Professional Documents
Culture Documents
Aarathi Cholkeri-Singh, MD
PROGRAM CO-CHAIR
Larry R. Glazerman, MD
Mark R. Hoffman, MD
Kathy Huang, MD
Hye-Chun Hur, MD
Nash S. Moawad, MD
Angela M. Pratt, MD
Sangeeta Senapati, MD
Jessica A. Shepherd, MD
Matthew T. Siedhoff, MD
Karen C. Wang, MD
Sponsored by
AAGL
ProfessionalEducationInformation
TargetAudience
Educationalactivitiesaredevelopedtomeettheneedsofsurgicalgynecologistsinpracticeandin
training,aswellas,otheralliedhealthcareprofessionalsinthefieldofgynecology.
Accreditation
AAGLisaccreditedbytheAccreditationCouncilforContinuingMedicalEducationtoprovidecontinuing
medicaleducationforphysicians.
TheAAGLdesignatesthisliveactivityforamaximumof3.75AMAPRACategory1Credit(s).Physicians
shouldclaimonlythecreditcommensuratewiththeextentoftheirparticipationintheactivity.
DISCLOSUREOFRELEVANTFINANCIALRELATIONSHIPS
As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must
ensurebalance,independence,andobjectivityinallCMEactivitiestopromoteimprovementsinhealth
careandnotproprietaryinterestsofacommercialinterest.Theprovidercontrolsalldecisionsrelatedto
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
contentofthisactivityarerequiredtodiscloserelevantfinancialrelationshipswithcommercialinterests
related to the subject matter of this educational activity. Learners are able to assess the potential for
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finalsafeguardsinassuringthataCMEactivityisindependentfromcommercialsupport.Webelievethis
mechanismcontributestothetransparencyandaccountabilityofCME.
TableofContents
CourseDescription........................................................................................................................................1
Disclosure......................................................................................................................................................3
PortPlacement,NeedleLoadingandTissueReapproximation
A.CholkeriSingh..........................................................................................................................................5
ExtracorporealKnotTying
A.CholkeriSingh..........................................................................................................................................9
IntracorporealKnotTying
H.C.Hur......................................................................................................................................................16
SutureSelectionandTechnologiesUsedinGynecologicLaparoscopy
K.C.Wang...................................................................................................................................................19
CulturalandLinguisticsCompetency.........................................................................................................24
PG 201
Laparoscopic Suturing: Practical Tips for Needle Management,
Knot Tying and Suture Use (Simulation Lab)
Aarathi Cholkeri-Singh, Chair
Joseph (Jay) L. Hudgens, Co-Chair
Faculty: Angela Chaudhari, Larry R. Glazerman, Mark R. Hoffman, Kathy Huang, Hye-Chun Hur,
Gretchen E.H. Makai, Nash S. Moawad, Angela M. Pratt, Sangeeta Senapati, Jessica A. Shepherd,
Matthew T. Siedhoff, Karen C. Wang
Course Description
This workshop provides an overview of laparoscopic suturing and knot tying techniques, which will
include both intracorporeal and extracorporeal knots. The course will offer hands-on suturing simulation
where experienced faculty will actively guide participants through the training steps. Various
applications for different suture materials and technologies utilized in gynecologic laparoscopy will also
be reviewed. The course is designed for gynecologists in practice who want to develop or improve their
suturing skills for immediate application in their surgical practice.
Course Objectives
At the conclusion of this course, the participant will be able to: 1) Manipulate and load a needle
laparoscopically for tissue reapproximation; 2) perform extracorporeal knots; 3) perform intracorporeal
knots; 4) outline the advantages, disadvantages, and clinical applications for extracorporeal versus
intracorporeal knots; 5) distinguish advantages and disadvantages of various suture materials, including
barbed suture; and 6) distinguish advantages and disadvantages of suturing technologies used in
laparoscopy.
A. Cholkeri-Singh
A. Cholkeri-Singh
All Faculty
A. Cholkeri-Singh
All Faculty
All Faculty
9:55 Break
10:10 Intracorporeal Knot Tying
H.C. Hur
All Faculty
K.C. Wang
All Faculty
All Faculty
PLANNER DISCLOSURE
The following members of AAGL have been involved in the educational planning of this workshop and
have no conflict of interest to disclose (in alphabetical order by last name).
