the learning curve for laparoscopic hysterectomy has been estimated between 30-80 procedures, depending on the measured
M AN U
outcome (10), the average graduating resident is NOT prepared to safely perform a laparoscopic hysterectomy without additional training. AAGL fellowships are fulfilling this need.
In 2007, we carried out a study to compare the basic laparoscopic skills of
TE D
random PG4 residents (Postgraduate level 4) with PG5 (Postgraduate level 5) trainees at the end of their first year of AAGL fellowship at our institution (11) The test included five functions: to introduce a needle with suture through a
EP
trocar, to pick up a dropped needle and place it in the correct direction for
AC C
suturing, to perform two passes of a continuous suture, and to perform an extracorporeal and an intracorporeal tie. Time was measured in all functions except picking a needle which was measured by the number of movements. Results were compared between PG4 and PG5 and are shown in Table I. Not a single PG4 performed correctly all five skills while all PG 5 did (Table I), with markedly increased efficiency when time to completion and number of movements are compared (Table II). The study showed the deficiencies in basic
ACCEPTED MANUSCRIPT
laparoscopic skills for PG4 and the unambiguous benefits of only one year of exclusive training in MIGS.
RI PT
Practice Can practicing gynecologists maintain, improve, or incorporate new surgical techniques with the present day surgical volume? The answer is simply no.
SC
The numbers of ACOG fellows has increased from 13 in 1951 to 56,957 in 2012
M AN U
(12). Considering the 8 year period from 1979 to 2006 the number of ACOG fellows increased by 54% whereas during the same period of time the overall number of gynecologic operations decreased by 46% (13). The outcome is an 81% reduction of the annual number of surgeries per practicing gynecologist
TE D
from 132 in 1979 to 25 in 2007 (Table III).
Considering the annual number of hysterectomies performed by each practicing gynecologist from 1980 to 2007 (Table IV) there has been a
EP
continuous decline from 28 in 1980 to 9.8 in 2007 (14).This number has continued to decrease and in 2010 it was merely 8.5 (15), an obviously
AC C
inadequate number. If in addition one considers four different hysterectomy approaches, the number is plainly insufficient to just maintain safe surgical skills. This reduction in numbers has also been noted for radical hysterectomies,
which is concerning for the training of gynecologic oncology fellows. In 1988 there were 48 radical hysterectomies available for each fellow in training, while in 2008 the number was only 28 (16).
ACCEPTED MANUSCRIPT
Conclusion We are not training residents in MIGS adequately, and once we graduate
RI PT
them they don’t have a sufficient surgical volume to maintain, not to mention improve, safe surgical skills. Isn’t it time to admit our specialty requires a separation of training and surgical practice?
SC
My dear friends, I am not asking anymore if it is time, I am saying IT IS
TIME to act and to separate the O from the G. It is also TIME to test MIS skills to
M AN U
trainees on a regular basis and to practicing gynecologists at the time of recertification. It is also TIME to develop a subspecialty of MIGS. Separate does not mean divorce, it means evolving to a focused type of residency training where individuals with surgical orientation expand their
TE D
surgical skills instead of learning about obstetrical care and move on to a surgically focused practice. As oncologists are referrals for the surgical treatment of cancer, surgical gynecologists should be referrals for benign gynecological
EP
conditions requiring surgical expertise.
AC C
I congratulate and applaud my predecessors in AAGL who 42 years ago had the wisdom to create an association dedicated to pioneer the development of MIS, the optimal surgical approach for our patients. To them, to all previous past presidents and members, to the present members, and to the future ones, I congratulate you and thank you. We have an important role to accomplish.
ACCEPTED MANUSCRIPT
References
RI PT
1. Symmonds, RE. Current concepts in gynecological surgery. Guest Editor, Clin Obstet Gynecol, 19 (3), September 1976
2. Tingulstad S, Skjeldestad FE, and Hagen B. The Effect of Centralization of
SC
Primary Surgery on Survival in Ovarian Cancer Patients. Obstet Gynecol
M AN U
2003; 102:499-505
3. Teresa P. Díaz-Montes a, , Marianna L. Zahurak b, Robert L. Giuntoli II a, Ginger J. Gardner a, Robert E. Bristow Uterine cancer in Maryland: Impact of surgeon case volume and other prognostic factors on short-term mortality.
