Pediatric & Adolescent Gynecology – A “How To” Approach (Didactic) PROGRAM CHAIR Joseph S. Sanfi lippo, MD PROGRAM CO-CHAIR Sara Brucker, MD Heather Appelbaum, MD Marc R. Laufer, MD Robert K. Zurawin MD Sponsored by AAGL Advancing Minimally Invasive Gynecology Worldwide Professional Education Information Target Audience This educational activity is developed to meet the needs of residents, fellows and new minimally invasive specialists in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 3.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to 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 content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME. Table of Contents Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 3 A Pediatric and Adolescent Gynecology Minimally Invasive Practice – A “How to” Approach J.S. Sanfilippo ................................................................................................................................................ 4 Minimally Invasive Surgery in the Pediatric and Adolescent Patient: Vaginoscopy, Hysteroscopy, Laparoscopy and Robotics R.K. Zurawin ................................................................................................................................................ 19 Pediatric and Adolescent Gynecologic Emergencies H. Appelbaum ............................................................................................................................................ 35 Endometriosis in Adolescents – The Beginning of the Story M.R. Laufer .................................................................................................................................................. 53 Surgical Approach to Müllerian Anomolies and Vaginal Agenesis S. Brucker ....................................................................................................................................... 64 Pediatric Gynecologic Oncology R.K. Zurawin ................................................................................................................................................ 72 Gynecologic Outcomes of Bariatric Surgery in the PAG Patient J.S. Sanfilippo ............................................................................................................................................. 78 Fertility Preservation – How and Why S. Brucker .................................................................................................................................................... 88 Cultural and Linguistics Competency ......................................................................................................... 94 PG 212 Pediatric & Adolescent Gynecology – A “How To” Approach (Didactic) Joseph S. Sanfilippo, Chair Sara Brucker, Co-Chair Faculty: Heather Appelbaum, Marc R. Laufer, Robert K. Zurawin This course is designed to allow clinicians to establish an “adolescent-friendly environment” in their office setting. Strategies for practice development focused on minimally invasive surgical expertise will be presented. A “how to” approach is the underlying theme for all lectures in the postgraduate course. Gynecologic surgeons are increasingly being called upon to manage Müllerian anomalies; pre-operative as well as intra-operative expertise will be emphasized. As surgeons, we are asked with increasing frequency to assist in fertility preservation when a young patient is faced with a diagnosis of cancer or other chronic debilitating disease. Counseling and discussion of options for future fertility will be succinctly presented. The problem of obesity is a recurrent concern for clinicians; evaluation, counseling and management of obesity continue to challenge the gynecologist. Various surgical approaches that clinicians with advanced minimally invasive expertise should be able to acquire will be presented in a readily applicable manner. Current concepts with regard to management of adnexal masses, torsion, and endometriosis in the young adult will allow surgeons to garner the latest advances of gynecologic surgery in this age group. Learning Objectives: At the conclusion of this activity, the clinician will be able to: 1) Use the learning process to provide counseling and expertise to facilitate development of an adolescent and young adult gynecologic surgical practice focused on minimally invasive surgical techniques; 2) evaluate and manage Müllerian anomalies with surgical as well as non-surgical approaches will be stressed; and 3) discuss the challenges of managing. Course Outline 8:00 Welcome, Introductions and Course Overview J.S. Sanfilippo 8:05 A Pediatric and Adolescent Gynecology Minimally Invasive Practice – A “How to” Approach J.S. Sanfilippo 8:30 Minimally Invasive Surgery in the Pediatric and Adolescent Patient: Vaginoscopy, Hysteroscopy, Laparoscopy and Robotics R.K. Zurawin 8:55 Pediatric and Adolescent Gynecologic Emergencies H. Appelbaum 9:20 Endometriosis in Adolescents – The Beginning of the Story M.R. Laufer 9:45 Questions and Answers All Faculty 9:55 Break 10:10 Surgical Approach to Müllerian Anomolies and Vaginal Agenesis S. Brucker 1 10:35 Pediatric Gynecologic Oncology R.K. Zurawin 11:00 Gynecologic Outcomes of Bariatric Surgery in the PAG Patient J.S. Sanfilippo 11:25 Fertility Preservation – How and Why S. Brucker 11:50 Questions & Answers All Faculty 12:00 Course Evaluation/Adjourn 2 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 Kimberly A. Kho* Frank D. Loffer, Executive Vice President/Medical Director, AAGL* Linda Michels, Executive Director, AAGL* M. Jonathan Solnik* Johnny Yi* SCIENTIFIC PROGRAM COMMITTEE Ceana H. Nezhat Consultant: Ethicon Endo-Surgery, Lumenis, Karl Storz Other: Medical Advisor: Plasma Surgical Other: Scientific Advisory Board: SurgiQuest Arnold P. Advincula Consultant: Blue Endo, CooperSurgical, Covidien, Intuitive Surgical, SurgiQuest Other: Royalties: CooperSurgical Linda D. Bradley* Victor Gomel* Keith B. Isaacson* Grace M. Janik Grants/Research Support: Hologic Consultant: Karl Storz C.Y. Liu* Javier F. Magrina* Andrew I. Sokol* 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). Heather Appelbaum* Sara Y. Brucker* Marc R. Laufer* Joseph S. Sanfilippo* Robert K. Zurawin Consultant: Conceptus Incorporated, Ethicon Endo-Surgery, Hologic Asterisk (*) denotes no financial relationships to disclose. Pediatric & Adolescent Gynecology Minimally Invasive Practice “A How To” Approach Disclosure Joseph S. Sanfilippo, MD, MBA Professor OB, GYN, Repro Sciences I have no financial relationships University of Pittsburgh to disclose. Magee-Womens Hospital 4 5 PEDIATRIC PATIENT . Patient Involved in History . Frog-legged Position . Knee-chest Position . “Show and Tell” . Low power Magnification . “Good job” ADOLESCENT EXAM-PARADIGM PELVIC EXAM SHIFT . TOOL KIT-ACOG . “Do You Use Tampons?” . First Exam . “Gynecologic Encounter” 13-15 Y/A – Collaborative with Primary Care Provider – Rapport with OB GYN – No Pelvic Exam – Followed By Annual Visits . Age 21 years of age Stewart F et al JAMA 2001;286:671 ACS, NIH, ACOG 2002 Tool Kit for Teen Care . The Tool Kit for Teen Care is a comprehensive resource designed by the ACOG Committee on Adolescent Health Care to help every office care for adolescent patients. 6 SCREENING FOR SEXUALLY TRANSMITTED DISEASES .