Art Arellano, Professional Education Manager, AAGL*
Viviane F. Connor
Consultant: Conceptus Incorporated
Frank D. Loffer, Executive Vice President/Medical Director, AAGL*
Linda Michels, Executive Director, AAGL*
Jonathan Solnik
Other: Lecturer - Olympus, Lecturer - Karl Storz Endoscopy-America
SCIENTIFIC PROGRAM COMMITTEE
Arnold P. Advincula
Consultant: CooperSurgical, Ethicon Women's Health & Urology, Intuitve Surgical
Other: Royalties - CooperSurgical
Linda Bradley
Grants/Research Support: Elsevier
Consultant: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharmaceuticals
Speaker's Bureau: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharm
Keith Isaacson
Consultant: Karl Storz Endoscopy
Rosanne M. Kho
Other: Honorarium - Ethicon Endo-Surgery
C.Y. Liu*
Javier Magrina*
Ceana H. Nezhat
Consultant: Intuitve Surgical, Lumenis, Karl Storz Endoscopy-America
Speaker's Bureau: Conceptus Incorporated, Ethicon Women's Health & Urology
William H. Parker
Grants/Research Support: Ethicon Women's Health & Urology
Consultant: Ethicon Women's Health & Urology
Craig J. Sobolewski
Consultant: Covidien, CareFusion, TransEnterix
Stock Shareholder: TransEnterix
Speaker's Bureau: Covidien, Abbott Laboratories
Other: Proctor - Intuitve Surgical
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).
Aarathi Cholkeri-Singh*
Joseph L. Hudgens
Consultant: Karl Storz Endoscopy-America
Angela Chaudhari*
Mark R. Hoffman*
Jian Qun (Kathy) Huang
Presented by:
Port Placement, Needle Loading,
& Tissue Re-approximation
Disclosures
Objectives
System
Ipsilateral
Ergonomics
2. Reapproximate
Assistant
3. Knot Tying
One Sided
Contralateral
Suprapubic
Ideal Triangulation
Gravity
Poor Ergonomics?
Ergonomics?
No Assistant
Two Sided
Needle Holders
Straight
Curved
For desired needle angles >135o
Self-Righting
Endo Wrist Articulating
Hand-held
Da Vinci Robot
System
1. Set the Needle
2. Re-approximate
3. Knot Tying
Laparoscopic
Robotic
Needle Entry
System
Set (perpendicular)
Parallel ((tissue))
Rotate (key)
Tie Knot
Direct-trocar
5mm..Backload
Backloaded
8mm..SH-1
8mm SH-1
Abdominal Wall
Reset
A-B-C
A = 2cm
from Swedge
B = 1/3
from Point
C = 1/3
from
Swedge
A-B-C
Right Hand
Left Hand
System
Set (perpendicular)
Novice
Parallel ((tissue))
Rotate (key)
Expert
Tie Knot
Reset
Hiemstra et al JMIG 2011 vol. 18, pgs 494-499
References
1. Joseph L. Hudgens, RP Pasic. Geometrically
Efficient Laparoscopic Suturing. 40th Global
Congress AAGL, 2011
A. Port placement.
B. Understanding the relationship between the
tissue, camera, and ports.
2 Resad P.
2.
P Pasic,
Pasic RL Levine.
Levine A Practical
Manual of Laparoscopy 2nd Edition. New
York: The Parthenon Publishing Group 2002
Disclosures
Ihavenofinancialrelationshipstodisclose.
AarathiCholkeriSingh,M.D.,FACOG
ClinicalAssistantProfessorof
ObstetricsandGynecologyatUIC
AssociateDirectorofMinimallyInvasive
GynecologicSurgery
DirectorofGynecologicSurgical
EducationatALGH
Objectives
anunreliablesutureknotcanspoilthe
outcomesofanotherwisebeautifully
p
performedsurgicalprocedure.
g
p
Reviewprinciplesofknotsecurity
OverviewofapplicationsofExtracorporealKnots
UnderstandExtracorporealKnottyingtechnique
p
y g
q
Extracorporealknottroubleshooting
unknownauthor
Videodemonstrationsofextracorporealknotusein
gynecologicsurgery
Roleofextracorporealknotsinlaparoscopicsurgery.www.laparoscopyhospital.com
PrinciplesofKnotSecurity
1.
