Where the Society is Going

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Roberta Speyer: “This is Roberta Speyer, Publisher of OBGYN.net, and we’re reporting from the International Congress of Gynecologic Endoscopy which is the American Association of Gynecologic Laparoscopists 27th annual meeting here in Atlanta, Georgia. Today we’re talking to the President of the Association, Dr. Ronald Lebean and Dr. Paulo Berazzo, a member from Brazil. What we’d like to discuss today gentlemen is where is the society going, where has it been, and how is the new technology with the Internet and the outreach that that provides going to change things in the future?”

Dr. Ronald Lebean: “The society was, is today, and is in the future mainly interested in education. So our goal and our mission is to educate physicians in the technologies of endoscopy. That is going to be our role in the future so that as technology advances, AAGL will try to have people in our ranks who are on the cutting edge and who are interested in teaching. We have and will continue to try to be able to look at what’s evidence based medicine and put out to the physicians what is good and be able to discuss how to do it and how to avoid complications.”

Roberta Speyer: “The name American Association is maybe a little misleading because really your membership is not strictly North and South American, is it?”

Dr. Ronald Lebean: “No, it is not, a large number of our membership are not American. They’re European, Asian, and certainly South American so we are American only in title. There has been, in fact, some interest in changing the name of American, likewise though we’re the AAGL the American Association of Gynecologic Laparoscopists, we’ve also left the term laparoscopy, we are endoscopists.”

Roberta Speyer: “This is true.”

Dr. Ronald Lebean: “As this meeting has shown, we deal a great deal with hysteroscopy, it’s use, and complications. We have in the past worked with microsurgery and with ultrasonography. We were one of the leaders in starting and getting the interest in ultrasonography.”

Roberta Speyer: “I wasn’t aware of that. I was just at a meeting in Edinburgh for the International Society for Ultrasound in Obstetrics and Gynecology; it was a fabulous meeting. You were there for the beginning of that?”

Dr. Ronald Lebean: “At the very beginning, we had people who had an extreme interest in ultrasonography, and indeed put on a lot of conjoined courses. Early on at the onset of the interest in ultrasonography, we had in our programs speakers on ultrasonography so we’re not so uni-focused.”

Roberta Speyer: “As the name might…”

Dr. Ronald Lebean: “As the name might imply. There’s a funny feeling when you have a name for many, many years - 27 years, and all of a sudden think should we change the name? Interestingly enough, I’ve even had other people from other countries say, “No, don’t change the name, we’re used to the name.” So I don’t know, we’re going to conduct a survey of our membership to see what they think we should do.”

Roberta Speyer: “What do you think, Dr. Berazzo? Of course, from a South American perspective you like the name American.”

Dr. Paulo Berazzo: “In Brazil, we are intending to change the name of the society too because the name is Brazilian Society of Laparoscopic Surgery, we intend to change the name to Brazilian Society of Endoscopic Surgery. Maybe a good idea is World Society of Endoscopy for the AAGL.” 

Dr. Ronald Lebean: “That’s great, and I hope that you respond to our inquiry. That’s a good one, the World Society of Endoscopy.”

Roberta Speyer: “Tell me why did you come to this meeting, it’s quite a trip, and what have you gotten out of it yourself?”

Dr. Paulo Berazzo: “Because this meeting is almost the real international and world meeting of endoscopy and gynecology.”

Roberta Speyer: “The AAGL is. Now with the new technologies that are emerging that you’ve seen, how long have you been - the whole twenty-seven years, doctor?”

Dr. Ronald Lebean: “No, but I’ve been around for over twenty years, around twenty-one or twenty-two of those years, something like that. My interest really started around 1980.”

Roberta Speyer: “When you started, what was the focus then and how is it changed over the years do you think?”

Dr. Ronald Lebean: “The focus then was strictly sterilization.”

Dr. Paulo Berazzo: “Yes, all on diagnosis.”

Dr. Ronald Lebean: “But the AAGL’s big focus was on sterilization. Indeed, we were responsible or partly responsible for some of the explosion in the use of laparoscopy for sterilization. AAGL produced guidelines and many of the members at that time were people like Dr. Melvin Cohen, Dick Soderstrom, and Dr. Kleppinger who invented the...”

Dr. Paulo Berazzo: “Kleppinger bipolar resting forceps.”

