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An Updated History of the American Association of Gynecologic Laparoscopists (2001–2017)

2018; Elsevier BV; Volume: 26; Issue: 1 Linguagem: Inglês

10.1016/j.jmig.2018.06.011

1553-4669

Resad Pasic, Ronald L. Levine,

Endometriosis Research and Treatment

The American Association of Gynecologic Laparoscopists (AAGL) is the largest association of its kind in the world with a membership of over 8000 and extending to over 110 countries around the globe. It has become the gathering place for gynecologists to share their experiences and to teach and learn from their colleagues. The association is proud to count among its membership some of the foremost authorities in gynecology and pioneers in techniques and procedures. AAGL started as the brainchild of Dr. Jordan Phillips (1923–2008), who served not only as the founder of AAGL but also as chairman of the association's board of directors for 30 years (Fig. 1). Dr. Phillips became aware of the use of modern-day laparoscopy while watching Dr. Melvin Cohen in Chicago operate with this relatively new modality in the late 1960s. Dr. Phillips wisely was prescient regarding the use of laparoscopy for the future, and in 1971 he recognized the need for an organization promoting this method of surgery. With the aid of his wife Eleanor, AAGL was incorporated as a not-for-profit entity that year. The first meeting of AAGL was held at the Stardust Hotel in Las Vegas, NV, in November 1972. The positions of officers were assigned by mutual agreement; Jordan Phillips became the president, Richard Soderstrom the vice president, Jacques Rioux the secretary, and Louis Keith the treasurer. Although this organization envisioning the use of laparoscopy was the first of its kind, laparoscopy actually had a long history in medical science in the form of endoscopy. There were many innovations throughout the years, but the beginning of more modern endoscopy probably can be attributed to Bozzini, who in 1807 invented the first light reflector that directed light rays into the body of a living animal and then redirected them to the eye of the observer [1Bozzini P. Der Lichtleiter oder Beschreibung einer einfacher Vorrichtung und Anwendung zur Erleuchtung innerer Hohlen und Zwichenerraume des lebenden animalishen Korpers. Landes-Industre-Comptior, Plano, TX: Weinmar1807Google Scholar]. Endoscopy continued to be developed through the years by many innovators including Desormeaux, Aubinalis, Pantaleoni, and Nitze, among others, until the beginning of the 20th century. Kelling used a cystoscope in 1900 to look into the abdomen of a dog that he insufflated with air. He called his procedure “celioscopy” [2Kelling G. Uber oesophgoscopie, gastroskopie und colioskopie.Munich Med Wirsh. 1902; 49: 21-24Google Scholar]. The first reported observation of the human peritoneal cavity with optical instruments was performed by Ott in Petrograd Russia in 1901. Jacobeus in Stockholm, Sweden, was the first to describe laparoscopy in 1910 [3Jacobeaus H.C. Uber die moglichkeit, die zystoskopie bei untersuchung serosen hohlungen anzuwenden.Munich Med Wschr. 1910; 57: 2090-2092Google Scholar]. The modern era of laparoscopy started with Raul Palmer in France performing endoscopic gynecologic procedures, which he called celioscopy [4Palmer R. Instrumentation et technique de la culdoscopie ginecologique.Gynecol Obstet. 1947; 46: 422-429Google Scholar]. After 1958, Hans Frangenheim in Germany popularized the abdominal method of laparoscopy, which was the basis for modern-day surgical laparoscopy. He also used laparoscopic movies to photograph human ovulation. However, “laparoscopy” during this era was primarily limited to diagnostic procedures and tubal sterilization. In 1955, Fikentscher and Dr. Kurt Semm in Kiel, Germany, introduced the automatic laparoscopic CO2 insufflator to maintain the pneumoperitoneum. Dr. Semm called his procedures “pelviscopy” to differentiate them from “laparoscopy” [5Fikentscher R. Semm K. Beitrag zur methodik der utero tubaren pertubation.Geburtshilfe Frauenheilkd. 1967; 27: 1029PubMed Google Scholar]. Dr. Semm also invented a myriad of pelviscopic instruments and created a complete pelviscopic instrumentation set. He pioneered many laparoscopic procedures and started a new era of modern laparoscopy. In November 2001, Dr. Richard Soderstrom published a special article titled “A History of the American Association of Gynecologic Laparoscopists” [6Soderstrom R. A history of the American Association of Gynecologic Laparoscopists.J Am Assoc Gynecol Laparosc. 