2000 SLS Presidential Address

PURPOSE

Thank you for the opportunity to present this presidential address at the annual meeting of the Society of Laparoendoscopic Surgeons (SLS). My purpose today is to concentrate on you, the members of the society, the participants in this meeting, and the future we share as the Society of Laparoendoscopic Surgeons. I will present our past, our present, and my hopes and dreams for our future.

THANKS TO OUR FOUNDERS

Today I would like to give thanks to those who conceived of and founded this society. These individuals contributed of their lives so that today we can be here participating in this millennial celebration of laparoendoscopic surgeons. To know where you and I can go together with this society, it is important that we know our origins and our goals.

I give special thanks to Dr Paul Wetter and Janis Chinnock who, beginning in 1988, opened their home and their lives to the foundation of a society that would provide information and education in the field of laparoscopic, endoscopic, and minimally invasive surgery and that would recognize individuals who made an outstanding contribution to that field. That the society exists is a tribute to their dedication, constant attention to our needs, and vision of a future where surgical intervention is less painful, more effective, and truly less frightening, not only for our patients but also for ourselves as well. For your work and your dedication, I personally, and we as a society, thank you.

Special thanks also go to Dr Hilliard Jason and Dr Jane Westberg who have devoted their lives to teaching physicians how to be educators and who gave us our unique format where specialties come together under the umbrella of laparoendoscopic surgery to discuss common problems and to generate solutions to those problems.

In addition, I would like to thank Dr Joseph Gurri, Dr Carlos Suarez and Dr George Tershakovec who gave countless hours in those early days of the founding of SLS. Together with Ronald Fieldstone, who is one of our trustees, they helped to build the foundation on which SLS now stands.

I would also like to give a special thanks to each of our past presidents, whose ranks I will now join: Harry Reich, Joseph B. Petelin, Douglas O. Olsen, Carl Levinson, Michael Kavic, Robert J. Fitzgibbons, Jr., and Joel Childers. Each of these individuals has contributed significantly to the growth and development of the Society of Laparoendoscopic Surgeons and to each of them we owe special thanks. They have now become organized as a president's council and are assisting the Board of Trustees in guiding the Society of Laparoendoscopic Surgeons, and for this we are most grateful.

A special thanks to our staff: Charlotte Donn, director of administration and publications; Rosemary Helenbrook, meeting planner; Vicki Sharp, administrative assistant; Flor Tilden, coordinator of membership services; and Barbara Ward, director of design and marketing. This staff has done so much for our society and contributed so much to us as members that it is truly impossible to ever repay them. Our heartfelt thanks to each of them for their tremendous support.

In addition, a special thanks to Michael Kavic, editor in chief of the JSLS, Journal of the Society of Laparoendoscopic Surgeonsand Patricia Fleck-Kavic, editorial assistant who together with Charlotte Donn have produced such an incredible journal as the JSLS. A special thanks to Michelle R. Perez who just finished her last issue of JSLS with us and had completed volumes 1-4 and to Ann Conti Morcos, both incredible copy editors who have helped us with the production of this wonderful journal.

Countless individuals have contributed to SLS, and although time does not permit me to thank each of you personally, we as a society thank each of you from our hearts.

GOALS AND ACHIEVEMENTS

A society should be judged by its goals and measured by its record in achieving those goals. What are our goals? Are we achieving them? What can you and I as individuals contribute to help SLS achieve its goals?

SLS was established to help ensure the highest standards for the practice of laparoendoscopic surgery. SLS achieves this goal by:

1. Providing an efficient, centralized source of information and instruction for surgeons and other health professionals

2. Holding conferences for the exchange of ideas and expertise

3. Encouraging and supporting hospitals and medical schools in providing high-quality, formal training for laparoendoscopic surgery

4. Promoting scientific study and its publication

5. Recognizing individuals who have made outstanding contributions to the field of laparoendoscopic surgery

Let us look at each of these objectives and how SLS has achieved them:

1. Providing an efficient, centralized source of information and instruction for surgeons and other heath professionals

To meet the objective of providing an efficient centralized source of information and instruction on laparoendoscopic surgery, SLS developed and publishes the Journal of the Society of Laparoendoscopic Surgeons, which through August 31, 2000 had published 136 scientific papers, 56 case reports, 10 reports on techniques, 9 profiles on laparoscopy, and numerous additional articles. This is a monumental achievement for a young society.