TE D
Gynecol Oncol 2006; 103:1043-47
4. Chan JK, Kapp DS, Shin JY, HusainA, Teng NN, Berek JS, Osann K, Leiserowitz GS< Cress RD, O’Malley C. Influence of the Gynecologic
EP
Oncologist on the Survival of Ovarian Cancer Patients. Obstet Gynecol 2007;109:1342-50
AC C
5. Robert E. Bristow RE, Santillan E, Diaz-Montes TP, Gardner GJ, Giuntoli, II RL, Meisner BC, Frick KD., Armstrong DK. Centralization of Care for Patients With Advanced-Stage Ovarian Cancer A Cost-effectiveness Analysis. Cancer 2007;109:1513-22 6. Bristow RE, Zahurak ML, Diaz-Montes TP, Giuntoli RL, Armstrong DK. Impact of surgeon and hospital ovarian cancer surgical case volume on in-
ACCEPTED MANUSCRIPT
hospital mortality and related short-term outcomes. Gynecol Oncol 2009; 115:334-38
RI PT
7. Rogo-Gupta,LJ, Lewin SN, Kim JH, Burke WM, Su X, Herzog TJ, Wright JD. The effect of Surgeon Volume on Outcomes and Resource use for Vaginal Hysterectomy. Obstet Gynecol 2010; 116: 1341-7
SC
8. Boyd LR, Novetsky AP, Curtin JC. Effect of Surgical Volume on Route of
M AN U
Hysterectomy and Short-Term Morbidity. Obstet Gynecol 2010;116:909–15 9. American Council for Graduate Medical Education, 2012 data 10. Kho RM. Comparison of Robotic-Assisted Laparoscopy Versus Conventional Laparoscopy on Skill Acquisition and Performance. Clin Obstet
TE D
Gynecol, 2011; 54: 376-381
11. Akl MN, Giles DL, Long JB, Magrina JF, Kho RM. The Efficacy of Viewing an Educational Video as a Method for the Acquisition of Basic
EP
Laparoscopic Suturing Skills. J Minim Invasive Gynecol. 2008 ;15:410-413
AC C
12. ACOG: American College Obstetricians and Gynecologists, manpower statistics 2012.
13. Oliphant SO, Jones KL, Wang L, Bunker CH, Lowder JL. Trends Over Time With Commonly Performed Obstetric and Gynecologic Inpatient Procedures. Obstet Gynecol 2010, 116: 926-31
ACCEPTED MANUSCRIPT
14. NHSR available at: http://www.cdc.gov/nchs/products/nhsr.htm. Hysterectomy in the US and oophorectomy 1979-2007.
RI PT
15. HCUP-Nationwide Inpatient Sample: Agency for Health Care and Research Quality 2013
16. Ward SKN, , M. McHale, E. Alvarez, C. Saenz, S. Plaxe.1998-2008
SC
Estimated rate of decline in radical hysterectomies available for training in the
AC C
EP
TE D
M AN U
US, 1998–2008 Gynecol Oncol 2012, 127: S30 ; 10.1016/j.ygyno.2012.07.082
ACCEPTED MANUSCRIPT
Table I. Percentage of PG4 residents (n=12) and PG5 AAGL fellows (n=4) at end of first year at Mayo Clinic in Arizona performing basic laparoscopic skills (11)\ % correct PG4
RI PT
Task
PG5 AAGL Fellow
67
100
Intracorporeal knot tie
50
100
Extracorporeal knot tie
75
100
M AN U
SC
Inserting a needle through a trocar
TE D
Table II. Comparison of performance of PG4 (n=12) vs PG5 (n=4) AAGL fellows at Mayo Clinic in Arizona on five basic laparoscopic skills (11)
EP
PG4
AC C
Inserting a needle through a trocar
7 sec
PG5 AAGL Fellow 2 sec
Intracorporeal knot tying*
5 min
36 sec
Extracorporeal knot tying*
2 min
30 sec
Pick up dropped needle
6 moves
3 moves
2 passes running suture
9 min
1.7 min
ACCEPTED MANUSCRIPT
16.7 min
3.5 min
RI PT
*maximum time allowed
SC
Table III. Total number of gynecological operations and number of ACOG* fellows in 1979 and in 2006, and number of annual operations per ACOG fellow in 1976 vs
1979
Number of ACOG fellows
2,852,000
TE D
Number of operations
M AN U
2006..(12,13)
21,364 132
Change
1,309,000
46% decrease
51,123
54% increase
25
81% decrease
EP
Number of operations per fellow
2006
AC C
*ACOG: American College of Obstetricians and Gynecologists
Table IV. Number of hysterectomies per gynecologist in 1980 and 2007 in USA (14)
Year
Hyst
ACOG fellows
Hyst per ACOG fellow
1980
647,000
22,516
28
2007
517,000
52,385
9.8
RI PT
ACCEPTED MANUSCRIPT
Hyst: total number of hysterectomies; ACOG: number of fellows of American
AC C
EP
TE D
M AN U
SC
College of Obstetricians and Gynecologists
PII:
S1553-4650(14)00052-1
DOI:
10.1016/j.jmig.2014.01.022
Reference:
JMIG 2244
To appear in:
The Journal of Minimally Invasive Gynecology
Received Date: 24 January 2014 Accepted Date: 25 January 2014
Please cite this article as: Magrina JF, Presidential address, The Journal of Minimally Invasive Gynecology (2014), doi: 10.1016/j.jmig.2014.01.022. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
RI PT
ACCEPTED MANUSCRIPT
42nd Annual Meeting of the AAGL
Javier F Magrina, MD
TE D
Mayo Clinic in Arizona
M AN U
Isn’t it time to separate the O from the G?