2001; 8: 475-485Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar], which encapsulated the years from 1973 to 2001. With Dr. Soderstrom's permission, we are using the same format to describe the history of AAGL from years 2001 to 2017. We contacted presidents who served during that period and asked them to provide a short synopsis of their board's term as they remembered it. The statements from the presidents are solely their opinions and not AAGL or the authors. We have made minor changes to adjust for the length of the reports and to change the nominative singular “I” to the plural “we” to represent the board during that time. We are grateful to all of these presidents. Our board changed our accounting system to better allow assessment and planning (accrual method). As vice president, I ran the meeting 1 month after 9/11! Forty percent of speakers did not make it to the conference. We instituted the industry-sponsored symposia at $25,000 each, saving us from an organization with little reserves to the wealthy one we became! During my presidency, the big issue was name change, and we initiated the process of changing the organization and journal names despite much resistance. We also chose Dr. Stephen Corson as the new editor of the journal after Dr. Hunt resigned. I was fortunate enough to serve as president of AAGL in 2003. It was a very good year. Our goal during those 12 months was to shorten, organize, and streamline AAGL board meetings. It was an initiative that carried on for several subsequent years and was ultimately successful. We ran the first annual meeting in which the keynote speaker had an onstage “virtual” presence. Richard Blackwell, MD, spoke from Birmingham, AL, “teleporting” into the auditorium via virtual reality—another AAGL first. Finally, it was with great sadness we bid farewell to a giant in our field. Professor Kurt Semm passed away in July before the 2003 annual meeting. He will be forever missed. For the first time in the organization's history, we worked to introduce and integrate pelvic reconstructive surgery into AAGL academic and didactic armamentarium. We accomplished this by inviting relevant companies to the annual meeting to both demonstrate and display in the exhibit hall as well as support key authorities from here and abroad to discuss and debate the use of the then novel approach using a midurethral sling for anti-incontinence surgery. Those personally invited included Dr. Ulf Ulmsten from Norway, who developed the concept and led the pivotal studies that established the usefulness of the midurethral sling. Since this introduction, companies dedicated to pelvic reconstructive surgery have played a key role in supporting AAGL and its academic mission. As a natural result, the reputation of AAGL was elevated in the academic surgical arena, and a kinship was started between AAGL and the American Urogynecologic Society. Moreover, this ultimately provided urogynecologic procedures as an inlet to attain AAGL fellowship training as well as a means to equally satisfy requirements for Center of Excellence in Minimally Invasive Gynecology certification. During this period, the board was committed to having increased participation of international members in the annual meeting and their having an active role on the board. Dr. Mauro Busacca, the chair of the Affiliated Societies Committee, worked to increase their participation in AAGL. Our board worked to increase our efforts to include women and younger members in the governing structures and programs of our organization. Dr. Barbara Levy organized the very successful Women's Luncheon, and Dr. Lisa Roberts worked with younger members and female members to involve them more in AAGL. Dr. Andrew Brill led our efforts with the Industry Committee to increase communication with our corporate partners and to identify mutually beneficial opportunities that met and exceeded all ethical standards that were in place. We created a Research Committee under the chairmanship of Dr. Michael Diamond and a Guidelines Committee that developed guidelines for minimally invasive gynecology. During this time, we moved into our own building, which allowed Linda Michels to improve the excellent work of her staff by using new computer equipment and software, increasing efficiency and performance. Dr. Frank Loffer, the medical director, modified the bylaws, which streamlined operations and increased the board's oversight of AAGL activities and increased committee participation. The board focused more on the financial and budget process during the year. We also conducted a financial audit of the organization that was successfully completed. Of course, AAGL's major activity was education so we spent more time and effort quantifying the results of our teaching activities and hoped our efforts improved our teaching and made our annual meeting and courses even better. We had a very active board. We established 7 AAGL registries online as follows: Cervical Pregnancy, Complications of Synthetic Vaginal Mesh for Prolapse, Incisional Hernia at Trocar Sites, Port-site Recurrences after Laparoscopic Surgery for Malignancy, Pregnancy after Endometrial Ablation, Vaginal Cuff Complications, and Vaginal Cuff Recurrences after Laparoscopic Surgery for Malignancy. We also published guidelines for hysterectomy and hysteroscopy. We resumed freestanding courses for hysteroscopy. Our board implemented strategic goals for AAGL to ensure our continued growth and success. The board developed a functioning Oncology Committee as well as online voting for officers and trustees. We initiated 2-year terms for 3 international members, and it was the first time an international member ran for secretary–treasurer. In order to continue working closely with our international members, we planned the first joint international meeting held in Palermo, Italy, in June 2007. The AAGL had always been an international organization with international speakers, the flying doctors team, and Jordan Phillip's passion to share minimally invasive surgery throughout the world. The international