SutureMaterial
TypeofSuture
2. TypeofKnot
3. SurgicalTechnique
Naturalvs.Synthetic
Naturali.e.Chromic
GOAL=tissueis
approximatedand
secured
Tissuefluidsalterabilitytoholdknot
Synthetic
Multifilament
Lieflatmorereadilysecondarytolessmemory
Monofilament
Lesstissueinflammation
Slippageandweakenfromsurgicalinstruments
4. Lengthofcutend
Frictionisgreaterforbraidedmultifilamentthan
SanzLE.Selectingthebestsuturematerial.ContemporaryOb/Gyn.2001;5772.
SchubertDC,UngerJB,MukherjeeD,etal.Mechanicalperformanceofknotsusingbraidedandmonofilamentabsorbablesutures. AmJObstet
Gynecol.2002;187(6):143842.
monofilamentsuture
GoldenbergEA,ChatterjeeA.Towardsabetterlaparoscopicknot:usingknotqualityscorestoevaluatethreelaparoscopicknottyingtechniques.
JSLS2009;13(3):4169.
SanzLE.Selectingthebestsuturematerial.ContemporaryOb/Gyn.2001;5772.
.
AmorteguiJD,RestrepoH.Knotsecurityinlaparoscopicsurgery.SurgEndosc.2002;16:15981602.
Roleofextracorporealknotsinlaparoscopicsurgery.www.laparoscopyhospital.com
Typeofknot
SutureLength
Intracorporeal
Singleusesuture,minimumlengthofsutureshould
be27inches(70cm) standardlength
Extracorporeal
Slidingknot
Coefficientoffrictionnot
q
y
equallydistributed
betweensutureends
Eachendofsutureenters
andleavesknotinsame
direction
Oneaxialstrandisheld
undertensionastheother
tiesaroundit
Squareknot
Coefficientoffriction
equallydistributed
betweensutureends
Eachendofsutureenters
andleavesknotinopposite
direction
Multipleuseorpursestringsuture,recommend
lengthofsuturetobeminimum48inches(122cm)
SchubertDC,UngerJB,MukherjeeD,etal.Mechanicalperformanceofknotsusingbraidedandmonofilamentabsorbablesutures. AmJObstetGynecol.
2002;187(6):143842.
AmorteguiJD,RestrepoH.Knotsecurityinlaparoscopicsurgery.SurgEndosc.2002;16:15981602.
LaparoscopicKnots
LaparoscopicKnots
Amorteguietal,SurgEndosc 2002
1surgeon,7typesofknots
140knotsconventionalvs.140knotslaparoscopic
20braidedpolyester
b id d l
46throws
Knotsmeasuredforbreaksusingtensiometerandknot
slips>3mm
S
SlidingKnot
1or2indicatesnumberofflatsquareknots
X
throwinoppositedirectionfromprevious
=
throwinsamedirectionasprevious
//
changeofaxialstrandandnextthrowturnsinsamedirectionasprevious
# changeofaxialstrandandnextthrowturnsinoppositedirectionfromprevious
AmorteguiJD,RestrepoH.Knotsecurityinlaparoscopicsurgery.SurgEndosc.2002;16:15981602.
AmorteguiJD,RestrepoH.Knotsecurityinlaparoscopicsurgery.SurgEndosc.2002;16:15981602.
LaparoscopicKnots
LaparoscopicKnots
IntracorporealSquare
Knots
Goldenbergetal,JSLS 2009
ExtracorporealSliding
Knot
3surgeons,100knots,20silk,
4throwsmeasuredforknot
slipsandbreaksusing
tensiometer
Extracorporealsquareknots
vs.
Intracorporealslipsquare
vs.
Intracorporealflatsquare
Theseconfigurationshadsuperiortensilestrengthto
otherstestedinlaparoscopicgroup(p<0.05)
Figure2.AgraphicalrepresentationoftheKnotQualityScore
(KQS).Itisbasedonthequartilesofthevariable.Therectangular
boxcorrespondstothelowerquartileandtheupper
quartile.Thelineinthemiddleisthemedian.
Nosignificantdifferencebetweenthese3configurations
AmorteguiJD,RestrepoH.Knotsecurityinlaparoscopicsurgery.SurgEndosc.2002;16:15981602.
GoldenbergEA,ChatterjeeA.Towardsabetterlaparoscopicknot:usingknotqualityscorestoevaluatethreelaparoscopicknottyingtechniques.JSLS
2009;13(3):4169.
