Post Program Survey
From Simulation Training to Mastery of MIGS: Strategies to Optimize Complex Surgical Cases
Originally Broadcast: Thursday, February 25, 2021 at 7:00 PM EST
Course objectives:
Demonstrate via high-fidelity simulation the key surgical steps to successful conventional & robot-assisted TLH
Illustrate seamless integration of uterine manipulation technology & robotics
Use pre-recorded surgical cases to analyze & highlight best practice techniques
Compose strategies to overcome common obstacles in complex surgical cases
Presenters
Arnold P. Advincula, MD, FACOG, FACS
Chetna Arora, MD, FACOG
Welcome and thank you for attending. This event is brought to you by cooper surgical, a leading provider of medical devices for women's health care. For 31 years, cooper surgical has worked with health care providers to provide highly effective clinic and practice based contraceptive, surgical and obstetric solutions to complement our portfolio of trusted and reliable medical devices. We have also broadened our offerings, investing in the areas of reproductive genomics and in vitro fertilization. We are fully committed to helping improve the delivery of health care to women and their families. Cooper surgical manufacturers over 600 clinically relevant medical devices used by healthcare providers and offices, clinics, operating rooms, labor and delivery suites and reproductive IVF clinics worldwide. Clinicians overwhelmingly say they trust our products for their reliability, innovation and efficiency. Here are some other interesting facts you may not know about Cooper surgical. Since our inception in 1990, our focus has always been women's health care with more than 600 medical devices and over 3200 product numbers across a broad range of market segments. Physicians know and trust our products. We ship over 1450 orders per day, of which 99.7% are shipped the same day. Our customer service department handles over 2100 inquiries per day. We employ 1800 people worldwide. We're pleased to provide this educational opportunity on behalf of cooper surgical. Welcome and thank you for participating in tonight's event. My name is Doug K marketing director for cooper surgical and I will be the meeting manager for this evening's program. A couple of notes on how the demonstration will run. We have an approximately 75 minute time limit with interactive questions and answers with dr Advincula and DR Arora. Throughout the live demonstration. At the end of the demonstration, they will participate in a 15 minute dedicated Q. And a session. We would also like to extend a special thanks to our colleagues at Guy Nissim, intuitive applied and the Columbia simulation lab that have provided equipment for this demonstration and been critical partners in bringing this program together. Tonight's program is entitled from simulation training to mastery of MIG strategies to optimize complex surgical cases are distinguished presenters are dr Arnold Advincula and dr Chander Arora, of the division of gynecologic specialty surgery at Columbia University Medical Center and the new york presbyterian hospital. Now doctors Advincula and dr Arora. Thank you. Well, good evening everybody and greetings from new york city uh and from Columbia University where we are beaming out live from the education center here on our healthcare campus. Um I'm really super excited to be joining all of you this evening together with my partner Dayton Aurora. Uh you know, one of the things that we've definitely missed during the course of the past year because of the pandemic has been the ability to really interact with folks and to be able to teach and share the things that we learned along the way clinically in the operating room and in clinical practice. And so really our goal tonight as Doug was saying is to spend the next really hour and 15 minutes, hour and a half kind of going through a lot of different concepts answering questions exactly. Starting with we're gonna start with the instrumentation, move on over then to simulation and then categoric dissection. And I think during this time take and I discussed that this is live. So we're going to be open to uh just tailoring the program to any questions or content that you want. We'll be calling quote unquote audibles during the whole program. So let us know what you want to see what you want to hear, what you want to know about. We're definitely gonna do that. But certainly before we get started, one of the things that I wanted to do since I think we're very fortunate that there are individuals who donate their bodies to science and allow us to to learn from that and to teach is to take just a moment of silence here before we begin the program. And thanks for those individuals that do that on our behalf. Okay, great. Well why don't we begin? So what do you think we start with the instrumentation? Let's do it. So this is a full table of all the types of uterine manipulators you could ever imagine. We've got all different sizes and three different types to talk about today. Yeah. So cheap. You know, one of the things that you know often comes up as a question is, you know, first of all, how do you choose a manipulator And what are the differences here? So maybe it might be helpful for us to talk about the about the differences in terms of types of manipulators, particularly when we're doing hysterectomy. Yeah, when we're doing a hysterectomy, I mean you can choose the different ones that suit you in our practice. You know, we have eight surgeons and everyone kind of picks which ones work best for them. This one's the delineate er what's nice about it is that you're able to insert this tip after you've sounded the uterus you get a sense of how long that is. And the markings are here, you'll place this one in after you dilate to about an eight french. And then you'll be able to place this up to the fungus, insert the balloon to inflate it if you can use a syringe to kind of show that here we'll demonstrate with a 60 CC. But you can just use a 5 10 cc syringe and you'll be able to inflate the balloon here so that you're actually set in the right spot. And then once you do that then you can take your instrumentation out, you slide the coefficient in that has the Koopa to me ring on it and then you lock it in place based on where you sounded. And so what's nice about this is just an all in one piece. There's no assembly required. Has a built in new mo clutter balloon. Exactly. And essentially uh you know, it's used exclusively for hysterectomy. So there's really no other purpose for this device except for hysterectomy. There's no chroma perturbation tubing in this. But again, it's an all one piece system comes in four different cup sizes. So you have a four centimeter cup, 3.53 and 2.5, which I think is really important to know. And the other thing that often comes up is that there is the availability of a soft cup. And so you can see that here, this one is a little bit more malleable for when you have those situations where you know it's a much more tighter, narrower and troy this, forgetting that in, let's talk about the arch, which is another option that some of our partners utilize. So the arch, you can use it alone, particularly with these roommate tips. Do you have all various sizes for different size, utilize that you're encountering then if you add it with the co efficient cup on top of it, you're able to use it similarly to the delineate er It's just a three part setup. But what's nice about this one is you could use it for say a myomectomy. And so you're able to use this without any of the cup meeting for the actual lobotomy purpose when you do a hysterectomy which you tend to utilize. I do too. But when I do anything that's non hysterectomy, I tend to utilize the arch and I just like it for being able to position the uterus for things like myomectomy. If you're doing a sacred apoplexy or any type of endometriosis surgery, it does require a tip. So like in this case, if I were to have sounded the uterus to let's say 10 centimeters, which is the green tip, you want to place that in through here with the perfect roomie tip. Just twist it in until it's flush. That's right. And there are channels on the sides here where you can place these to the tubing into the grooves to keep it out of the way that keeps it neat and tamed. I like to say you want to keep the tubing control. And that's particularly helpful when we talk about the ally and having them in the right channels. But we'll show you that later. That's right. So here here, this could be used just for routine manipulation. Right? So you have this device, it's got the chroma perturbation tubing and the tubing that allows you to insert plate the balloon on the tip. But as I said, if you want to then utilize our atomizer ring, then you would grab one of these which is the coefficient. And the way this is placed is it's back loaded. So, you know, one of the biggest difficulties of placing unit manipulators is that if you can't back load the cup, then it's really hard to place it vaginally. So in this case we can do that and we can mount this at the back end and again, that allows you, that's that's put together now it allows you to place it into the uterus. Similar pattern is what channel described. You gotta inflate the balloon tip once that's in the uterus, then you're going to slide this down until it locks into place. There's gonna be a clicking noise that you might hear and it's going to fall into a groove here. You can zoom in, there's a groove here and then there's a locking mechanism here that you're gonna lock down and that keeps that nice and secure. And so some of our partners like to utilize this manipulator quickly when you're dealing with a very large uterus, this is certainly not gonna bend, and you can definitely create the kind of torque that you need for that. Now let's talk about the so just so you can see on every one of these tips, they have the new McClure balloon. So let's switch over now to the roomy, which is sort of I call it sort of the classic, right. This is the classic manipulator that most folks are familiar with from cooper surgical. Um it has this point of articulation where you can create some level of anti reflection and retro flexion as well as the typical full unit and inflection retro flexion side to side, right? Different as you can see their coefficient. So similarly you would put the tip on the roomy. So just like you would with a delineate and you just screw it onto the top. Then all you do is you follow it down the channels similar to the way we just did