• SBE ISGE Joint Meeting - Sao Paulo September 2009
• XVIII Annual Congress March 2009 Pattaya,Thailand
• XVII Annual Meeting - Bari Italy
• ISGE Annual Meeting, Japan March 19-23 2007

“Say it ain’t so Smalls”

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is a famous quote from the movie Sandlot; when it comes to minimally invasive gynecologic surgery, that’s exactly the case.  How can it be that the specialty of medicine that introduced laparoscopic surgery now trails in innovation, acceptance and adoption?  You say I’m wrong, well let’s examine these facts…..  According to industry estimates prior to 2004, and more recently Thomson Reuters, between the years 1998 and 2007, the number of laparoscopic cholecystectomies rose from 90 percent to 95 percent, and laparoscopic bariatric surgeries increased from 30 percent to over 90 percent.  The number of laparoscopic appendectomies nearly tripled from 27 percent to 70 percent.  Yet, in this same time period, the laparoscopic approach to hysterectomy remained dismally small; that is, a minimal rise from 10 percent to 20 percent (figure 1).

What is just as alarming is the lack of knowledge that women have regarding minimally invasive gynecologic surgery.  In 2008, an internet survey was conducted by Russell Research, in the United States.  Over 50 percent of the 526 participants, 18 years or older, had experienced at least one of the following symptoms:
• Stress urinary incontinence
• Menorrhagia
• Fibroids
• Organ prolapse
This survey revealed a number of startling findings.  Less than 40% of women surveyed knew that hysterectomies could be greatly reduced by newer, less invasive techniques, and only 45 percent of women had ever heard of myomectomy.  Less than 50 percent of women suffering from menorrhagia were aware of endometrial ablation, and only one in five women surveyed understood that endometrial ablation could be performed as an “in-office” procedure.  Furthermore, one in three women with symptoms of stress urinary incontinence were unaware of sling procedures, and just 19 percent of women knew that sterilization could be performed in an office setting.
These findings supported the contention of the surveyors that while the public is well aware that cholecystectomy and bariatric surgery are laparoscopic procedures, when it came to pelvic health disorders, patients were unaware of their options.  The study also revealed the tremendous bond of trust that the patient has with her gynecologist.  Nearly every woman who participated in the survey expected their ob-gyn would inform them about minimally invasive treatment options, even if the doctor doesn’t offer them.  Furthermore, the treatment regimen prescribed would involve the least amount of pain.  Finally, 94 percent of women expected their gynecologist to offer options of care that least effect lifestyle. 
There is an obvious disconnect between the fact that women are unaware of their minimally invasive gynecologic options, yet they also believe their gynecologist is providing them with the most innovative and least invasive options.  Adding to this, the fact that the number of hysterectomies performed via a minimally invasive approach is depressingly low, it is obvious that patients are neither being informed of their treatment options completely, and minimally invasive gynecologic surgery is not being performed on a large scale.  It is my belief that this disconnect is, in part, because physicians are afraid to lose their patients and endure disruption of their revenue stream.  Even in countries where there are centers of excellence in minimally invasive gynecologic surgery, there is still the problem of physician availability.  Ultimately, in each scenario, it is the inability of enough gynecologists being able to perform minimally invasive gynecologic surgery that is at the center of the problem – the epicenter.  I believe this stems from a lack of proper education and consistent training in minimally invasive gynecologic surgery.  In the United States, this can be well documented by The Accreditation Council for Graduate Medical Education (ACGME).  In Table 1, the National Resident Data Summary Report is presented for residents performing operative laparoscopy as the primary surgeon, as well as, assistant.  Given the fact that a residency program in obstetrics and gynecology in the United States is a four year commitment and that thirty percent of residents perform 50 or less laparoscopies in their training, this averages approximately 12 laparoscopies per year.  In Table 2, hysteroscopy experience is reviewed, revealing even more dramatic results. 
Competency in minimally invasive gynecologic surgery can only improve when case numbers increase during training.  One way of ensuring this goal is to increase patient awareness concerning minimally invasive gynecologic surgery.  As more patients seek out physicians providing these services, they will undergo their procedures at training facilities.  Moreover, physicians involved in resident training must be competent to perform minimally invasive surgery; the trainers must be trained, the teacher must be taught.  Furthermore, resident education in minimally invasive gynecologic surgery must be more uniform.  Interestingly, as of July 2009, all general surgery residents in the United States are required to complete a course entitled Fundamentals of Laparoscopic Surgery (FLS).  Presently, there is no such program for resident education in gynecology within the United States, or for that matter, throughout the world. 
It is the ISGE that must take this call to action and accept its necessary leadership role as the premier international society, to overcome these obstacles to advancement in minimally invasive gynecologic surgery worldwide.
Not only must the ISGE continue to host its very successful international congresses and regional congresses, it must expand on our regional teaching programs.  Ultimately, we must develop a successful “train the trainer” program, which has been the vision of our President, Stefano Bettocchi.
In order to insure success, the ISGE must have industry support.  Our business partners must work with the ISGE to promote its educational endeavors.  Moreover, working with industry, the ISGE must take on the task of promoting minimally invasive gynecologic surgery to women worldwide.  With this information, women throughout the world will be able to self advocate and seek out competent minimally invasive gynecologic surgeons as their needs arise.