10
ExtracorporealKnots
RobotassistedLaparoscopicKnots
Decreaseoperativetime
Easytoperform
Quickertotiethanintracorporealknots
Q
p
Largervariabilityin
thestrengthofthe
knotsmadeusing
therobot,which
correspondedto
higherpercentageof
unravelingknots
Tensilestrengthcomparabletointracorporealknots
MufflyT,McCormickTC,DeanJ,etal.Anevaluationofknotintegritywhentiedroboticallyandconventionally.AmJObstetGynecol 2009;e1820.
SharpHT,DorseyJH,ChovanJD,etal.Theeffectofknotgeometryonthestrengthoflaparoscopicslipknots.ObstetGynecol 1996;88:40811.
ReynissonP,ShokriE,BendahlP,etal.TensilestrengthofsurgicalknotsperformedwiththedaVincisurgicalrobot.JMIG 2010;17(3):36570.
SurgicalTechniqueof
ExtracorporealKnots
Applications
GeneralGYN
Ovarianreconstruction
Vaginalcuffclosure
Cervicalstumpclosure
Myomectomy
Inlieuofadditionalport
andgrasper
Repairs
Bladder
Bowel
UterinePerforation
UroGyn
Sacrocolpopexy/Sacrocer
vicopexy
Paravaginaldefectrepair
Burch
McCall
McCallsCuldoplasty
sCuldoplasty
Interruptedorpursestringstitchplacedintissue
Bothendsofsutureoutsideoflaparoscopicport
Knotformedoutsideofabdominalcavity
Laparoscopicknotpushermountedadjacenttoknot
Tensionplacedonbothendsofsutureaslaparoscopic
knotpushercinchesdownandsecureseachknotto
tissue
6. Releaseknotpusherfromsuture
7. Repeatthrows(steps26)
1.
2.
3.
4
4.
5.
REI
Cufftuboplasty
TubalReanastomosis
Usefulforanyinterrupted
orpursestringsuturing
GoldenbergEA,ChatterjeeA.Towardsabetterlaparoscopicknot:usingknotqualityscorestoevaluatethreelaparoscopicknottying
techniques.JSLS2009;13(3):4169.
InoueH,KumagaiY,NishikageT,etal.Asimpletechniqueofusingnovelthreadholdingandknotpushingforcepsforextracorporealknot
tying.SurgToday 2000;30:5713.
BehmT,UngerJB,IvyJJ,etal.Flatsquareknots:are3throwsenough?AmJObstetGynecol.2007;197:172.e13.
AmorteguiJD,RestrepoH.Knotsecurityinlaparoscopicsurgery.SurgEndosc.2002;16:15981602.
LaparoscopicKnotPushers
11
ExtracorporealKnot
TheAmericanCollegeofObstetriciansandGynecologists(ObstetricsandGynecology,1992,79:143147.)
ExtracorporealKnotVideo
SutureTail
Cuttingtailofknottooshortcompromisesknot
integrityasitcaneasilyunravel
Troubleshooting
Suturetooshort
g 5
p
Needlethrough5mmport
Suturetwisting
Openknotpusherreleasedearly
12
ShortSuture
NeedleBackloading
NeedleBackloading
UntwistingSuture
ReplacingKnotPusher
ReplacingKnotPusher
13
LaparoscopicBabcock
VaginalCuffRepair
Uterosacral Suspension
OvarianReconstruction
Oophoropexy
14
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Question
Roleofextracorporealknotsinlaparoscopicsurgery.www.laparoscopyhospital.com
Sanz LE.Selectingthebestsuturematerial.ContemporaryOb/Gyn.2001;5772.
SchubertDC,UngerJB,Mukherjee D,etal.Mechanicalperformanceofknotsusingbraided
andmonofilamentabsorbablesutures.AmJObstet Gynecol.2002;187(6):143842.
GoldenbergEA,Chatterjee A.Towardsabetterlaparoscopicknot:usingknotqualityscores
toevaluatethreelaparoscopicknottyingtechniques.JSLS2009;13(3):4169.
Amortegui JD,Restrepo H.Knotsecurityinlaparoscopicsurgery.Surg Endosc.2002;16:1598
1602.
6
SharpHT,DorseyJH,Chovan JD,etal.Theeffectofknotgeometryonthestrengthof
laparoscopicslipknots.Obstet Gynecol 1996;88:40811.
InoueH,Kumagai Y,Nishikage T,etal.Asimpletechniqueofusingnovelthreadholding
andknotpushingforcepsforextracorporealknottying.Surg Today 2000;30:5713.
Behm T,UngerJB,IvyJJ,etal.Flatsquareknots:are3throwsenough?AmJObstet Gynecol.