the delineate er same concepts and then there's an arrow here and there's a simplistic arrow as well on top of the actual cup portion. So basically all you do is you follow the arrows to the arrow here, you make sure this part is bent down and then you can bring this back, just slide it back, it's just a little bit of a gift, just like the delineate er did. And then all you do is you just pop this in so now this pieces in here and whenever you want to push this up to the actual cervix itself and you're just going to slide this forward the similar way and just like dr Advincula said, if you go like this, so I go this way, right, Arnie and then I can show retro version this, That's right, that's right, and you just want to make sure that this white arrow and the black arrow line up because that's going to lock into place, see how that locks into place. That means that this is secure and you almost have like a tactile and an audible tactile sense a feel and an audible click with the roomy and the arch when you're placing those coefficients and I think those are really important because the one thing you don't want to have happen is migration of the cup or any kind of movement, Right? I mean that can make or break a case to be honest. I mean people sometimes disregard the most simplistic step in people's minds, right? You put a union manipulator case, go, we get the ports in. You know, sometimes we have resident or a fellow or someone placing the uterine manipulator below and we're ready to put the gas on and get started. But if this part isn't perfect, it can make the case go from a simple our case to like a three hour disaster. So, so here, just to review, we've got a roomy tip on the traditional roomie to handle. Now that's articulated with a back laudable coefficient, we've got the arch with the coefficient cup and the roomy tip and then we have a delineate er all in one unit. Um, but all similar concept and design. You need to know the sound of the uterus and you need to make sure that you also understand the cup size, right? So let's talk a little bit about sounding and getting in. You know, one of the things that people often don't realize is that when you place these manipulators or a roomy tip, You've got to dilate, right, I've seen physicians sometimes try to place these devices without dilation. And so yeah, you definitely need to dilate. And I always say to at least 21, French with a cracked dilator is how I remember it to really make it easy for these to go through because they do have a little bit of a soft tip. So if you're not dilated it's not going to go through. Right question just came in. How does your technique change if you're dealing with oncology patients? I feel like the same principles apply, you know, in terms of the manipulator choice, I think it's really what you feel is your most comfortable with. Obviously people choose the tool that they're going to be most comfortable with utilizing during a hysterectomy. I do know that for a lot of oncologists, they do like to use the soft tip just because that allows them to deal with a postmenopausal hypo estrogenic narrow enteritis, they can manipulate. This is a little bit more malleable and then to be able to slide that in. So I think to me that that really is again, surgeon choice in terms of what you want to use just to touch base real quickly. Also about the tips as you know, there's a wide variety of tips that are available. Often folks don't know that there's a really short tip which is the yellow. I remember things by color. So I know that there's the yellow, there's a there's a purple and a white 866. And these ones are your little ones. This is also a six too. But it's just a more narrow lumen. If you have maybe like a cyanotic off. So you're just trying to play something but it has a little bit more flexibility. So if you don't need as much manipulation that what about in a situation? Say we have like a leap or a cone or the cervix, vaginally is a little bit shortened or maybe not even visible. What would you recommend? It's a great question that comes up a lot people think that you can't place manipulator if somebody's had like a cold night cone or a leap in the cervix is flushed with the vaginal apex. The most important thing. And I hope people are listening to this is that as long as you can identify and us dilate the appropriate canal and get into the cavity, it does not matter that there is not any cervix in the vagina because there's also that intraperitoneal component of the cervix. So once you place this and you're able to get this in the uterine cavity appropriately, that's right. And you slide this forward into the into the for nicks and you lock this in with your appropriate sounding. Then when you look at this from up above, it is gonna look exactly the same as if there was a survey sitting inside this cup, right? So you want to make sure that that it sits in the for nick's but you're going to be able to do your tlhe so quick question that came in. It was actually questions are pouring in. One of the questions just came in. What do you do? This is from dr darwish. If the cervix is so bulky that you can't slide the cup all the way up if the cervix doesn't fit inside. Oh, that's a good question. That's a really good question. There's definitely a variety of sizes. The biggest one on the cups are is a four centimeter diameter four for all of the devices, 3.53 and 2.5. I'll be honest with you. The sweet spot for cups is like 3.5. Right? But but the question that came in from from one of our viewers was you know, what do you do when the service is too bulky? That's a tough one, because I rarely encounter that. But I will tell you one situation where I find things very helpful is that when you have a very elongated cervix, sometimes the cervix is a bit elongated and kind of like this whole thing, usual cervix is like 3 to 4 centimeters. And sometimes with those big, they get cold in the pelvis and the cervix. And you really want to make sure that this cup sits up in the for nick's right, because that's the one nice thing about a coke cup if you look at the different cups on the market, it's not tapered right? The well is equal the whole way down. And that's a good thing because anytime you have something tapered. But the item that you're putting in it is a little bit longer than the cup. That thing's not gonna sit all the way up right. Where it does with the coke up and you know, what we can maybe do is if you guys could cue up that first video and loop it um, that you know while kate and I are talking, let me know when the video is looping. There's a video that I'm going to play that that's in a cadaver that show. And I showed us that a lot of the toxic gifts and some of you may have seen it already where I dissected out the poster lead for the broad ligament and the ureter, the uterine, the cup is in and and with that as that video is playing. You'll be able to appreciate that when the cup is fitted appropriately and you push it in. There is what I call a margin of safety. You're gonna have a nice distance between where the ureter is and where you would normally take your, your medical, I would say maybe these next questions, you can demonstrate one of them came in was what would you do if the, you're dealing with severe cervical stenosis. This from dr Oberoi and then the same question. She's also transitioning right now from v care to the delineated with Ally and want some tips on the learning curve. That's something when we yeah well let's touch base. What do you do when you have to deal with the fanatic service? Some of the tricks that we employ to get in. You know when it comes to a cyanotic cervix you can do all the things you would otherwise think of doing. Like a dilation to try and get in. You can use lacquer marduk probes not my favorite cause sometimes you can create a false tract. Then you can consider even a cruciate incision Single Stab incision. You can do it under visualization. You know this is the time when you are doing a hysterectomy so the specimen is coming out so you really can take an opportunity to switch the order of your routine. Really put your ports in first, do it under guidance and other situations. You know you think about doing these under ultrasound guidance but here the Uterus is coming out so use that laparoscopic help to see what you're doing exactly. And I'll tell you that some things I've learned through the years and I've been in practice for 20 plus years now. I hate HLA caramel duck probes because I think they tend to create a false passage. So my goal is I love prattville Laters. And I usually take the smallest or second smallest dilator. And I use that to probe And then I go right to an 11 blade and make a crucial decision where I see the dimple. If you can make that crucial incision, but that doesn't facilitates the dilation you're going to get in. But again, if it's cyanotic, put the scope in first, watch it from above. It makes it so much easier when you do that quickly before we move on to the next. It's always amazing how much you have to to cover cover all at once. These are the white tips, a lot of tips that we can use. Exactly kopecks is right. So this one is if the cervix is off, so this is if the cervix is in place. So we have a lot of other other tips that we can use on the regular arch. So you can certainly use the hoyt tips. There's the sacred tips, whether you're going to do a sacred text or sacred cervical Pepsi. Uh, these are the things that are available to be able to be utilized and we'll go, we'll come back to this. But I just want to kind of emphasize that there are a lot of sort of versatility that exists with the manipulation platform. And basically you sort of choose your, your, your instrument that you want to use for the case and then we'll come back to some of these other things as we move over. So let's let's kind of jump over to the next station here set of gloves for you right here. Perfect. So this is the dinosaur model and this model is a really incredible model and you can see kind of here from a little bit of the demonstration that you've got a full, it's fully equipped. So you've got your uterus cervix, glow peon tubes, ovary, bowel, your eaters, vasculature. Everything is really in here. And what's nice about this is that every part of the step of a. T. L. H. Can be executed here in a bloodless way. And it also is it's food grade. So this is a model that can be easily transported. You know, you can get on a plane. It's there's a lot of difficulty sometimes with catalytic specimens just