In addition, SLS established a Web site that provides ongoing instruction and exchange of information for surgeons around the world. Discussion sites are included on areas such as robotics, laparoscopic nephrectomy, hernia repair, and a multitude of other subjects. In addition, the Web site contains a list of laparoscopic and endoscopic fellowships and laparoscopic meetings hosted by over 200 organizations around the world, information and registration forms for SLS meetings, patient information pages, and SLS membership directories for surgeons to find colleagues and for patients to find physicians in their area who practice laparoendoscopic surgery.

2. Holding conferences for the exchange of ideas and expertise

SLS has sponsored over 54 meetings and conferences. Nine of these have been annual meetings, 15 have been conferences, and over 30 have been postgraduate courses covering such subjects as prevention and management of complications, surgical energy sources and electro-surgery, surgical techniques, stress incontinence and pelvic floor reconstruction, endometriosis and abnormal uterine bleeding, gastroesophageal reflux disease (GERD), cholecystectomy, common bile duct management, fascial defects and hernias of the abdominal wall, as well as many other topics. SLS has done a tremendous job in providing conferences for the exchange of ideas and expertise.

3. Encouraging and supporting hospitals and medical schools in providing high-quality, formal training for laparoendoscopic surgery

Early in its history, SLS committed itself fully to supporting medical schools in training for laparoendoscopic surgeons. One of the ways that this has best been accomplished has been through the SLS Outstanding Laparoendoscopic Resident Award Program. SLS provides this award to the outstanding resident who demonstrates great interest and promise in the fields of operative laparoscopy, endoscopy, and minimally invasive surgery. In the year 2000 alone, 114 of these awards were provided. SLS has committed itself to encouraging education in hospitals and medical schools in laparoendoscopic surgery. Another way that SLS provides for this encouragement is through the SLS Resident Paper Award, which is provided each year and highlighted as a special part of our annual conference. Each of us should make note of the time of this presentation in our program and ensure that we attend and provide encouragement to our residents by paying attention to the work that they are doing.

SLS has provided an honorarium for the Best Resident Paper Awards, beginning in 1997 with Amy Elizabeth Martin, in 1998 Sridhar Chalasani, in 1999 Claudine Siegert, and in the year 2000 Andrew Shapiro. These awards have been provided to encourage the highest level of involvement of residents in the Society of Laparoendoscopic Surgeons and in its work in research and publication.

4. Promoting scientific study and its publication

SLS has been deeply involved in promoting scientific study, and it is my hope for our future that it becomes more deeply involved with these projects. Thus far, SLS has developed significant work through the outstanding efforts of our chairman, Paul Alan Wetter. Dr Wetter has presented his study titled “Trends in Operative Laparoscopy” in numerous countries by invitation because of the prominence of the Society of Laparoendoscopic Surgeons and the outstanding work that was conducted in this study. SLS surveyed its membership for a special study on laparoscopy during pregnancy, a study that was published in the Journal of Reproductive Medicine in January of 1997 by Mark B. Reedy, MD. In addition, Dr Wetter presented his work on “Multispecialty Consensus: Diagnostic Laparoscopy” at several conferences in 1997 and 1998.

Through our research committee and the work of our board of trustees, SLS is now accepting proposals for studies of critical importance to laparoendoscopic surgeons. The research committee, under the leadership of Dr Douglas Ott and Dr Richard Satava, has recently funded a major study on skill assessment to be directed by Dr Richard Satava.

In addition, through the publication of JSLS, indexed in Index Medicus, the society provides a forum for the publication of excellent scientific studies. SLS envisions a role in sponsoring its own studies so that unbiased literature can be developed in this field.

SLS has also published its work in book form, Prevention & Management of Laparoendoscopic Surgical Complications, a publication of excellent quality that has truly set the standard for excellence in publications in the field of laparoscopic surgery.