2007;197:172.e13.
TheAmericanCollegeofObstetriciansandGynecologists(ObstetricsandGynecology,1992,
79:143147.)
Muffly T,McCormickTC,DeanJ,etal.Anevaluationofknotintegritywhentiedrobotically
andconventionally.AmJObstet Gynecol 2009;e1820.
Reynisson P,Shokri E,Bendahl P,etal.Tensilestrengthofsurgicalknotsperformedwiththe
da Vincisurgicalrobot.JMIG 2010;17(3):36570.
A34yearoldwomanwhodesirespregnancyhashad18months
withoutconception.Shehasbeenfoundtohavearighthydrosalpinx
andisoptingtoundergolaparoscopictubaplasty fortreatment.Upon
insertionoftheuterinemanipulator,theuterinefundusisperforated
andactivelybleeding.
Whatisthebeststepinmaintaininghemostasisatthesiteoftheuterine
perforation?
A. Dessicate thearea
B. Placesurgicalhemostaticagent
C. Placeaninterruptedsuture
D. Notreatmentnecessary
E. Notapplicabletomyareaofpractice
CorrectAnswer:C
15
Disclosures
Intracorporeal KnotTying
Ihavenofinancialrelationshipsto
disclose.
HyeChunHur,MD
BethIsraelDeaconessMedicalCenter
Director,MinimallyInvasiveGynecologicSurgery
AssistantProfessor,HarvardMedicalSchool
Indications
Objectives
Indicationsforintracorporealknottying
Basicequipment
Technique
breakdownofsteps
helpfultips
videodemo
General:
any indication for
extracorporeal knot tying
can be applied to
intracorporeal
p
knot tying
y g
Specific:
more delicate suturing,
tying knots off tension
bowel repair
bladder repair
peritoneal closures (e.g.
sacrocolpopexy)
knotpusherunavailable
Equipment
LaparoscopicNeedleDriver(curved,locking)
LaparoscopicNeedleGrasper(straight)
LaparoscopicScissors
Suture,cut68inches(interruptedvsfigureof
eightsutures)
10mmtrocar(directdeliveryofneedle)
5mmtrocar(backloadneedle)
16
BreakdownofSteps
Tips: IntracorporealKnotTying
1. Selectappropriatetrocarsizeforneedledelivery.
2. Cutsutureinadvance.
Interruptedsuture 6inches
Figureofeightsuture 8inches
Continuousrunningsuture 12inches
3. Placesuture.
3
Place suture
4. Throw46squareknots(oppositedirection).
Vicryl 4throws
PDS 6throws
5. Cutsuture,removeneedleunderdirectvisualization.
Replicateaninstrumenttie.
InterruptedSuture
ImportantTips
FigureofEightSuture
17
Conclusion
If you can do an instrument tie, you
can do intracorporeal knot tying.
Questions?
Laparoscopicsuturingandintracorporeal
knottyingisaskillthatanyonecanlearn
andmasterinthedrylabsetting.
ContinuousRunningSuture
18
Disclosures
Alternative Suture and
Technologies used in
Gynecologic
y
g Laparoscopy
p
py
I have no financial relationships to
disclose.
Karen C. Wang, MD
Associate Director MIGS, Fellowship Director
Brigham and Womens Hospital
Instructor, Harvard Medical School
AAGL November 6, 2012
Objectives
Laparoscopic suturing
Technically challenging
Diminished tactile feedback
Lack of depth perception
Tremor amplification
Limited instrument mobility
Solution?