Dr. Ronald Lebean: “Those instruments were invented mainly for sterilization procedures.”

Roberta Speyer: “So these were pretty exciting times, and the whole concept then was to move towards laparoscopy. Was it a challenge to get people to embrace this?”

Dr. Ronald Lebean: “Absolutely, that wasn’t as hard because prior to 1972, in the United States anyway, there were laws in many of the states that required large numbers of children before a woman could be sterilized. There was a formula of the age times the number of children had to be more than the figure two hundred. In Kentucky where I was in training in the early days, they would not sterilize a woman unless she had six living children.”

Roberta Speyer: “The mortality rate, I suppose, was greater but still that’s an awful lot.” 

Dr. Ronald Lebean: “That’s an awful lot.”

Roberta Speyer: “I have five.”

Dr. Ronald Lebean: “But when they struck down the laws in 1972, then there was a virtual explosion of people able to have sterilization. Then as laparoscopy became more accepted as being minimally invasive and highly successful, then there was this literal explosion in interest in laparoscopy.”

Roberta Speyer: “So the membership at that time was increasing and growing. The conferences that you would attend yearly, would there be a lot of introduction of new technology? Do you see as much introduction of new technology now? How do the times compare?”

Dr. Ronald Lebean: “There wasn’t very much new technology then. New technology really started in the 1980’s, and a lot of it you probably could give great credit to Professor Kurt Semm from Kiel. Dr. Semm was doing advanced endoscopic procedures - laparoscopic procedures - and some people such as myself heard about Dr. Semm, met him, and saw his work. I went to Germany in 1983, I came back and I did the first series, and reported the first bilateral oophorectomy done in the United States by endoscopy based on the stuff that we learned from Kurt Semm. Indeed, we had to order equipment from Germany because there was no equipment in the United States that was being manufactured to do it.”

Dr. Paulo Berazzo: “There is a funny history about Professor Kurt Semm. When he performed the first appendectomy, he was banned from the German Society of Surgery.”

Roberta Speyer: “Really, why?”

Dr. Ronald Lebean: “A lot of people and Kurt himself would say that he’s crazy. That’s what Kurt would do.” 

Roberta Speyer: “He would point to his head.” 

Dr. Ronald Lebean: “They said he was crazy, and indeed, when I first published a series in 1985, it was called the Economic Impact of Pelviscopic Surgery, and I think it’s the first paper in the United States that talked about that kind of thing, and people laughed at me. They thought I was a nut case.” 

Roberta Speyer: “Was laparoscopic surgery used on women initially for sterilization and then went on to other…?”

Dr. Ronald Lebean: “Diagnosis first then they went to sterilization.”

Roberta Speyer: “What about doing other types of surgery on men and children, did that all come later?”

Dr. Ronald Lebean: “That came later, the general surgeons were very late into it. The first laparoscopic cholecystectomy was not until around 1989.”

Dr. Paulo Berazzo: “The first laparoscope cholecystectomy was by a French gynecologist.”

Roberta Speyer: “Really.”

Dr. Ronald Lebean: “The first one’s that were done in the United States were Reddick and Saye, one was a general surgeon and one was a gynecologist because the gynecologists were the experts in laparoscopy but we were the experts in sterilization.”

Roberta Speyer: “Oh, you’re the experts in everything, you know that. But that’s very interesting, did you think that the general surgeons had a resistance, that they felt that you were undermining maybe a system that they had established and they were very comfortable with?”

Dr. Ronald Lebean: “No, they just thought we were crazy. I went in the early 1980’s to some prominent general surgeons in Louisville, Kentucky, which is a pretty big medical center, and I said - I think we should be able to do a gallbladder by laparoscopy, let’s do some research on it, and let’s do some animal studies. They kind of patted me on the back, told me to calm down and I’d feel better in the morning. They laughed, they literally laughed.”

Roberta Speyer: “What was the equipment like then, it wasn’t as thin and so sophisticated with the viewing angle, was it or how was it?”

Dr. Ronald Lebean: “The equipment was, first of all, the only equipment. There was none at that time being produced in the United States.”

Roberta Speyer: “So that’s why you had to go to Germany.”

Dr. Ronald Lebean: “Literally none, and the original stuff was all coming out of Germany.”

Dr. Paulo Berazzo: “Tuttlingen the city.”