5. Recognizing individuals who have made outstanding contributions to the field of laparoendoscopic surgery

Each year, SLS recognizes individuals who have made contributions to the field of laparoendoscopic surgery and who have provided leadership to all of us in this field. The Excel Award is recognized around the world as an award for those who have achieved the highest level of distinction in the field of laparoendoscopic surgery. Our Excel Award winners since 1991 include Harry Reich, Eddie Joe Reddick, Kurt Semm, George Berci, Jaroslav “Jerry” Hulka, Camran Nezhat, Bernard Dallemagne, Jordan Phillips, William B. Saye, J. Barry McKernan, Professor M.A. Bruhat, and this year's award winner Professor Sir Alfred Cuschieri.

These individuals, who have been selected and honored with the Excel Award, have made such significant contributions to the field that listing them is listing a “Who's Who” of laparoendoscopic surgery.

In addition, the Society of Laparoendoscopic Surgeons has granted the honor of chairing our Annual Meeting to the following individuals who have contributed greatly to our field: in 1998 Edvaldo Fahel, MD, PhD, general surgery, Salvador-Bahia, Brazil and Charles Ng, MD, obstetrics and gynecology, Singapore; in 1999 Achille Gaspari, MD, general surgery, Rome, Italy and Christopher Sutton, MD, gynecology, Surrey, England, United Kingdom; in 2000 Peter M.Y. Goh, MD, general surgery, Singapore. To each of these individuals, we are very thankful for their participation and contributions to our Society and to our field.

As you attend this meeting and other meetings of SLS, remember our purpose: To bring together specialists in laparoscopic surgery to promote excellence. You are active participants in a laparoscopic society with a membership exceeding 6000. You are an active participant in a society whose Web sites have over 9000 exchanges of information each week from over 105 countries and that are a primary resource for laparoscopic education. You are an active member of a society that produces a journal, the JSLS, Journal of the Society of Laparoendoscopic Surgeons, indexed in Index Medicus, with a circulation of over 8000. You are an active member of a society that gathers specialists from around the globe to meet face-to-face to learn, interact, debate, and share their experiences in a format not found in other societies. This is a society to which you can contribute, in which you can participate, and of which you can be proud.

Only in SLS can a general surgeon, a gynecologist, a urologist, and other laparoscopic experts meet together to share their common experiences involving minimally invasive surgical techniques. By your involvement in this meeting and in this society, you are now at the forefront of new surgical technology and innovative ways to share knowledge in this growing field.

UNIQUE OPPORTUNITY

SLS provides a unique opportunity for you as an individual to participate, and by participating, to make your life more meaningful, more fulfilling, and more personally rewarding. By coming to this meeting, each of you has made a significant contribution already to our society. But I would like to ask more. I would like to ask you to give of yourself so that the rest of us can benefit from your knowledge and your experience. If you are attending a session and a question occurs to you, ask it. How else can each of us benefit from your ideas and your questions?

If you are presenting at a session, take the extra step of writing up your material and sending it to the JSLS for publication. How else can you reach that wider audience so that all of us can benefit from your knowledge and experience? If you are chairing a session and a comment occurs to you, make it and share it with each of us. For how else can each of us learn from your personal experiences? And for the future participate in one of the SLS committees. The updates you will hear tomorrow morning at this meeting have been prepared by the SLS committees devoted to specialty areas. We have openings on these and other specialty committees. Offer to participate in these committees. These committees meet primarily on the Internet and do not require of you major travel. Involve yourself in the society at a committee level and help it–and you–reach our common goals.

HOUSEKEEPING

A housekeeping matter, as your president and convention cochairman, I recommend that each of you study the program carefully. It is a menu. It is a guide to a rewarding and fulfilling experience. To take full advantage of it, read it ahead of time, and decide on the programs you want to attend. And I have a special request to the speakers and to the section chairs–keep to your times. I realize no one wants to embarrass or give affront to anyone else, but if a speaker or a participant has lost track of time, then that person needs a guide, and I give you permission as the chair of that session to be that guide, to keep that person on schedule, and to keep your session in order.

ADDITIONAL THANKS

Before I outline two areas in which I would like to see additional SLS involvement for the future, I would like to thank our honorary chairman, Dr Peter Goh of Singapore and our Excel Award winner Dr Alfred E. Cuschieri for their remarkable contributions to the field of laparoendoscopic surgery. Each of them will address you during this meeting.