SC
Presidential address
Dear friends and colleagues, I want to share with you my views on the
EP
present training and practice of minimally invasive gynecologic surgery (MIGS). They are based on the evolution of our surgical specialty and the implications
AC C
resulting from this. As I present you with the evidence, the role of this association, AAGL, will be apparent. The rapidly expanding field of surgical technology has deeply impacted our specialty of Gynecology, a different and separate specialty from Obstetrics. I fail to see a common ground between the two specialties of Gynecology and Obstetrics other than patient’s gender. The diseases, ailments, conditions, and
ACCEPTED MANUSCRIPT
disorders of a pregnant woman have nothing in common with a woman with a
RI PT
gynecological malignancy, symptomatic fibroids, or advanced endometriosis.
In 1976, Dr Richard Symmonds, a key surgical mentor during my residency, addressed the need to develop a purely gynecologic surgical subspecialty, rather
SC
than in oncology alone (1). His rationale was that highly specialized, high volume surgeons, and in particular when practicing in dedicated centers, had improved
M AN U
outcomes and reduced costs as compared to unspecialized, low volume surgeons. There is now extensive published evidence confirming his early statements, embracing many surgical specialties. A few of the extensive evidence is referenced here (2-8). His coaching inspired me to abandon
TE D
obstetrics and to pursue a surgical career exclusively in Gynecologic Surgery and Oncology.
EP
Evolution
Gynecological surgery has evolved from a maximally invasive surgical
AC C
approach using abdominal incisions, to a minimally invasive specialty (MIS), using small stab wounds. I consider this a revolution more than an evolution. MIS is here to stay, to expand, and to dominate the surgical practice of gynecologic surgery. The advantages of reduced blood loss, shorter hospitalization, and faster recovery are common outcomes in practically all studies comparing laparotomy with MIS, either laparoscopy or robotics. Indeed, there should be a minimal use of laparotomy in gynecology, which should be almost a purely
ACCEPTED MANUSCRIPT
minimally invasive surgical specialty, what we are already addressing as MIGS:
RI PT
Minimally Invasive Gynecological Surgery. Here a major role for AAGL.
Implications
Many, if not most of us in this room learned two approaches to hysterectomy:
SC
vaginal and abdominal. Present day trainees are required to learn two more
M AN U
approaches to hysterectomy: laparoscopic and robotic, and the single incision technique for each one of them. They are also required to learn about primary care…and all in a shorter residency time.
TE D
Residency training hours have been limited to 80 hours a week. Considering that past residents would easily log 100 hours a week, it is a reduction of 20 hours of training per week. The cumulative result of the reduced hours over a
EP
period of four years, adds to 4,240 hours, which equals to180 days or the equivalent of 6 months. Yes, present day residents are required to learn more
AC C
surgical techniques and primary care with reduced training hours. Training
Have we evolved consequently in our training as our surgical field has embraced MIS techniques? The answer is simply no.
ACCEPTED MANUSCRIPT
In 2012, 1,221 graduates (9) were given certificates to practice Obstetrics and Gynecology, a license which allows them to practice the entire aspects of the specialty to all women, unless their request for specific surgical privileges is
RI PT
denied by the credentialing and privileging committee of the hospitals they are applying to. In 2012, obgyn residents graduated with an average of 59
abdominal hysterectomies, 38 laparoscopic hysterectomies, and 19 vaginal
SC
hysterectomies (9). Considering the learning curve for laparoscopic hysterectomy has been estimated between 30-80 procedures, depending on the measured
M AN U
outcome (10), the average graduating resident is NOT prepared to safely perform a laparoscopic hysterectomy without additional training. AAGL fellowships are fulfilling this need.