Dr. Ronald Lebean: “Yes, Tuttlingen, it was all coming from there. In fact, the original equipment I first had when I got it all the fittings were European so we had to change the fittings for the gas. The instructions that came with the insufflator and all the stuff I had were all in German, there was nothing translated.”

Roberta Speyer: “It would be interesting to have a museum or at a meeting sometime where you could maybe show some of the early equipment. Have you done that?”

Dr. Ronald Lebean: “I’ll tell you something even funnier, even though this is going on for recording, I don’t think it’s anything. I just recently came across some things - letters that I had saved that I sent to Ethicon for the archives, and this was an exchange of letters between Ethicon and myself. There was no endosurgery then, and because I saw the literature in Germany made by Ethicon Germany, Ethicon in the United States had no idea about it, and I tried to get them to produce it in the United States and they didn’t. I had a letter that was sent to me by one of their vice-presidents that said, “We doubt that there will be a future in this type of…”

Roberta Speyer: “About this sort of work, I think they’ve changed their minds.”

Dr. Ronald Lebean: “I think so.”

Roberta Speyer: “Of course, he’s not with them anymore.”

Dr. Ronald Lebean: “I don’t think so but there’s been a big change.”

Roberta Speyer: “But that is true. We have an article on OBGYN.net right now that discusses all the people that have said - this will never work and that will never work through technology about computers and that’s very true. So really you were pioneers, and you had to be able to stand up against that laughter which we can laugh about now because we know where the technology eventually led us and how much it has improved the quality of women’s lives but in the beginning it wasn’t as funny as it is telling it now. I’m sure it must have been difficult at times to have respected colleagues that didn’t believe in what you knew was going to change the world.”

Dr. Ronald Lebean: “I think I addressed this in my presidential address on Thursday morning.”

Roberta Speyer: “By the way, just for our listeners, we will have that entire address which is a wonderful address attached and available on OBGYN.net to this recording. But go on doctor.”

Dr. Ronald Lebean: “I talked about the fact that the people had to be brave literally to talk about these things because they were ridiculed, but this goes all the way back to the beginning of pioneers. A pioneer in anything, you have to take certain risks if you’re going to be a pioneer, and you’re a nut case until it’s proven. Then people say - I was with him all the time.”

Roberta Speyer: “One last thought, Dr. Lebean. If you had to think of one thing that you’ve seen at the conference here, is there something new on the horizon or is there something we should be watching that’s the next big breakthrough?”

Dr. Ronald Lebean: “There are several, of course, one of the big things is in hysteroscopy with the newer methods of doing hysteroscopic surgery to try to make it safer. There are such things as bipolar electrodes rather than unipolar and using safer fluids. However, there are always dangers there too, it doesn’t mean that it’s completely safe but better and safer ways to doing things, and better ways to take tissue out of the abdomen. I’ve given many talks in which I say the Holy Grail of laparoscopy is a perfect or an excellent morcellator, a way that we can get tissue out of the body. With an excellent morcellator or methods to remove tissue and better and easier ways to suture, to put this into the hands of the everyday gynecologist so that they can translate the skills they have into endoscopy. That type of thing is coming and people will be able to utilize their skills easier. As it is now, such things as endoscopic suturing has a rather steep learning curve, and hopefully, we can change that with some of the newer instruments that are out there.”

Roberta Speyer: “Do you see this also?”

Dr. Paulo Berazzo: “I agree that hysteroscopy is having a big rise in endoscopic gynecologists. We have a course and everybody’s interested in hysteroscopy now but before they weren’t. We have new alternatives to hysterectomy and it’s good.”

Dr. Ronald Lebean: “The idea is we are basically a society for the healthcare of women, and whatever we can do to improve the healthcare of women and make it easier for women to have that healthcare in a safe form and less intrusive manner, that’s what we’re about. Certainly the production of instruments and equipment to do that is where we’re trying to point industry and industry is pointing at us.”

Roberta Speyer: “Thank you so much Dr. Lebean for taking the time out of your very busy schedule to come and talk to the OBGYN.netters.”

Dr. Ronald Lebean: “It’s my pleasure.”

Roberta Speyer: “Thank you, and thank you Dr. Berazzo for coming and giving us a South American viewpoint on some of these things.”

Dr. Paulo Berazzo: “Thank you.”