because it needs to be ethically handled and appropriately um you know used and there's a lot of maintenance and you know, there's financial costs and the circumstances around and can be quite challenging. But with the dinosaur model, it's nice because you can in a compact way teach all the same steps. That's right. Like like I said, it's U. S. D. A. You know, approved food grade, you know, animal biologics that have been constructed to mimic a hysterectomy and we've had a lot of experience working with this change in particular because she did a thesis project on this when she was our fellow. But it's really a great teaching tool. We're going to utilize it today because we can utilize energy with it. It has the key anatomical structures that when you're teaching hysterectomy, whether it's with residents fellows practicing positions. We can really highlight sort of the key concepts as it relates to your manipulation. But before we get started with that, let's talk a little bit about ally because it's what I call the iron intern in our life. We always talked about that, but it is a great what I call a great asset for when you do cases where you need for one static positioning. But it can also certainly be used for manipulation when you're doing a hysterectomy. And so before we even get started with this, what I'm gonna do is take this off. Yeah, we're gonna show you a couple of different things here with this before we go, let's go ahead and take this off. So we can. So basically this is just the class that allows this device to connect. So we'll show you this part in a second. Now we're going to go into more detail about the mounting because that's a critical piece that people often, you know, feel intimidated with because it's a piece of equipment that you're gonna mount to the bed rail of your table in this case for the sake of time. We've got it mounted but we're gonna show you real time mounting on an actual flower bed with a cadaver and how that interacts also with robotic surgery. So we'll get to that shortly. But normally when this is brought out to the field, um this is gonna be brought out and mounted to the bed rail and it's going to be in a very lax position here. Uh it's gonna get plugged in. There is a foot pedal here that we utilize to activate it so that once we turn it on it's gonna engage and then we can step on this and then we can bring this up and there are a lot of different drapes that get utilized with this. And so we're gonna show you those drapes right now we did cut this one for the sake of this, but I just wanted to demonstrate this is how you can keep this whole drapes sterile. So when you're draping the legs and using whatever drape you do for laparoscopy, basically this would be the way to cover the whole instrument. So you're able to kind of move it throughout the case. That's right. So we cut that so you'd normally clip this on and pull the drape down over this. Um, this particularly the white one. Uh we called the white adapter is the adapter that we use for either an arch handle or a roomy handle. And what you'll see here is there's pictures, so based on which instrument you're gonna use, your going to mount it in that direction. So I don't need it mounted this way if it's a roomy this way if it's an arch and so I tend to utilize the arch a lot. So I like to have it when I'm setting things up, is I'm gonna set it so that I'm ready position. So when I come in with this, this is gonna go in in position for the arch arch handle. If you can see right here, there's too little pieces right here that just kind of clip in and they're completely locked in. You don't have to adjust it at all at the end of the cave. And I'm gonna show them how that clips on here. This one has just for demonstration and typically you're going to have a manipulator in when you mount the allies. So but just so that you can get a sense of how this looks. If you were if you were going to have this in a patient and mount this, this would sit here like this and you would bring this around, right? This is gonna lock like this, right? And that's gonna sit and that's gonna hold. So if you're doing a local taxi for example, this is what what you would have inside holding. And that's why I called the iron intern because it never gets tired which is going to hold this and then there's a steady operative field, right? But we're gonna rotate this so we can mount this to the the ruby. I'm gonna put this back over here, you do that. So basically you can see here here's the handle and it mirrors this just identical to that. So the handle is this way. So just like we had used the arch this way, the room he goes this way and it's just going to lay into the groove and similarly click shut. Now there's a little bit of a learning curve with clipping these things on for sure, a lot of it again, it's like it's that sort of tactile, you feel it, you get the click and then it goes in. It's almost things have to kind of spoon in uh into into the appropriate alignment. But once you do that it's very very quick. So literally to mount this, you know, you're gonna you're gonna position your patient on the table, you're gonna put them in the stirrups, you're gonna mount the ally and then you can go ahead and prep and drape your patient and drape this thing and then you're good to go, you know, you still have to do your usual put the manipulator and things like that while we're doing that. We normally have this flexed over to the side, so it's not in our way. Um we'll go into detail a little bit again with the mounting on the other side, but let's go ahead and start with the showing off the model so you can see the model here, but we're going to take a peek and show you a little bit more inside and bring this out over here. So we can see this now with the goddess in model comes with this box trainer and a monitor. Now obviously we have to monitor behind this because we have another monitor here off to the side that we can use. We wanted you to be able to see how you know, again this is something that you could work with with your reps in your hospital for doing a teaching program. You know, get a dinosaur model, get an Ally and their learn how to use the ally, learn how to use it with. Because again, there's a learning curve, right? I personally, I don't use the room as much because I find that it's another variable of learning how to flex the handle, right, knowing what an inflection versus reflection what you're comfortable with. I like to just kind of up down side side that's kind of my my my my ship, so to speak. No pun intended, but that's kind of the one that I use for that reason. But there is a there is a good way that you can practice by integrating all of this and then it gets you familiar before you go into the operating room, then you have a better sense of how to do things. So let's go ahead and do a walk through here. Yeah. So if you don't mind, we'll use the uterine manipulator itself and I can kind of demonstrate some of the anatomy here. So I did get to use this as dr a was really nice to say my thesis project was where I, you know, we studied people of varying skills using this kindness and model to do a hysterectomy. But just while he's so nicely showed it to you here. Here's a nice funded with a poster of my oma. You have a very real looking ovary with some pathology, whether there's a little derm oid cysts or polycystic ovary. You have a really nice representation of the fallopian tubes and it's obviously bilateral. Here's your round ligament on the side. There's a nice utero ovarian, this is your rectum, your sigmoid coming down to the side. They have it. There's also underneath this peritoneum which you'll be able to see below. There's your order, there's the pelvic vasculature, the ligaments as you'd expect. And of course the cup is here so that you'll be able to see us when we get to what would be a Koopa to me. So we're just going to try to just show you how, you know from this perspective, there's a lot that you can do right, like, like I have this on the ally, I've got an affliction, I've got exposure and if I needed to and one of the things that I've learned and I'm gonna share this with all of you to hear me say this all the time when you move the positioning system. I find it's a two handed job, right? Like it's not something that I would do, like just from the beds everyone hand because it's not, it's not, it's just even with all the strength in the world, it's very hard to do it. So what I like to do and I'm going to step aside here is again, you want to have the foot pedal someplace that's easy access. But depending on who's going to move it is, I like to be able to have two hands, right? So I got two hands so I can move the handle and I can move sort of that goose neck as well. So I can create sort of the exposure that I need. So that when I when I have it the way that I want then then I can let go. But I that's why this thing is drapes sterile the whole way. So you can do two hands and hold that. I find that extremely helpful when, when we're doing stuff. So um let's go ahead and we'll try to take down some of it. Just so you can see the value of when you get the exposure that you need an inflection, a little bit over to the contra lateral side of what we're gonna work. We're gonna try to go down initially here, the variance. I'm gonna take that. We're just gonna use the voi in here. And what's nice about the guidance and models. You can use energy. So you can see how that really gives the person learning an opportunity to be able to see the effect of an energy device. And we're coming through the tissue and you can see that it's it's got real tissue effect to it just coming through that. And some of the tissue is a little bit a little bit thick. So something it's gonna mimic a little bit as if it was like a fibrosis or endometriosis. And it just gives you a little bit of a sense of like what you need to do. And these models can be tailored to what you educationally want to learn. What's nice about this is you can start with a myomectomy then do the hysterectomy part of the model. So you get two for one and you can see there's a fibroid built into this. So again that that emphasizes how, let's say you have the arch in there with the ruby tip and you want to position it for doing the new creation and then the subsequent repair. So all these things are extremely helpful. So there are the layers of the broad ligament here. So as you can see the tube is inserted where you would expect it to in the corner. Well with all of the three anatomical