mission was confirmed with the addition of international regional representation on the board. The final validation of AAGL as an international organization came with the 1st AAGL International Congress on Minimally Invasive Gynecology, “Understanding and Treating Abnormal Bleeding,” in Palermo, Italy, in June 2007. The meeting was a huge success with over 600 participants from 32 countries. Numerous structural changes happened in 2007 to meet the needs of AAGL's growth and diversity. The change made by Dr. Janik in 2006 to move the planning of the annual meeting from the board to the Scientific Program Committee was adopted as the template for future annual meetings. Numerous passionate discussions occurred in 2007 about expanding cosmetic surgery as part of AAGL. A trial balloon of a panel on cosmetic surgery in gynecology was added to the 2008 annual meeting. Special interest groups were established to meet the needs of subgroups within AAGL including gynecology, urogynecology, and infertility/endometriosis. The special interest groups have since expanded and function as vital contributors to the annual meeting as well as the research and educational missions of AAGL. Our board made a point to gather speakers from around the globe. In fact, 30% of the assigned lecturers were international. Working closely with Errico Zupi, president of the Societa Italiana di Endoscopia Ginecologica, AAGL sponsored a special session for this excellent group of clinicians and researchers. Our interest to provide AAGL with an international stamp continued when we had the 2nd AAGL International Congress on Minimally Invasive Gynecology in conjunction with the Brazilian Society of Gynecologic Endoscopy. In the presidential address, we noted a study involving patients showing the very poor understanding of minimally invasive surgery and the options provided. As a result, through the efforts of Linda Michels and the home office, we went to major industry players and raised over a half a million dollars to upgrade our patient website and to work with a public relations firm to enhance AAGL's ability to bring their mission to patients. Not only did we sponsor a media event, but also we were able to get several of our physicians coverage in various lay periodicals. Our biggest disappointments were that we were unable to bring about a classification system of endometriosis and a similar program to the Society of American Gastrointestinal and Endoscopic Surgeons “Fundamentals of Laparoscopic Surgery,” both of which were introduced and favorably agreed on by the board. Several important decisions were made during this period that have had a positive effect on the organization as a whole. For the first time, AAGL board meetings were conducted electronically, and board books were also distributed as electronic files. We also reinforced the rule (previously voted by the board) stating that board members are not allowed to hold any prominent position at the national meetings. This practice was abandoned a few years later. Another positive component was AAGL's commitment to globalization. This was the year that Dr. Errico Zupi was elected to serve as the international vice president. The year 2008 was difficult because of the passing of AAGL's founder Dr. Jordan Phillips. That year we dedicated the 2008 annual meeting in his honor. The Global Congress took place in Las Vegas, NV, in 2008, and this was the largest meeting to date; the number of participants surpassed 2000 for the first time. Emphasis was placed on hands-on training, and we conducted 4 suturing courses, 3 cadaver laboratories, and 2 hands-on hysteroscopy training courses. The AAGL Foundation announced the creation of the Jordan M. Phillips M.D. Endowment, a campaign to raise $5 million over 5 years to fund research, fellowships, and patient education. We also started negotiations with Fundamentals of Laparoscopic Surgery to adapt their training and credentialing module for minimally invasive gynecologic surgeons or to develop our own Essentials in Minimally Invasive Gynecology, which proved to be an overwhelming task and continued to be finished by subsequent presidents. AAGL also acquired SurgeryU, the largest database of surgical streaming videos, which to this day represents a great teaching reference for physicians and trainees. SurgeryU has become an essential part of AAGL's educational initiatives, highlighting experts in the field. We are proud and honored to have been a part of AAGL during this time. Although the name of AAGL was well-known and recognized in Europe and North America during the time before our board served, this was not true in Asia and Latin America. Our board discovered that 90% of Chinese gynecologists had never heard of AAGL. The board then worked to strengthen our relationships in Asia and Latin America using 3 initiatives. First, we worked closely with the Chinese OB/GYN Association. Second, we implemented surgical tutorials led by Dr. Ray Valle in different regions of Mexico and Central America. We further strengthened the relationships by implementing meetings in Japan and Argentina to enhance the visibility of AAGL. The board attempted to initiate a Center of Excellence program titled Essential in Minimally Invasive Gynecology, a 2 assessment-based certificate program for gynecologic laparoscopy and