The Minimally Invasive Surgery Program
The University of Michigan
Department of Obstetrics and Gynecology
Sawsan As-Sanie, MD, MPH
Arleen Song, MD, MPH
1500 E. Medical Center Drive
Women’s L4100, Box 0276
Ann Arbor, Michigan 48109-0276
PHONE: (734) 764-8429
FAX: (734) 647-9727
Educational Objectives for the Minimally Invasive Surgery (MIS) Rotation
Submitted 9/8/08, updated 12/7/09.
The overall objective of the MIS rotation is to provide the resident with a strong
foundation in laparoscopic and hysteroscopic skills that would be necessary and
expected of a generalist OBGYN after residency training. It is expected that the
resident’s primary goal at the end of this rotation is to independently perform the wide
range of laparoscopic procedures that should be offered by a general obgyn in either a
community or academically-based clinical practice.
In order to achieve these goals, the resident will participate in both the outpatient,
intraoperative, and inpatient evaluation and management of MIS patients.
The objectives of the outpatient portion of this rotation are to become competent in:
(1) The evaluation and management of complex chronic pelvic pain patients, with a
focus on the physical exam, differential diagnosis, and medical/surgical treatment
options for women with chronic pelvic pain.
(2) The preoperative evaluation of minimally invasive surgery candidates with a
focus on how to determine best surgical approach (traditionally laparoscopy, Da
Vinci-assisted laparoscopy, vaginal surgery vs. minilaparotomy).
(3) The evaluation and management of postoperative complications seen in
minimally invasive surgery.
The objectives of the surgical portion of this rotation are listed below. Please note that
this rotation will focus on a wide-range of advanced laparoscopic procedures, and will
NOT be limited to Da Vinci-procedures only.
1. To provide the fundamental training in laparoscopic and hysteroscopic surgery.
2. To provide resident education in the basics of laparoscopy in areas such as correct
patient positioning to prevent perioperative neuropathies, different ways of
obtaining pneumoperitoneum, and correct port placement.
3. To expose the resident to advanced laparoscopy and operative hysteroscopy and
have the resident assist in such procedures. Participation in advanced
laparoscopic procedures is expected once the resident has demonstrated full
understanding of the basic principles of laparoscopy and has demonstrated
proficiency in basic laparoscopy.
4. To familiarize the resident with the daVinci system so that the resident will be
able to select the appropriate patient for surgery, choose appropriate port
placement, dock the da Vinci robotic system independently, and be proficient as
the bedside-assistant in da Vinci cases. Proficiency as the bedside-assistant
includes the appropriate manipulation of the uterine manipulator, as well as
anticipating the needs of the primary surgeon with little direction or guidance.
This will require thorough knowledge of the anatomy and steps of each type of
surgical procedure.
5. Once the resident has shown proficiency in the above tasks, the goal would be
familiarize the resident at the console. This will involve the following:
a. Prior to the start of the MIS and GYN ONC rotation in the third year of
residency, all GYN residents will receive didactic and dry lab training on
the da Vinci Robotic Surgical System. All residents will first complete an
online training program designed by Intuitive Surgical to familiarize
surgeons with the da Vinci system. Following successful completion of
the online training program, residents will participate in a one-on-one dry
lab training session with an MIS and/or GYN ONC faculty. The dry lab
training session will include modules to learn appropriate docking of the
robotic device, manipulation of the robotic arms, dissection, transaction
and suturing. An overview of the training modules is attached. These
training modules are available at any time for any resident to practice on at
their convenience once they have completed their formal dry-lab session.
b. Once the resident has proven proficiency in the dry lab, the resident
should be able to suture interrupted, figure-of-eight, and running sutures,
as well as tie intracorporeal knots. These skills can be performed on a
myomectomy case or closure of the vaginal cuff during a total
laparoscopic hysterectomy.
c. Once the resident has sufficiently exhibited proficiency in suturing and
knot tying and has shown facility with basic maneuvering of the
instruments, the resident will be able to spend more time at the console
participating in lysis of adhesions and one side of a simple hysterectomy
case. The goal will be for the fellow to perform one side of a
hysterectomy, and the resident will complete the other side of a
hysterectomy.
6. The OR time will be supplemented with the online tutorials and testing.
7. The resident will keep a case log. The case log should include a detailed
description of the operative procedure and which portion of the case they
participated in as primary surgeon, first assistant, vs. bed-side assistant.
In order to achieve the objectives of the surgical and intraoperative portion of this
rotation, residents may expect to achieve the following goals by the end of their
residency training:
**Please note that these are general guidelines. The level of involvement with each
surgery will depend on the individual resident’s skill level, difficulty of case, and most
importantly, the proficiency demonstrated by each individual resident as the rotation
progresses.
(1) To become proficient and truly independent in performing the following
procedures:
a. operative laparoscopy with lysis of mild to moderate adhesions
b. excision and ablation of stage I, II, and some forms of stage III and IV
endometriosis
c. laparoscopic adnexal surgery including ovarian cystectomy,
oophorectomy, and salpingectomy
d. operative hysteroscopy with removal of endometrial polyps and
submucosal fibroids
e. minilaparotomy with TAH, myomectomy, adnexectomy
f. total laparoscopic and laparoscopic supracervical hysterectomy of ≤12-14
week size uterus with minimal pelvic and bladder adhesions and/or
endometriosis
g. Da Vinci-assisted total laparoscopic and laparoscopic supracervical
hysterectomy of ≤12-14 week size uterus with minimal pelvic and bladder
adhesions and/or endometriosis
(At the discretion of the attending physician, the resident will do one
side and the MIS fellow will do the other side. The attending may
intervene if difficulty is encountered.)
(2) The resident will also be exposed to and participate in the following procedures.
Based on the individual resident’s proficiency and progress in this rotation, he/she
may have the opportunity to participate in all aspects of the following procedures
over the course of the rotation. In doing so, he/she may become proficient and
independent in performing the following procedures:
a. Laparoscopic ureterolysis
b. Laparoscopic excision or ablation of stage III or IV endometriosis
(3) The resident will also be exposed to and participate in the following procedures
according to their level of proficiency. However, due to the complexity of these
cases, it is not expected that the resident be able to perform these procedures
independently by the end of the rotation. These cases are considered fellow-level
cases.
a. Da Vinci-assisted total laparoscopic and supracervical hysterectomy of
≥16 week size uterus, any size uterus with severe pelvic or bladder
adhesions and/or endometriosis
b. Total laparoscopic and laparoscopic supracervical hysterectomy of ≥16
week size uterus, or any size uterus with severe pelvic or bladder
adhesions and/or endometriosis
c. (±Da Vinci-assisted) laparoscopic excision of ovarian remnant
d. (±Da Vinci-assisted) laparoscopic trachelectomy
e. Da Vinci-assisted laparoscopic myomectomy (the resident will participate
in suturing the myoma bed. However, enucleation of the fibroid in most
cases should be considered a fellow or attending-level portion of the
procedure)