In 2007, we carried out a study to compare the basic laparoscopic skills of
TE D
random PG4 residents (Postgraduate level 4) with PG5 (Postgraduate level 5) trainees at the end of their first year of AAGL fellowship at our institution (11) The test included five functions: to introduce a needle with suture through a
EP
trocar, to pick up a dropped needle and place it in the correct direction for
AC C
suturing, to perform two passes of a continuous suture, and to perform an extracorporeal and an intracorporeal tie. Time was measured in all functions except picking a needle which was measured by the number of movements. Results were compared between PG4 and PG5 and are shown in Table I. Not a single PG4 performed correctly all five skills while all PG 5 did (Table I), with markedly increased efficiency when time to completion and number of movements are compared (Table II). The study showed the deficiencies in basic
ACCEPTED MANUSCRIPT
laparoscopic skills for PG4 and the unambiguous benefits of only one year of exclusive training in MIGS.
RI PT
Practice Can practicing gynecologists maintain, improve, or incorporate new surgical techniques with the present day surgical volume? The answer is simply no.
SC
The numbers of ACOG fellows has increased from 13 in 1951 to 56,957 in 2012
M AN U
(12). Considering the 8 year period from 1979 to 2006 the number of ACOG fellows increased by 54% whereas during the same period of time the overall number of gynecologic operations decreased by 46% (13). The outcome is an 81% reduction of the annual number of surgeries per practicing gynecologist
TE D
from 132 in 1979 to 25 in 2007 (Table III).
Considering the annual number of hysterectomies performed by each practicing gynecologist from 1980 to 2007 (Table IV) there has been a
EP
continuous decline from 28 in 1980 to 9.8 in 2007 (14).This number has continued to decrease and in 2010 it was merely 8.5 (15), an obviously
AC C
inadequate number. If in addition one considers four different hysterectomy approaches, the number is plainly insufficient to just maintain safe surgical skills. This reduction in numbers has also been noted for radical hysterectomies,
which is concerning for the training of gynecologic oncology fellows. In 1988 there were 48 radical hysterectomies available for each fellow in training, while in 2008 the number was only 28 (16).
ACCEPTED MANUSCRIPT
Conclusion We are not training residents in MIGS adequately, and once we graduate
RI PT
them they don’t have a sufficient surgical volume to maintain, not to mention improve, safe surgical skills. Isn’t it time to admit our specialty requires a separation of training and surgical practice?
SC
My dear friends, I am not asking anymore if it is time, I am saying IT IS
TIME to act and to separate the O from the G. It is also TIME to test MIS skills to
M AN U
trainees on a regular basis and to practicing gynecologists at the time of recertification. It is also TIME to develop a subspecialty of MIGS. Separate does not mean divorce, it means evolving to a focused type of residency training where individuals with surgical orientation expand their
TE D
surgical skills instead of learning about obstetrical care and move on to a surgically focused practice. As oncologists are referrals for the surgical treatment of cancer, surgical gynecologists should be referrals for benign gynecological
EP
conditions requiring surgical expertise.
AC C
I congratulate and applaud my predecessors in AAGL who 42 years ago had the wisdom to create an association dedicated to pioneer the development of MIS, the optimal surgical approach for our patients. To them, to all previous past presidents and members, to the present members, and to the future ones, I congratulate you and thank you. We have an important role to accomplish.
ACCEPTED MANUSCRIPT
References
RI PT
1. Symmonds, RE. Current concepts in gynecological surgery. Guest Editor, Clin Obstet Gynecol, 19 (3), September 1976
2. Tingulstad S, Skjeldestad FE, and Hagen B. The Effect of Centralization of
SC
Primary Surgery on Survival in Ovarian Cancer Patients. Obstet Gynecol
M AN U
2003; 102:499-505
3. Teresa P. Díaz-Montes a, , Marianna L. Zahurak b, Robert L. Giuntoli II a, Ginger J. Gardner a, Robert E. Bristow Uterine cancer in Maryland: Impact of surgeon case volume and other prognostic factors on short-term mortality.