hysteroscopy, but it proved to be more difficult and we did not accomplish this. The board reviewed feedback from fellowship site directors and recommended to extend the fellowship program to 2 years. During our tenure, we succeeded in increasing gender diversity in membership, involving international members, pairing younger co-chairs with seasoned chairs to increase their visibility, and using an electronic format for poster and abstract presentations for the first time at our annual meeting program. Our board cajoled our members to become more socially aware and involved because women's bodies had become a social battleground. We asked, “Do you live in a bubble? If so burst it” because we forgot that our gynecologic specialty involved an organ system with personal, political, and moral meanings that resonated far beyond the walls of the operating room. The board realized we needed to be involved in the pipeline of social problems that bring our patients to us. We also recommended the use of motivational interviewing techniques to encourage positive behavior change with our patients so that they could become the best versions of themselves. We asked that we put on our glasses and look after ourselves and support one another. The working capital of medicine is not buildings, robots, hysteroscopes, instruments, and technology; it is the minds, bodies, and emotions of physicians and caregivers. We thought it vital that we remember to care for the caregiver. Patients first doesn't mean self last. The dictum at the time was “put on your oxygen mask first,” which aptly reminded us not to be afraid to put ourselves first. AAGL began as a highly specialized organization in the 1970s performing surgeries that others felt were unethical. By the time of our board tenure, our minimally invasive surgery approach was considered a “standard of care.” Our board's mission was to support AAGL initiatives that would raise our national and international perception as the go-to society for the promotion, education, and innovation for all minimally invasive gynecologic surgeries, both benign and oncologic. With the help of many individuals, we initiated and supported the following major programs we believed would help fulfill this mission:1.The AAGL Center of Excellence in Minimally Invasive Gynecology was headed by Steven Palter. It was developed to recognize individuals and programs that met strict diversity and volume of minimally invasive gynecologic surgery. The program was modeled after the bariatric BOLD database and was intended to direct insurance companies to surgeons and programs that have fulfilled standardized criteria. It was also intended to collect data on surgical outcomes as well as provide data-driven clinical pathways.2.A second major initiative was to develop an Essentials in Minimally Invasive Gynecology examination to test and certify knowledge and skills of fourth-year residents and practicing physicians. This effort was led by Ceana Nezhat and contained a didactic and skills assessment for laparoscopy and hysteroscopy.3.We began a Minimally Invasive Surgery Research Consortium aimed at evaluating and collating large volumes of surgical outcome data. This was headed by Jon Einnarson.4.We continued our international efforts by cosponsoring annual meetings in Japan, Argentina, Romania, South Africa, and Spain.5.The AAGL fellowship program was expanded from 1 year to 2 years to prepare for an eventual American Board of Obstetrics and Gyncecology certification status.6.We expanded local and regional hands-on and didactic courses aimed at third- and fourth-year residents.7.AAGL solidified its national and international status by publishing data-driven clinical guidelines and position statements on controversial subjects such as the value of robotic surgery in benign gynecology. In summary, AAGL had a very successful year in raising our status with joint efforts and quarterly meetings with the American Society for Reproductive Medicine, Society of American Gastrointestinal and Endoscopic Surgeons and the American College of Surgeons, the Surgical Collaborative in Ob-Gyn and the Council on Resident Education in Obstetrics and Gynecology, and the American College of Obstetricians and Gynecologists. We are proud of our accomplishments and are honored to have been able to be part of this time of growth for AAGL. This year was full of activity and achievements for AAGL. We discussed at length the issue of conflict of interest for board members because other societies had already established “clean” rules for board members. It was decided only executive board members had to be free of conflicts of interest and imposed only for future board members. The organization of the scientific program of the annual meeting, which required a lot of time of the board, was switched to the hands of the Program Committee, allowing more time to discuss other board issues. The number of members continued to increase at a fast pace. China was recognized as a significant associate that could play a large role in our growth, a goal continuing nowadays with regular China meetings every 4 months. There was an international expansion securing combined meetings with affiliated societies in 3 countries. Dr. Tommaso Falcone was selected as the new editor-in-chief of the Journal of Minimally Invasive