structures around the tube the way and then right here you can see we have the inside of the broad ligament. So if I go inside and I can spread, you can see inside that there would be um your ureter your vasculature and your minority will very great very well show you as it goes to the cardinal ligaments. So I'm gonna switch with you so you can demonstrate sort of separating the enter and post your leaf of the broad ligament. This is something that's great to simulate in practice with positioning because it really is critically important when you do A. T. L. H. To be able to separate that anterior post relief with the broad ligament. And take down that poster broad ligament so that you can lateral eyes the order right. And what's nice is you can use the uterine manipulator to help kind of guide your way and see dr it is kind of using the manipulator to hold the bulk of the weight of the uterus and he only has two ergonomically gently relax the uterus over And you can see here the anatomy is starting to show its way through. So you just do what you would normally do at this point. You know you hear we've done ovarian preservation on this side. The you can do where you remove the ovary as well and then you can get the anterior leaf here. You can see what looks like. I think this is what the round ligament right here coming up on it and then what I'm gonna do is I'm gonna reposition this so that we can show where the lobotomy cup is in the in the importance of that. So I'm coming across the round ligament here, what's nice about this model is the camera is kind of built in here. So you don't have to hold the camera when you're teaching. And it might be nice if you are doing like skills testing so that it's a standardized way of educating. So now when I separate this in the broad, you can see here is your uterine artery and then anatomically water under the bridge, right there's your ureter and it follows the path and it's also the color is very like as if it's the same color. And again, because we released the poster leaf of the broad ligament that's just going to drop this peritoneum away. There's a double layer on this so you just have to make sure that you get both layers and you can see underneath here, that extra ligament that's on that side here will be reflected of your cardinal ligament and your heterosexuals which are both captured in this model. So let me adjust this so that you can show kind of coming over the lobotomy bladder flap. Again, it's another good point of again, once you take down that broad ligament release the structures laterally come across and make the bladder flap that you can do that with this model. And so I'm gonna justice. And then if you guys wouldn't mind cuing up the video because one of the things that I wanted to make sure we touched based on is the value of the copa to me. We talked about the well being wide and accommodating and going up into the for nick's. I think that's extremely important when we do A. T. L. H. In terms of preservation of the uterus sickle ligament. Okay, here we go. So chain and look at that. That's so that's where the cup is in. You can see that this is a cadaver. So you know we were filming this in the cadaver to highlight things, see there's a little bit of endometriosis on that motorcycle ligament in the cadaver but see where the motorcycle ligament is inserting into the post your vagina and you can see where we would normally make the copa to me is going to be above that insertion of the motorcycle ligament into the post here vagina because you want to preserve those just for preventing prolapse. Lots of reasons why. Right? So instead of breaking that attachment, like we do in a traditional abdominal hysterectomy in a vaginal hysterectomy. What we do with laparoscopic hysterectomy, whether it's done conventionally with robotics is that I see that you want to see that bulge. I think you made a good point earlier that your case can go south in a hurry if that cup is not sitting in the right place right? Because when it's up in the for nix, you've got your gps charlie. Coe used to always say this lectures, that's my gps and that he's he's right. That absolutely is your gps. And again, you can see that there, look at that, see the cup all the way around circum friendly. And it gives you a full guide all the way through. And I think you do the same thing. I do you do a little safety check once we put these things in, we always look before we start the case to make sure we're happy with the position of that cup. Question came in Services sometimes he struggles with the posterior cul pa to me sometimes cutting to settle it or to call dad and missing that blue cup from the room to what would you advise them there? Right, well, you know, something we'll you know, we'll get to that when we get to the cadaver. It'll be a really good way to show that we're gonna show you some tricks about how to visualize really well. But before we do that, let's talk a little bit about sort of creating that bladder flap here. Yeah. So the round ligaments kind of taken down on this side and dr it is kind of showing me this on this over here. So yeah, thanks. And all I'm gonna do is I'm gonna continue to take your bladder flap, your broad ligament up to the front. And what's nice here is you can see there's actually a bladder underneath here and you can feel the cup right above. So if I push down here, there's my cup right here. So when I see my cup, what I'm gonna do. Yeah. So I'm gonna come across this right at the level because there's no need to go lateral or distal to that. And I think it's really good to be able to go right if you're gonna make a bladder flap and you have the cup push cephalopod, you want to make that bladder flap right over the fat part of the pottery. Exactly. Because then you can see this beautiful anatomy that this would be your pubic cervical fascia. So that pearly white which you will see in our category specimen there is often really I think the biggest mistake people make are that for some reason they get very bladder phobic which obviously you don't want to get into the bladder but you don't want to be coming across too high in the cirrhosis of the lower uterine segment. So you really wanna be over that that area where it's right over the fat part of the cup, you're gonna slide underneath that tournament and look how that opens up really nicely. And this model really demonstrates that. Imagine if you did start here, what would happen. So if you start here, you'll have to peel back that peritoneum all the way back. So you can safely make your co pa, to me, you're probably gonna encounter more bleeding. You're not gonna be able to see your anatomy as well and then it'll be a little bit more dicey when you do your actual cuff closure because you want to really have this margin of safety. So that black is really pushed away and that a vascular space and then this can be closed when you're closing that vagina and both the mucosa and the cervical fashion. Right, right. And then of course we're going to skeletonized the vessels here in a normal case. Now, hopefully we'll have some time towards the end of the program. We queued up some real like real, real videos from actual cases. But obviously one of the questions that comes up a lot is what do you do in a stuck bladder shaped bladders about this papa to me ring that you utilize our leverage when there's adhesions or scar bladder flap from prior cesarean deliveries. I feel like that's all we ever encounter. To be honest with all these higher order cesareans. But I will tell you that obliterated anterior cul de sac. This cup can save you because what you would do is normally an obliterated entire cul de sac. Because of previous cesareans, your posterior access is typically really free. So what I would do is normally clean out that posterior uh peritoneum. So the broad ligament tunnel, find that uterine artery and then right in this spot right here where you feel this cup and you see this uterine artery. What I would do is I would tunnel over it. Just keep pushing this device and tunnel tunnel tunnel and you'll see a video if we have time we can show that. But basically I'll fine this by going under the bladder in this margin of safety, right at this Koopa to me and continue to tunnel across. Taking this a vascular tissue in between doing the same exact thing on the other side and then addressing the midline petition. That's right. So you can always take the uterine before you even make the bladder doing a post your approach. But the other thing that you can do as well is the key here is that you don't want to make the bladder flap in the place you normally would because that's where the scarring is. You actually the safe space is actually a lot lower. You're gonna be a little bit lower on that ring. You're gonna find a spot where you can come over and it's okay if the bladder is stuck and pulled over. But if you can get underneath it, you're gonna find that sort of that whiskey tissue that's sort of not been compromised and that will help you guide you when you develop that area. But the cup is key. Quick question. There's only getting, you seem to be getting delineation and exposure with only the two of you with Ally. Is that realistic? It is realistic. But there is a learning curve and there are cases where you're going to struggle and it may not work for you right now. I find that, you know, the bigger the bulkier, the more sort of anomalous looking the uterus is, the harder it is to really gain the kind of exposure that you need. And that's where, you know, this is a good help, right? And I tend to take out pretty large uterus on a regular basis, constantly dynamically torque and twist and spin. But that's the key word dynamic. It can be static and you can have dynamic. It just lets you do both. That's right. Well, you know, we want to stay on schedule so we're going to move over now to the category portion and we'll show you how we're going to mount the Ally system. Exactly. So let me pull this back. So here we have our categoric model. And what we're gonna do is we're gonna place this Ally itself directly on it so we'll make sure that the camera can pan over so that you guys can see. Perfect. Great. So we have our robot set, we have our anatomical specimen and then we also have our robot here. So what we're gonna do is there's two very key spots where you're gonna hold. So here there's handle pieces where your fingers can go. Just follow the blue. So what and the other thing I mentioned before you mount it is that it's good to use