Barbed Suture
QuillTM
FDA approved 2004
Initiallyy used byy Plastics
Barbed suture
V LocTM
FDA approved 2009
19
QuillTM
Angiotech
Bidirectional
Helical pattern
Anchors every 1mm
Covidien
Unidirectional barbed suture
20 barbs/cm
Spiral configuration of barbs
V LocTM 90
Similar to Monocryl
V LocTM 180
Similar to PDS, Maxon
10
V-LocTM vs continuous
suture in lsc myomectomy
N = 19
Solitary intramural fibroids 33-5 cm
V-loc 90
Conventional
113.7 + 74.1 ml
168.6 + 75.1 ml
0.0076
Operative time
(total)
51 + 18.1 min
58 + 17.8 min
0.0616
Suturing time
0.0004
EBL
11
20
12
96
10 (4.2%)
281
23 non
non--pregnant ewes
Necropsy at 3 months
12 horns (52.2%) with barbed suturesuture-adhesions
10 horns (43.5%) with Vicryl closure
closure--adhesions
Einarsson et al. 2011 JMIG
14
13
His pareunia
Limited data
117 TLH, 82 completed
p
q
questionnaires
5 reported persistent dyspareunia (6.8%) at
6 months postpost-op
6 reported hispareunia (8.2%)
Case report
Bowel obstruction after TLH
0-PDO 14 x 14 cm Quill with Lapra Ty
Presented POD #30
On laparoscopylaparoscopy-tail of left end of barbed suture
(4cm) found as cause of point of volvulus
15
17
18
21
RD 180TM and TK
Running Device
RD 180TM and TK
5 or 10 mm
LSI Solutions
Single use
First used for heart valve surgery
Vaginal cuff closure
Titanium Knot
Trims suture
Secures suture
Permanent clips
EndostitchTM
Covidien
Single use
Vaginal cuff closure
19
20
EndostitchTM
10 mm
Shuttle needle
Option articulating tip
21
EndostitchTM
22
EndostitchTM Video
Conventional
Stitch placement
43 + 27 sec
151 + 24 sec
<0.0001
Knot tying
74 + 50 sec
197 + 70 sec
<0.0001
23
24
22
Suture Comparison
Suture
Name, Size
Type
Polydioxanone
Monofilament
80% at 14 days
80% at 28 days
V Loc
V-LocTM 90
V-LocTM 180
Monofilament
75% at 14 days
65% at 21 days
RD 180
Strongsorb 2
2--0
Monoglide 22-0
Monoglide 0
Multifilament
Monofilament
Monofilament
49% at 21 days
77% at 21 days
77% at 21 days
Endostitch
Polysorb3
Polysorb3--0
Polysorb 2
2--0
Poysorb 0
Multifilament
30% at 21 days
26
Cost $$$
References
Quill
$20$20-60
V-Loc
V-Loc 90 $20
V-Loc 180 $23
Endostitch
Tensile
Strength
Quill
25
RD 180 + TK
Absorption Rate
Device $140
$140--150
Suture $20
$20--28
V-Loc Suture $57
27
Adams JB, Shulam PG, Moore RG, Partin AW, and Kavoussi LR. New Laparoscopic Suturing
Device: Initial Clinical Experience. Urology 1995;46(2):2421995;46(2):242-245.
Alessandri F, Remorgida V, Venturini PL, and Ferrero S. Unidirectional barbed suture versus
continuous suture with intracorporeal knots in laparoscopic myomectomy: a randomized study.
JMIG 2010;17(6):7252010;17(6):725-9.
Angioli R, Plotti F, Montera R, Damiani P, Terranova C, Oronzi I, Luvero D, Scaletta G, Muzii
L, and Panici PB. A new type of absorable barbed suture for use in laparoscopic myomectomy.
Int J Gynecol Obstet. 2012;117:2202012;117:220-223.
Donnellan NM and Mansuria SM. Small bowel obstructing resulting from laparoscopic vaginal
cuff closure with a barbed suture. JMIG 2011;18(4):5282011;18(4):528-30.
Einarsson JI, Chavan NR, Suzuki Y. Use of bidirectional barbed suture in laparoscopic
myomectomy: an evaluation of perioperative outcomes, safety, and efficacy. 2011;18(1):922011;18(1):92-5.
Einarsson JI, GrazulGrazul-Bilska AT, and Vonnahme KA. Barbed vs standard suture:randomized
single--blinded comparison of adhesion formation and ease of use in an animal model. JMIG
single
2011;18(6):716--19.
2011;18(6):716
Greenberg JA, Einarsson JI. The use of bidirectional barbed suture in laparoscopic
myomectomy and total laparoscopic hysterectomy. JMIG 2008;15(5):621-3.
Miller J, Zaruby J, and Kaminskaya K. Evaluation of a barbed suture device versus
conventional suture in a canine enterotomy model. J Invest Surg 2012;25(2):107-11.
Siedhoff MT, Yunker AC, Steege JF. Decreased incidence of vaginal cuff dehiscence after
laparoscopic closure with bidirectional barbed suture. JMIG 2011;18(2):218-223.
28
23
US Population
Language Spoken at Home
California
Language Spoken at Home
Spanish
English
Spanish
Indo-Euro
Asian
Other
Indo-Euro
English
Asian
Other
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by the Institute for Medical Quality at http://www.imq.org
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discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of
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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.
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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.
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