Gynecology. Combined meetings were arranged with Spain, India, and Colombia. The actions of the different committees were necessary to achieve the board decisions. Linda Michels and Frank Loffer provided great insight into the decisions, and AAGL office personnel were outstanding in arranging the board meetings and carrying out board decisions. Overall, it was a great year. Two-thousand fourteen was considered a reconstructive year for AAGL, pursuing the mission of AAGL toward advancing minimally invasive gynecology surgery worldwide. The president's goals for AAGL, which included the ongoing project on credentialing minimally invasive gynecologic surgery, finalizing Essentials in Minimally Invasive Gynecologic Surgery criteria, and board function, were overshadowed by the public campaign started December 2013 against electromechanical power morcellation and advocating en bloc tissue removal with laparotomy for all patients with uterine myomas. On April 2014, the US Food and Drug Administration issued a black box warning on power morcellation. The board created a Tissue Extraction Taskforce leading to AAGL's position statement—morcellation for tissue extraction should be improved but not abandoned because it was beneficial to most patients and risk data were scant, imprecise, and did not outweigh the benefits of minimally invasive approaches [7AAGL Advancing Minimally Invasive Gynecology Worldwide AAGL practice report: morcellation during uterine tissue extraction.J Minim Invasive Gynecol. 2014; 21: 517-530Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar]. Contradicting opinions on industry relations and conflict of interest policies led to the formation of a past presidents ad hoc committee, which led to 13 constructive recommendations to AAGL board of directors, the majority of which were implemented, including the update on AAGL bylaws, conflict of interest policies, and the role of AAGL leadership. Dr. Ceana Nezhat, who had previously published on safe tissue extraction techniques and had warned about parasitic and iatrogenic myomas secondary to improper electromechanical morcellation, was contacted by many patient advocates and reporters at the time. Dr. Nezhat warned at the time that minimally invasive surgery as a whole should not be overshadowed by the electromechanical power morcellation dilemma. Dr. Advincula served for 18 months rather than 12 during a period of transition and rebirth. Dr. Robert Zuravin resigned from the Board of Directors, and his presidency year was split between Dr. Advincula and Dr. Einarsson. This board made a series of initiatives and embarked on the development of a new logo and tagline—“Elevating Gynecologic Surgery.” During the creation of this new image, innovative educational programming was developed and realized with the 1st Global Hysterectomy Summit and the 6th World Robotic Gynecology Congress. The Fellowship in Minimally Invasive Gynecologic Surgery boot camp concept was made even more expansive while introducing funding mechanisms for research grants and exposure to instruction in clinical research for the next generation of surgical leaders. This board searched for a new editor-in-chief of SurgeryU, AAGL's powerful video-sharing platform. We established the annual John F. Steege Mentorship Award and paid homage to 1 of the pillars of the AAGL organization, Dr. Franklin D. Loffer, with the naming of the annual presidential address after Dr. Loffer. Some of the initiatives that we continued to develop included the Essentials in Minimally Invasive Gynecology test, a validated high-stakes examination in gynecologic surgery. The board recognized the need for a standardized competency test because we believed this would enhance the safety of surgery for our patients. We worked with other stakeholders to ensure widespread adoption at rollout. Other important initiatives included the development of a prospective surgical database in gynecologic surgery as well as an initiative for sustainable surgical education in developing countries, starting with a program in Malawi. We also further matured our vision and our future goals. This began with the rollout of a new logo in 2016. The new logo emphasized the tagline, which read “Elevating Gynecologic Surgery.” This emphasized that AAGL was no longer a minimally invasive surgery society, a laparoscopic society, or an American society. AAGL was an international gynecologic surgical society, and we were actively training fellows in advanced gynecologic surgery. These graduating fellows are the backbone of our organization and have already begun to change the landscape of gynecologic surgery. Our ultimate goal was to develop a board-certified subspecialty in advanced gynecologic surgery. These pelvic surgeons would be akin to gynecologic oncologists in that they can safely take care of any nonmalignant pathology in the pelvis, including that which involves the bowel, bladder, ureters, and nerves. We thought it would undoubtedly lead to improved surgical outcomes for our patients. We thought it was likely that the first step toward this goal would soon be realized with the designation of minimally invasive gynecologic surgery as an area of focused practice. We recognized that board certification is a long-term goal, and we would continue to work toward the realization of that goal.