this little rolly because it brings it close uh you know, it's got the foot pedal built into it and that that house is it? And then the plug, but it's nice to use the rolling. So you don't have to carry it all the way over. But it's balanced with the blue blue handles. As chapman said. Now the other thing to keep in mind as well is the railing here. So you know, so we have the bed rotated around. We're not going to leave it this way when we actually do the docking on the robot. But you normally want to have your your bracket for your stirrup at the end of the table rail. Now this is one of those beds that has a break in the table railing system. So we're gonna have a little modification here, but you want to have the bracket for the patient stirrup at the end of the bed and then the bracket for the ally is gonna come behind and this whole unit is gonna kiss the other. And that's the goal is to kind of kiss it that gets you an optimal position. The other thing that you often can look at to is to make sure the green on off button essentially lines up with the perineum, right? That's another good landmark, but go ahead. Let's mount that so you can see this piece will go right into this bracket and then this piece is that spacing that's in between. So you just when you put it on, make sure the brackets truly aren't kiss, they eventually will when the piece comes in. So I'm gonna grab it like I traditionally would. So I think you guys can see me through here. So what I'm gonna do is I'm going to pick it up, it is a little bit heavy, but if you're holding it with both hands like this, you'll be able to handle it. So he's moving away the actual cart that it comes on. And what I'm gonna do is I'm gonna go under. Thanks so much. I'm going to go under this and just drop it in and then you're gonna lock this bracket in a little bit, a little bit more. Want to make sure you guys can see, can you see that how that how that drop down? Just want to make sure you guys can see that. It literally doesn't take all but 30 seconds. I just want to make sure that sits in all the way and then your goal is really to, you know, I can't bring this too far forward, but I normally have this kissing with the other bracket, right? And then we lock this down, you want to make sure that's locked down. Then we're going to plug it in and turn it on and once we turn it on, then we're going to do the same thing we did before is I'm gonna bring it up and in this case here, what we're gonna do is we're gonna go ahead and put the blue drape on so we need to grab the blue drape wherever we put that. And we also similarly cut this part off so that you're able to see it go on a little bit more simply the blue drape for the delineate er because we have a delineate already pre placed in the cadaver just for the sake of time. I'm gonna go ahead and place this here And it clicks in just like the White one. Just got to get the drip out of the way. There you go. This would normally then just come down all the way around but you can see that here that's the other adapter and this is only specific to the delineate. Er but we'll talk about this once we get this flipped around so why don't we go ahead and flip this around so that that we can get this teed up for the if you want now. And what we'll do is we actually have another model up and ready to go. So we're going to show you is using the arch and using it for a Hoyt tip. So just like we have demonstrated before this is if you're doing a Sacred cotopaxi. So the dinosaur model that we have ready to go basically it will have the cough already closed. So it's gonna be a sacred couple pixie and this would be able to be placed inside. So we already have part of it placed by one of our handy dandy helpers. So while they're getting all of that set up, I just placed this tip on. So basically there's a groove in this, just like you have before you can lift this off and then the device will be able to pan back and pull right back out. So I have it clicked in ready to go. And now what we're gonna do is we're gonna place this in where there was, where we have the vagina already closed dr or could you stand to the side just a little bit. So I have this place in the vagina and if we can also show and demonstrate what's happening inside. So if you don't mind panning up to show this camera right here to show her perfect. So basically now, here we have a nicely demonstrated post hysterectomy model. So the uterine arteries are on the side there, just as you would have them. And the pa to me has been miraculously closed quickly for us for the sake of time. But what's nice here about this white tip is basically I can push in with a lot of, you know, strength here and just be able to give you to demonstrate you both the, the retro version for your bladder dissection and making sure that your posteriors that you're able to place your mesh, you know, we're not Euro guides here, but we know that this is a great device that our cohort likes to use. Okay, we're gonna go ahead and get started, yeah, I think we're good on this side here, so we can switch on over and I have the 30 scope. I think that's a great, a great model that you came up with to talk about once we're moving to a hysterectomy now in the last part of the program. And one of the things, if you want to bring that over, maybe we can get a good camera shot here. Um about what happens when you don't have this thing situated in the right location during the course of a hysterectomy, right? And I'm gonna have you talk about that while I get everything teed up here, so we can sort of emphasize that. Often people sort of disadvantage themselves when they're doing a difficult case because they're getting for manipulation, because they're not all the way set up with a proper fulcrum, I guess, is the best way to put it. And so I think this really gets that point across. Yeah, I think so too. So, you know, when you're putting in a manipulator, it's a really hard concept sometimes to teach because you can't really show it in real time, you're in in the vagina, you can't show how this cup is articulating with the cervix, you can't show the effect of a manipulator placed in the wrong position. So what we did is we took one of the dinosaur hysterectomy pieces and we actually left the cervix fully intact and what we did is that we buy about it. So now you can just see the inside so here's the endometrial cavity, you can see the top cut portion here, the Miami atrium as reflected anatomically correct with the model and the Ceresa. So I'm probably gonna finish this before you know Arnie's got this robot doc. But basically all you gotta do is put your place your cervix in and what I want to show is that if you don't have this tip at the at the oneness of the uterus, look what could happen if you have it placed here so to speak. Your cervix is flesh but the tip of the uterus itself is only halfway through now imagine if you're trying to anti vert what's going to happen, that uterus heavy portion of that uterus is gonna fall behind and you're going to get this kind of pointed aspect of that uterus showing through this rosa and you're gonna have this heavy portions that you're not gonna be able to get that post your papa to me with a lot of these. Now imagine if it's not a nice little 10 week uterus right? What about if you have a big post here in my oma at that point what happens is that you're gonna have even more bulk now even if you have it say mid cavity it's still not optimal but what you can do is by showing this device you're able to put it up to the funding of the cabin, you can show that you truly can get the full articulation and if we have time we can demonstrate on the white board, a couple of other parts of this. I think that he's almost all set. Alright. I think we're good here. I know we I didn't spend a lot of time showing the docking process here because this program is not focused necessarily on all the fundamentals of the of the robot on A. T. L. H. We just don't have enough time to do that. But One of the things I wanted to emphasize is that you know once we have the robot dot it does not interfere in any way with the positioning system that's here. We can easily bring the robot in, doc get everything set up and either hook it up and change is going to demonstrate it being hooked up in the beginning as well as freely moving it around. But at this point we have everything set. So I want to demonstrate a few things in the last sort of I'd say 15 minutes here is I'm gonna walk through a LH changes are going to talk about some of the finer things that we've grown to appreciate with good unit manipulation. To me that's like 60% of your case right? But don't you agree. Like if somebody is really good down below you're going to be set with your case, even if it's a hard one because they're just giving you the exposure, you need the tension that you need, and so I find that exactly. So I'm gonna go ahead and sit down and make sure that everything is kind of teed up here. I want to make sure that you can see a monitor take that. I don't know if you can see this or not. I think I'll be all set all right, So we have to delineate er already in and we've already put the blue tip on, like we demonstrated before. And so basically all I'm gonna do is I'm gonna I'm gonna place this ally in the position following the curvature on here and just be able to clip it in and it is pretty straight forward. It clips in pretty quickly. You do get that feedback as Arnie had mentioned before, which is exactly what you want to feel. You shouldn't be shoving it on or forcing it on if you're forcing it on, it's not articulated right? It might pop off and you might not get that range of motion that you really want. So do take your time to practice making sure that's on correctly. So I want to kind of demonstrate some key principles for the T. L. H. Um And with the use of the manipulator that I think are critically important. First of all, I got a 30 degree scope, so we're gonna look 30 down and I'm gonna have to show me the enter cup. So what I did for the sake of time is I did part of the dissection because I just want to demonstrate some key things, right? Um you know you got to look for this bulge, right? Because that's what you wanted. That tells you that you have appropriately placed the cup up against the for nick's right? And this is a couple we're using here is a three is a 3.0. Cup. So that's what we have here. What I did in this case is this patient still has her ovaries. And so if you can just anti flex it now we're going to