TE D
Gynecol Oncol 2006; 103:1043-47
4. Chan JK, Kapp DS, Shin JY, HusainA, Teng NN, Berek JS, Osann K, Leiserowitz GS< Cress RD, O’Malley C. Influence of the Gynecologic
EP
Oncologist on the Survival of Ovarian Cancer Patients. Obstet Gynecol 2007;109:1342-50
AC C
5. Robert E. Bristow RE, Santillan E, Diaz-Montes TP, Gardner GJ, Giuntoli, II RL, Meisner BC, Frick KD., Armstrong DK. Centralization of Care for Patients With Advanced-Stage Ovarian Cancer A Cost-effectiveness Analysis. Cancer 2007;109:1513-22 6. Bristow RE, Zahurak ML, Diaz-Montes TP, Giuntoli RL, Armstrong DK. Impact of surgeon and hospital ovarian cancer surgical case volume on in-
ACCEPTED MANUSCRIPT
hospital mortality and related short-term outcomes. Gynecol Oncol 2009; 115:334-38
RI PT
7. Rogo-Gupta,LJ, Lewin SN, Kim JH, Burke WM, Su X, Herzog TJ, Wright JD. The effect of Surgeon Volume on Outcomes and Resource use for Vaginal Hysterectomy. Obstet Gynecol 2010; 116: 1341-7
SC
8. Boyd LR, Novetsky AP, Curtin JC. Effect of Surgical Volume on Route of
M AN U
Hysterectomy and Short-Term Morbidity. Obstet Gynecol 2010;116:909–15 9. American Council for Graduate Medical Education, 2012 data 10. Kho RM. Comparison of Robotic-Assisted Laparoscopy Versus Conventional Laparoscopy on Skill Acquisition and Performance. Clin Obstet
TE D
Gynecol, 2011; 54: 376-381
11. Akl MN, Giles DL, Long JB, Magrina JF, Kho RM. The Efficacy of Viewing an Educational Video as a Method for the Acquisition of Basic
EP
Laparoscopic Suturing Skills. J Minim Invasive Gynecol. 2008 ;15:410-413
AC C
12. ACOG: American College Obstetricians and Gynecologists, manpower statistics 2012.
13. Oliphant SO, Jones KL, Wang L, Bunker CH, Lowder JL. Trends Over Time With Commonly Performed Obstetric and Gynecologic Inpatient Procedures. Obstet Gynecol 2010, 116: 926-31
ACCEPTED MANUSCRIPT
14. NHSR available at: http://www.cdc.gov/nchs/products/nhsr.htm. Hysterectomy in the US and oophorectomy 1979-2007.
RI PT
15. HCUP-Nationwide Inpatient Sample: Agency for Health Care and Research Quality 2013
16. Ward SKN, , M. McHale, E. Alvarez, C. Saenz, S. Plaxe.1998-2008
SC
Estimated rate of decline in radical hysterectomies available for training in the
AC C
EP
TE D
M AN U
US, 1998–2008 Gynecol Oncol 2012, 127: S30 ; 10.1016/j.ygyno.2012.07.082
ACCEPTED MANUSCRIPT
Table I. Percentage of PG4 residents (n=12) and PG5 AAGL fellows (n=4) at end of first year at Mayo Clinic in Arizona performing basic laparoscopic skills (11)\ % correct PG4
RI PT
Task
PG5 AAGL Fellow
67
100
Intracorporeal knot tie
50
100
Extracorporeal knot tie
75
100
M AN U
SC
Inserting a needle through a trocar
TE D
Table II. Comparison of performance of PG4 (n=12) vs PG5 (n=4) AAGL fellows at Mayo Clinic in Arizona on five basic laparoscopic skills (11)
EP
PG4
AC C
Inserting a needle through a trocar
7 sec
PG5 AAGL Fellow 2 sec
Intracorporeal knot tying*
5 min
36 sec
Extracorporeal knot tying*
2 min
30 sec
Pick up dropped needle
6 moves
3 moves
2 passes running suture
9 min
1.7 min
ACCEPTED MANUSCRIPT
16.7 min
3.5 min
RI PT
*maximum time allowed
SC
Table III. Total number of gynecological operations and number of ACOG* fellows in 1979 and in 2006, and number of annual operations per ACOG fellow in 1976 vs
1979
Number of ACOG fellows
2,852,000
TE D
Number of operations
M AN U
2006..(12,13)
21,364 132
Change
1,309,000
46% decrease
51,123
54% increase
25
81% decrease
EP
Number of operations per fellow
2006
AC C
*ACOG: American College of Obstetricians and Gynecologists
Table IV. Number of hysterectomies per gynecologist in 1980 and 2007 in USA (14)
Year
Hyst
ACOG fellows
Hyst per ACOG fellow
1980
647,000
22,516
28
2007
517,000
52,385
9.8
RI PT
ACCEPTED MANUSCRIPT
Hyst: total number of hysterectomies; ACOG: number of fellows of American
AC C
EP
TE D
M AN U
SC
College of Obstetricians and Gynecologists