TWO AREAS OF ENDEAVOR

Two areas of endeavor exist to which I believe the Society of Laparoendoscopic Surgeons is uniquely positioned to make important contributions. These areas overlap and interact in ways in which we are only now beginning to understand and appreciate. These are the areas of pelvic pain from hernias and pelvic floor support problems. For the future, I would like to see SLS involved in research and in the publication of studies in these areas because SLS has a unique structure that brings together general surgeons, gynecologists, and urologists, all of whom are involved in these areas of endeavor.

PELVIC PAIN FROM HERNIAS

First with regard to hernias, it is my belief that hernias as a source of pain are not diagnosed frequently enough, especially in women. If we are to apply the strictest definition of hernia where a protrusion of tissue must occur through a fascial split, then I believe many women will suffer needlessly because in my experience early breaks in the fascia prior to any protrusion are the source of pain. These women seek help because they are experiencing pain, and this pain is frequently diagnosed as having an organ as its source. All too often, that organ is the uterus or an ovary, and a woman with a small split in the fascia ends up with a hysterectomy or an oophorectomy. After she has recovered from her organ removal, she finds that the pain that started her problems is still with her, and she looks for help once again. Through the efforts of SLS, general surgeons and gynecologists are coming together to explore issues of hernias as they relate to pain. In my experience, we as gynecologists have not developed the skills required to make a physical diagnosis of early hernia formation, and we as general surgeons have too easily dismissed the complaints of women, who may well have a hernia that is difficult to detect, as needing surgery on their uterus and ovaries for their complaint of pain.

I would ask that you look for certain things in the history of your patients that would lead you to an exploration for a hernia as a source of a problem with pain. This list is from my own experience and requires validation by others much more knowledgeable than myself. However, I offer it to you with the hope that some of your patients might benefit as many of mine have from having a previously undiagnosed hernia repaired. Look for complaints of low abdominal pressure; pain from recurrent muscle spasms of the back and pelvis; pain made worse with bending, lifting, or other physical activity; sensitivity or tenderness in the low abdomen and pelvis that comes and goes, frequently with increase in activity; pain along a distribution of a nerve that passes close to or in the area of the hernia. For the gynecologists and urologists among us, examine your patients for fascial defects in the abdominal wall and pelvis. Err on the side of referring too many, rather than too few, of your patients for evaluation of a possible hernia as the cause of pain. Better that your general surgeon colleague send you a note stating that a hernia is unlikely than that you leave a patient with a treatable hernia uncared for. Use the simple pulsion test, and refer, not based on your feeling that a bulge is present, but on patients' complaint of pain when they cough with your finger appropriately placed over the suspected fascial split/ hernia defect.

Gynecologists, general surgeons, and urologists all have a need for an atlas of the laparoscopic appearance of hernia defects. The importance of this can only be estimated, but it is instructive to review the work of William Saye, a past Excel Award winner of SLS, whose work was documented by John Miklos, one of our esteemed faculty, in a landmark study on sciatic hernias. They found that in up to 2% of women undergoing laparoscopic intervention for undiagnosed pelvic pain a sciatic hernia was identified and upon repair a substantial number of these patients had significant reduction in their level of pain. To paraphrase Bill Saye: The eye doesn't see what the mind doesn't know. Although the laparoscope is a tool that improves our vision, it has placed upon us a great responsibility to know what it is we see.

Besides sciatic hernias and the common, but also under-diagnosed, groin hernias in women, what about the obturator canal? It is well known from cadaver studies that up to 70% of women have obturator hernias. What we don't know is how many women experience symptoms from this hernia, and we don't know this because we don't look for this as a source of pain. Having coauthored the textbook Pelvic Pain: Diagnosis and Management and having contributed the chapter on hernias, I am humbled by the complexity of the problem and grateful for each hard-won success. Nothing is so rewarding to each of us as physicians as these words from our patients: “The pain is gone.”; “I can do what I want now and it doesn';t hurt.”; “That horrible ache just isn't there anymore.”

Albert Schweitzer once wrote: “We must all die. But that I can save him from days of torture, that is what I feel is my great and ever new privilege. Pain is a more terrible lord of mankind than even death itself.”