flex over. I just made a window underneath the I. P. Ligament. And I just want to show you the relationships of how that cup behaves in relation to the key structures you want to protect. Right? So I'm in the retro peritoneum here and I've dissected out the ureter right here is the order on that media leaf. Right? So I'm going to take off the allies. I can show you more dynamically. Okay, so china is pushing in. So here's the ring, right? Um when you release that, what you can notice is here is that when you cut that post early for the broad ligament. Normally this is up here, right? When this is released and she pushes in this thing drops out of the way, right? So this is lateral. Ized if I didn't this is what it looked like. But also, yes, and she doesn't push in, look at that, that's when you're like even just partially. But if I really give a push, there's so much more space, Right? And here's the and this is where you would normally take like, like your medical up here, but here's where the ureter is down below here, right? So you're far away. But you can see how close that would be if you didn't release this post early for the broad ligament and you didn't have good tension. Right? So you can see here here's the ureter again, you can see our structures here. This is the inter division coming off the internal iliad superior vestibule and here's the uterine. And again, it's water under the bridge. Right? So I just wanted to demonstrate what that looks like. There's the bladder. I'm just gonna, I'm just gonna come across this really quick here just for the sake of for the sake of time, can you put the power up too? Just a little bit? That's great. So I'm going to again, this isn't gonna bleed, but you know, technically we would um come across and you would use whatever bipolar energy device that you have, you're gonna you're gonna skeletonized and you're gonna come across here like this and again, it's nice to be able to make a window underneath here because then when whatever energy you use when you come across here like this and of course we've got an air seal running here, it helps evacuate the smoke pretty quickly on this, on a hysterectomy case, right? So I'm gonna come across here like this, right? Again, you can see that, you know, I've done this ahead of time but you can see what that what that does to the order when you lateral eyes it. Right? Alright, so let me, let's go to the other side though, let's just start it just so I can show some finer points again here. So you know again the assistant knows I'm going to work on this side. So it's cephalopod To the contra lateral side. Now this this cadaver is obese, so there's a lot of intra abdominal fat, right? This is 30 down. Let me show you 30 up and we're doing robotic surgery. It's good to use a 30 degree scope because look at the difference in view, it's 30 up. Somebody asked a question about how do you get in and and see well posterior and obviously that's a small uterus and sometimes you're gonna have trouble with the uterus. That's really both big. But let me tell you 30 degree scope, even on a big both uterus sometimes helps you see around and and you can see here where that devil is on that papa to me cup and again we talked about this earlier, your sacral ligaments going in, the poster vagina, We're going to make the decision about here is pushing it in pretty firmly. But if she doesn't push it in firmly, it really just starts to make a lot of this look hazy, right? So go ahead and push it in. All right, I'm gonna I'm gonna treat this as if we were not going to do a a correct me on this side. I just want to kind of get through this very quickly here because I assume most folks here watching this know how to take down the upper particles here, right? So you know all the way back down here. Um so you know, you come through and eventually you're going to come through what would be the round and I think that's the round heading out this way. So I'm gonna come through the round and again I'm looking for this view has me set up so nicely I can see the cup and I'm gonna come through the round ligament and once I come through the round ligament, what I wanna do is I want to be able to separate that anti and post relief with the broad ligament. Right? So being able to get into this space is key because what I want to do when I get into this space is I want to release this poster relief of the broad ligament so that that lateral eyes is the ureter that's running here. And again, my goal is to do that in the direction of where I'm going to be clamping right, I'm gonna be clamping a uterine roughly right about here. So I need to clear all this out and skeletonized it, right? So I'm gonna just finish taking the rest of the round ligament because I think there's still a little bit of it here and then it just drops this down a little bit lower like this and over this way. So I can see where that where that bulges of the cup. I think this is your point earlier, right? Which is coming across the fat part of the cup. So I'm just gonna create a little window here and just undermine there's my vessels here. And I think this was your point with like the O. A. C. The literally Interpol to cycle the bladder was stuck here like this. You can take this by releasing a post relief of the broad ligament here. Like this. Yeah. Just find your uterine and then you can get this uterine clipped here and then you can tunnel down a little bit lower and getting to like the sweet spot here where the bladder will be above you. The ring will be below you and then you can dissect and find the proper plane right now. Obviously in a case where it's not so scarred. You don't want to be down that low. You know obviously in this case we can we can start by coming across here like this. But you know, I like to make sure that you can see the cuba cuba cervical fashion. I'm gonna scope it and look at the tension when when china gives me attention. It makes this dissection so much easier. So I stay over the sweet spot of the Koopa. To me ring, I can see the coke up. I like the coke cup a lot because it bulges really nicely, right? But you can see that here and you can see that I've got my uterine right here and there's just a few more little attachments here that I can that I can release. But that's what I want to see that white cuba cervical fashion. A lot of times I'll grab the edge of the bladder reflection and I look for this, right? I look for that wispy tissue. So if you grab that and you score it like this, right? This is gonna allow you to then push the bladder down even further. Right? See how that just slides down. Look at that. You can see how that just comes down really nicely. And you know my philosophy. And has heard me say this a lot is when you make the bladder flap, don't skim make a nice bladder flap because once you're doing the Koopa to me, you're done, this is going to contract and you want to know where this edge of the bladder is. So when you do this, I usually make my bladder reflection and let it drop off the bottom of the cup like this. So I know I have a clean margin of safety and I'm gonna make my papa to me up on the upper edge of the cup, right? So we're gonna take the uterine here because I've already released all my this is just vessels only of skeletonized completely here. So I'm gonna seal this because I also want to show you the importance of also releasing your vessels off the side of the laparotomy cup. Right? So I'm gonna grab this here and let that smoke evacuate. And I'm pushing in really hard here. And if I wasn't pushing in, this is where that your door can come a little closer, You can get thermal spread or even kind of included in your vessel sealing or bipolar device. So what I did here is I have released, I call this the floor it, right, I've let my uterine come off of the cervical fashion here, off the side of the ring, right? There's no uterine here, my uterine is right here released laterally like a little bouquet or a floor it right. I do that all the time to make it easy. So when I do my papa to me, I don't run into the sky with the pressure that provided that slides off when you get into the right plane and allows you to adequately steal your vessels right now. Sometimes you may get a vein down there somewhere, so I'll release that as well, so that that's not in the way. But now it's just cut all the way around, right, gonna do the same thing on the other side so we can do the Koopa to me, right? Um Again, you can see here there's just a, you know, a few little attachments here which we can release some of this here. Had a little bit too deep here. I'm already seeing the cup because it's really thin tissue, but I'm gonna seal this here. Right. My uterine is here. My ureter is all the way down here, margin of safety with everything pushed in, right? So I find that again, this is this is critically important to come across your uterine like this and create that little florets, right? Let that thing slide off to the side, just like you do in an open case, right? You're gonna you're gonna take your handy bike, clamp off the cervix crab cut tie, let that slide off. Now, you're clean. You can even take even a medial bite here just to seal that. But now I can see the ring now is going to inflate the balloon. It's going to grab one of those syringes. The other thing to to know here, that's important is because you've addressed that uterine artery already and it's so lateral, you don't even have to look at it again for the rest of the case because you can just, you know that you've sealed it. You know, it's a long pentacle, you know, it's fully been addressed, that you can make your co pa to me without any concerns and I don't like to inflate the balloon until I'm ready to do that to me that way, I'm not thrown off by that bull. Right? So now that's up and you know, you should decide where to make your co pa to me based on what you see, what you see easier. Sometimes it's better to do it posterior. If you've got a big bulk of uteruses to get in posterior lee first. Like you can see here we can certainly do that if we want because jake has got great pressure and I can come across and I can start posterior lee here again, I'm going above where the motorcycle ligaments insert. So I do like an open scissor blade and you can do this if you want, right? And you can get in this way, right? You feel where the where the, where the cup is, right here and you just come in, right? So there's my there's my cup, right? I can see that you can start posting some folks like to start post dearly, you can certainly do that again. This is the value of 30 up. Like look what happens when I do 30 down, um you don't see that as well, right? But when I go 30 up, you really get a great view posterior lee, that's a great way to be able to make your and this is a tiny uterus, you can imagine if you have like a 20 week uterus, you really want to do an M. S. Approach. This is the way to use it, right? And then we're going to sort of drop that down a little bit and I'm just going to show you if you were to start on the top, right? So you're gonna start on the top. I may go 30 down to get a better view. And look I can see that the coke cup, it really bulges nicely. I'm gonna make and I always use a slightly open scissor blade, whatever energy source you want. And I use co ag and I just moved quickly, right? So I'm just coming across here like this and and I can see now that there's the bevel, right? So I'm gonna try to be on the beveled edge. And the whole idea here is I try not to like push too hard. I like to art to the tissue while she gives me tension. Um Because then then I'm then I'm able to not dig into the cup, right? If I push too hard, I'm gonna dig and create grooves. So I just sort of paint a little bit and I just asked my, you know, it was assisting me, okay, I'm gonna go to this side first, right? And we're gonna come around and you can see here I'm just painting And then since I'm 30 done I'm gonna go 30 up to try to get a better view on the side. You can see how that changes things all of a sudden. I'm just gonna come around here and you know, the key is that as you're pushing, you don't want your assistant to push so hard that then you end up, you know, prematurely popping in and and and not being able to like finish the lobotomy safely. And then again here I'm just gonna come around again on this side, we're almost through. But again, I'm just kind of arc into the tissue. I'm like barely pushing and just painting using my energy coming around efficiently like this to create a clean Koopa to me. Right? And then here we are. And she's quite ready to deliver this through. And there's so again 30 degrees scope up and down. Use your scissors, get the bulge. Use the beveled edge. And again, if you look closely here you can see that in many ways we have preserved where the lobotomy ring in the in the in the motorcycle ligament come come into the poster vagina. Right? So to me that's that's the that's sort of key to doing an efficient co pa to me particularly. You let the uterine vasculature lateral eyes, right? And then you can see here she pulls this through and we can maybe just leave this in the vagina as a corpse for normal peritoneum, small uterus. But you can see here that because the bladder has been nicely developed. I know where my where to take my bites. When I close the vaginal cup with suture right now, we may not have time to show the closure. But I will say that one of the important things I want people to keep in mind that when they close the cuff is make sure you get the corner right because sometimes the corners missed. And so josh do you think you just give me a needle driver really quick? Um So I can do this. I'm gonna pass you that needle. Okay? So when you pass the needle it's really important that you kind of decide what you want, how you want to load the needle, You can take it wrapped around where the needle's loose. If you're gonna hold the needle, you need to make sure that the needle tip is protected. If you don't protect that needle, you can completely get a really big black all the way up into the vagina. You can hook the bladder, hook the rectum cause astronomy. And you can cause issues with you know and Deuteronomy as well. So just be mindful and make sure everyone in the room knows how you're how you're introducing. So I'm I'm introducing it with the needle unprotected but loose placing it in the vagina. So I've got a 20. B. Lock here. That I'm going to use. Uh that's what I typically utilized on a Gs 21 needle. And in the last few minutes of the program here, what I want to just emphasize here is just when you close the cup C. C. What's nice is my uterine lateral eyes out here, far away. You can see that my my ureter is out here. Word of advice, if you get bleeding here, please don't just go in here and start defecating stuff without really elevating this annoying where the order is. I honestly think that's how some people sometimes get a delayed thermal injury. But you want to make sure that you do what I call the great the less stand and the greater than sign right jake has got the balloon in which helps us maintain the new mo. And you just want to make sure that you get that angle right. So I'm just making sure that I get a good a good bike to get the angle here right. And these are training instruments. So I normally use a mega non cutting needle driver but you want to be able to pinch this closed here right. You want to be able to make sure that that comes together ah nicely so that you have the corner secured right. And once you spread this through here pull that down, I can take the next bite here. You want to make sure that you get both the fashion and the you know the fashion and the vaginal epithelium, right? You want to get healthy bites. Now this cadaver is very, very thin, delicate tissue. So I want to make sure that I don't like pull this through, but you really want to make sure that you're securing your corners right? Like you want that like this thing didn't I didn't take the bike properly and you can see what I did here because I came into medial. I left this as a gap right? Like this may look like it's brought together, but it's really not right because I didn't take it far enough out to get that corner. So when you close the cup, you really want to make sure that you get this corner because to me this is what often will bleed delayed, that sutra needs to land here and I took that too far over. So in my rush to try to get this done, I'm demonstrating what I don't want you to do right now, if you see that there's no harm in going back and making sure that you get that right. So my point is make sure that when you take your angle bites that you truly get the angle right, so that this clamps down and then run your future right? Because I think that's an issue that often comes up when people close the vaginal cup. Now I can always come back and take that and get another bite back here to make sure that that's secure, right? So that I don't have an issue with the corner, right? Because you really want to make sure that that gets clamped down. So I can always go back and do that as you can see here and make sure that that gets incorporated and that stays down and again because because I don't I don't have any issue with knowing where the bladder is. I can easily close this, get good full thickness fights, do the same thing on the opposite side, get that, run it back once or twice, cut it off and then it's still going to be closed, right? That's what you really want to have. And again, you can see that you're nice uterine isolated here and here. That's really what you want to be looking like after A. T. L. H. I don't know how we are on time. It's 8 14. So we're getting close to the just about the Q. And a session that we've got about a minute here before we start Q. And A. It's a lot of material to cover. We really were doing a blitzkrieg of just trying to get a lot of things addressed with all of you. Are there any questions that we can start taking I guess in the last two questions also come in about the use of energy. One was any concern using mono polar for papa to me in terms of the vital, Ization of tissues or potential necrosis of tissues within the stitching line. And the second one, I'll ask now as well as a surgeon who switch from v. Care to the delineate. Er has seen some more. Our king using it. And I wonder if there's any reason for that. If there's anything that should be doing differently. I think that when it comes to using the manipulator itself and using mono polar energy. I think the key point here is you have to separate from the tissue art but go quickly. So what's nice about the cup and all your dissection is you can see the cup kind of circumferential. E if you move fast, you're not going to sit there and dedicate the tissue and have a concern for poor healing. But also when you close the vagina it's important to close with a thick, full thickness mucosa and cervical fashion. And that will allow for integrity of healing. Right? I mean I couldn't say that any better. I mean you really need to be like when you saw me do which is I mean I use coed but open scissor blade. I go quickly and I don't bury and hold it in one location. I don't dwell. I don't love my current dwell. I move fast almost like you're tickling the tissue. Go quickly. Open blade. I use co ag it works fine and I don't get as much of the arctic if you're getting a lot of barking. It may be that also there's a lot of bearing of the tissue. It may not have enough tension or the settings may be too high on your energy. Um I have used monopoly my whole career and I honestly believe it's it's it's not necessary energy that predisposes to like a distance. It's like how you use and do all the different steps. So good bladder flap means that when I make my papa to me, it's easier and then when I close my cup, that good bladder flap health because I can take this chicken and set a nice thick bite of the fashion and the epithelium of the vagina. And so like every step of the way, really, it's a part of that whole sort of constellation of things that you need to do to get a good outcome with your cuff closure and minimize any risk of distance or separation. Yeah, the question came in just now, thoughts on using something such as air seal to help maintain new mo in the early stage of the Koopa. To me, we pretty much use it almost exclusively. I mean, I think only an excel surgery or kind of minor surgery where we're not really making a laparotomy where the new mo can release quickly. We often use air seal exclusion air steel works great. We don't really lose any new mo. I mean, of course we have no clue to balloon up when we start the papa to me. So, you know, it may not be up during the case, but it'll be up right before papa to me, works great for that air seal on top of that. It's like double bonus of not losing new mo my only caveat for those folks who won't use the new motor scooter or don't inflate it and just rely on air seal. It's just you're having uncontrolled release of gas then from below. And I just think that