PELVIC FLOOR SUPPORT

SLS is uniquely qualified to address the issue of hernias as a source of pain because of the unique interaction of gynecologists, general surgeons, and urologists, all of whom understand the different parts of the body that can give rise to these fascial defects. But SLS is also uniquely positioned to address the issues of pelvic support, again through our unique interaction between urologists, general surgeons, and gynecologists. The process of the breakdown of pelvic support is one that is initiated by trauma or aging, resulting in nerve injury, weakness, and decline in the muscle structures leading to tears and breaks in the fascia. These same tears and breaks in the fascia that we call hernias in the abdominal wall have carried many names in gynecology when applied to the pelvis in women, such as cystoceles, rectoceles, enteroceles, and urethroceles. Now we understand that these are true hernias. These are breaks in fascia and ligaments that require the same attention and the same techniques as general surgeons have applied to hernias for the last 50 years. This is a paradigm shift for us as gynecologists to realize the fact that much of what we must do for our aging population is hernia surgery. The enterocele is, in fact, a break in the pubocervical from the rectovaginal fascia, and this fascia must be repaired. Vaginal vault and uterine prolapse are the result of breaks in the uterosacral ligaments, and these ligaments must be repaired for this support to be re-established. Rectoceles are, in fact, protrusions through breaks in the rectovaginal fascia or the Denonvilliers' fascia. We are now beginning to understand as gynecologists that we must repair these breaks in the fascia as though they were true hernias. We need help from our surgical colleagues and our urological colleagues to improve our techniques. Our rate of failure is unacceptably high. The recurrence rate of rectoceles after rectocele repair prior to the application of site-specific fascial repair was up to 50%. Now with site-specific repair, the failure rate at 5 years has been reduced to 20 to 30%. This is still unacceptably high. Any of you as hernia surgeons would find it unacceptable if you had a recurrence of groin hernia after repair of 20 to 30%. We as gynecologists have difficult problems to address in this area for which your experience as surgeons is applicable. How do we create tension-free repairs for the hernias that we call enteroceles, cystoceles, rectoceles, and vault prolapse? How do we create ligamentous support for the vaginal vault that can then prevent future recurrence of prolapse? And just as we now understand, through the anatomical dissections of A. Cullen Richardson, the nature of these fascial breaks, we also understand from the pathophysiologic studies of John Delancey the importance of pelvic floor muscle rehabilitation in sustaining these repairs. However, all of the pelvic floor rehabilitation that can be offered will not repair the tears in fascia and the breaks in ligaments. General surgeons, when faced with recurrence rates such as we gynecologists are now confronting, developed the tension-free techniques that have reduced groin hernia recurrence to its currently acceptably low levels. We need you to look at our techniques and look at our results and interact with us to find better solutions and more permanent answers to these pelvic floor support problems.

SLS IS UNIQUE

SLS is a unique organization that can address unique problems. I look forward to working with each of you as we address these problems of hernias as a source of pelvic pain and pelvic floor support defects, as well as other problems that cross specialty lines, as we improve medical care for the 21st century, as we lead in the adoption of the new technologies that improve the quality of life of our patients, and as we improve our own lives by selfless helping of those less fortunate who suffer from illness and disease.

Thank you for the opportunity to share with you these reflections on SLS, its past, present, and future. I would like to take this opportunity to thank your board of trustees who have so selflessly given their time and their talents this last year to your organization. W. Peter Geis our vice president and soon to be president; Farr Nezhat, secretary-treasurer; Robert Fitzgibbons, Jr, immediate past president; Richard Satava, trustee; Elspeth McDougall, trustee; Steve Eubanks, trustee; Carlos Suarez, trustee; Carl Levinson, trustee; Paul Wetter, chairman; Michael Kavic, ex-officio member; Linda Steckley, ex-officio member; and Ronald Fieldstone, ex-officio member. I would like to welcome our new board members, William E. Kelley, trustee, and Raymond J. Lanzafame, trustee. We are honored by your presence on the board of SLS.

Thanks to their efforts, the society has maintained its preeminence in the field of laparoendoscopic surgery, and you as members can be proud of the work that they have done for you and for all of us, and I give a special thanks to all of you here tonight for your participation, contributions, and your attention. Thank you.