there's been a lot of discussion about a year ago when the pandemic hit about just release of gas into the room. And so we're very cognizant about not having uncontrolled release of gas into the operating room. That's why having like a really good new mo clutter balloon or just being very mindful of how we manage normal Peroni um I think it's good for the whole team, you know, although there's a lot, you know, technically there really shouldn't be an issue with the release of it. We don't know a lot of things yet, so I think it's just better to be safe than sorry, in the operating room, staff will appreciate it. We've gotten several questions in from surgeons who are not currently using the ally system and we're asking several different questions about it, Kind of a long line. Is there a long learning curve? You know, what other benefits are you getting from it? Is it worth the learning curve if there is a long learning curve. So we got a few questions, I feel like I could probably speak to this, you know, I was a fellow just a few minutes ago and I will say that I didn't use it in my residency, I learned it coming into Columbia and yeah, there's a part of it that was a little bit challenging maybe with the arts just because there is a groove that isn't as clearly delineated with say the delineate or the roomy because that's that plastic to metal. But I will say this the it only took maybe about five or six tries and then you really are able to use it to your benefit, it's heavy, you just need to know where to pick it up. But then once you hold it in the right ergonomic way, you really don't feel that pressure in the wrong spot. I think it's changed the game for me as a new attending, I use it a lot, we're busy practice and I may not have as much help and when I don't have help, I need my iron intern as you know, Arnie had said before to help me get through the case. Yeah, I mean I I think the best thing to think about with this is that there's obviously a learning curve with any new tool, you gotta train your staff. What we're hoping to get across tonight is that it's pretty easy to set up, it's like a routine for us, it's like part of our repertoire, it drapes very quickly. Um if you do more than just hysterectomies, it's absolutely helpful. Like so in our practice we do a ton of reproductive surgery. So we do a lot of endometriosis, add next surgery, systemic Tommy's, myomectomy. Nobody wants to be the individual down below holding up a uterus or deflecting something up to the side. Fantastic for static placement. Another great example, like I said though there is a learning curve but it's one of the things, the more you use it, the more you realize, wow, this really is more of an asset than a hindrance. Again, we do a lot of reproductive surgery. So I think for like and I that really helps a lot to have that stable positioning of a uterus when I'm sewing or I want to pull something down to create some distance or obliterated posterior cul de sac and endo it's so nice to park that uterus up and just have it sit there while we can dig our way out of that mess. The surgeons came in with a question saying his practice, he's seeing a lot more patients with multiple C sections and struggling a little bit with where you cut as the bladder is the place to displace. Do you want to be more cephalopod or what? How would you address that video, The last video if you don't mind taking that up for us. If you can show it while sharing her tips and tricks here. Yeah, no problem. So we kind of alluded to it a little bit before and we didn't really have an obliterated anterior colder sack in either of our specimens we really wanted to show. But here's a picture and view actually of what would be an obliterate entire cul de sac. This patient had I think it was four or five cesareans for demonstration purposes and hear what I'll just narrate kind of over it. You know, we take down the ad next as you would traditionally do. But the important thing here start posterior really find your uterine artery where it's clean and then you're able to then tunnel over your uterine artery where you feel the cup. So here we're taking down that posterior peritoneum, just like we had kind of described typically in your cesarean population. Your post, your cul de sac is clean as you can see here. That's the key right there, right there, there's a uterine artery that's been pulled to the side. We're tunneling over and it's already kind of labeled right here. You can see where that bladder is anterior and there's a nice little give here where you'll see that cuba cervical fashion kind of showing itself. And the idea behind this is that you can seal your uterine artery even high if you need to because all you're trying to do is prevent bleeding in the spot while you get started and once you've tunneled over that space, just kind of like we demonstrated on the clean robotic model. You take what you can see you go from known to unknown. Use the same principles every time and you can dissect this out. But the key is that you don't want to be high on that. You want to be lower on the cup after you find where the uterine is. You want to find that sweet tunnel spot lower on the cup. But you gotta feel for that cup. That's what you really have. A consistent that really pushes really firmly up and in that's the key. It's critical. You want to go where the cesarean wasn't going the fresh tissue? That's right. I don't want to be where the C. Section cuts were. This wasn't a question. This is a surgeon recently started using Allies in the Ally is a game changer for me, best invention for total vaginal hysterectomy. So that was not a question, but I thought we'd get that in there. The question also came in uh that if you're doing cases again, I think it was again with the long uh with the long, that's what you would do. They're okay with the webinar be recorded. What about for diagnostic features? Are you primarily if you're doing something with endometriosis primarily using their, I don't know what happened. I used it over there by the with white tips. I use I use the arch an arch with ruby tip and I attach it to the ally. And if it's a quick case but it's always one of those situations where you don't have the allied and you regret it because then you find stuff. But if it's a diagnostic and I want to be able to really work on the uterus, like I just find Azumi can't do that for me and I can't lift up the heavy specimen. It's just not strong enough. But you get a tip in there on the end of the arch and it's quick, right? So instead of putting Azumi in I just put in the arch with a roomy tip. Then I've got the flexibility I got from a perturbation and I can do what I need to do. And then I have the luxury of also attaching it to an ally. What about for a super cervical hysterectomy? Do you see an advantage with one of these manipulators in particular for super cervical? It's a good question. We never we didn't have enough time to get to it. But one of the things that I do a lot, I don't know if you guys want to tee up. I guess it's probably the last thing we can show tee up the video on stage. Lobotomy because it's the same thing you do for a super cervical hysterectomy but we do it when we're doing a. T. L. H. Sometimes you have a very very big uterus. You can't see to do the Koopa to me. But you've done all the deception and you've sealed the uterine flatters down and at this point you already do a Koopa to me. Well what we do is I like to use the delineate. Er That's why use it on all my big cases because what I'm able to do is as you'll see on this case here is once the hysterectomy is done I'm able to basically amputate the uterus off the cervix just above where you would make a lobotomy right? You're going to see that right here in this video. This is where we're getting to the point where the uterus has been. The history is essentially done. And you can see the papa to me cut bulging there. It's a big top heavy uterus. But all I'm gonna do now is see the bulge. I'm gonna amputate with the scissor right in front of the papa to me cup right towards the head on this one. It'd be right through here right above it. That's exactly right. So you can see that here. It's all bulging nicely. We're gonna just start amputating there. The key is that you have to have a lot of cepal that pressure right? So that you can you can see where that is. And then we're just going to amputate until we hit the shaft right? But once you hit the shaft I'm gonna unlock the clip here. And while I hold the coefficient in the vagina, we're gonna slide the shaft out and pop it into the abdominal cavity just enough so that you can see it, make sure it's right there. You can see it showing we're gonna pop it in and then we're going to auntie flex, finish the amputation of the uterus off the cervix. And then at this point you can do your lobotomy, right? And you can see here now we're gonna anti flex, right? And we're gonna finish the copepods, the super cervical hysterectomy part. And once that's done, park the specimen up out of the way and it's straight straight forward. You know, as I say, game over. It's so easy. Now, at this point to do your papa to me, because you're in corpus, is it in the way? Right? So this takes a few minutes, usually less than five minutes to get situated. So you can But the key is that you can slide this right. This thing slides up and down on that coefficient so I can bring it out and then pop it in, lock it at a different location and a flex. Hope that helps. Very good. So that was great. This is gonna conclude, we're at 8:30 now. So that's gonna conclude all our questions for this evening. I can't believe this is an hour and a half. I guess when you're having fun time flies. I just want to thank again everybody who helped support us through this webinar this evening. We hope that you can walk away with some tidbits cooper surgical. Thank you for sponsoring this. We're excited to get back into the trenches, teaching, sharing the things that we've learned along the way. And obviously, you know, reach out to your reps if you have questions they can get those two and I will try to answer those for you. But I hope everybody walks away with something that can help them in the O. R. And good luck with your cases. So. Good. Thank you. Thank you dr Advincula. Thank you DR Arora and let us know if you would like to follow up demonstration from your cooper surgical sales representative again. Thank you and have a great evening. Great thanks.
Arnold P. Advincula, MD, FACOG, FACS
Chetna Arora, MD, FACOG