Objectives
Demonstrate interplay of uterine manipulation with optimization of surgical exposure
Formulate best practice techniques for colpotomy & vaginal cuff closure
Develop strategies for surgical dissection & suturing with high fidelity models
Illustrate clinical correlation with video vignettes
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 obstetrics 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 healthcare to women and their families. Cooper surgical manufacturers over 600 clinically relevant medical devices used by health care providers in 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'll be the meeting manager for this evening's program. A couple of notes on how the demonstration will run. We have an approximately 60 minute live session with interactive questions and answers with dr Advincula and Dr Arora. At the end of the demonstration, they will participate in a dedicated Q. And a session. We would also like to extend a special thanks to our colleagues from Dinos in that have been great partners in bringing this program together. Our program is the second of a three part webinar series on mastering minimally invasive gynecologic surgery. Tonight's program is entitled mastering migs to surgical simulation to increase proficiency in hysterectomy and reproductive surgery are distinguished presenters from Columbia University Medical Center and new york presbyterian hospital are Dr Arnie Advincula, chief of Gynecologic specialty surgery and dr Chandana Arora of the division of Gynecologic specialty surgery. Now dr Advincula and dr Arora. Thanks Doug for that kind introduction and good evening everybody. Hi, nice to see you guys again. We are really excited to be here with all of you this evening for those of you who are patching in as doug alluded to. This is the second in our webinar series and I guess really treatment without any delay. We should probably just jump right into things. We've only got an hour so we got to talk a lot everything about model. Sit here and I'm gonna bring it over. So this is the dinosaur model. We have just like last time we really like the way this demonstrates. But we've sliced the uterus in half and the intention here is to show you exactly what happens when you put in the manipulator so that you can get the best torque for a uterine surgery. Yeah, I mean, I think the two things you want to emphasize that, you know, we spend a lot of time in one of the earlier webinars talking about like manipulation, how you choose the different types of manipulators, what they bring to the table. Um We're gonna cut through a lot of that and just highlight two things. One is as as cheating alluded to, making sure that this is placed in the right location in the uterus, but secondly, picking the right cup and um so you know when you look at the cervix head on, I'm just gonna grab this model here. Um and this is thanks to Gunnison, which which develops these models that are handmade from basically food grade material, biologic material, you have the cervix here and it's so critical to make sure that when you're you're sizing the cervix that you choose the appropriate cup, you don't want to have one that's too small because then you're not gonna get actual placement up into the for nix and you won't really get clear identification and delineation when you're inside the actual pelvis doing your laparoscopy and we do highlight troubleshooting techniques and the other one too. So if you want to kind of recap that we can show you the ropes there. So this is a 3.5 centimeter cup which tends to be the most commonly utilized for the most part, that's what most people pull off the shop after they've sized the cervix. So you know, we're going to go and place that so that you can see how that cup fits around here. So traditionally just like you would you would have sounded the uterus, you'll have a 10 ocular mon you'll be able to give yourself some traction and then you're able to place the uterine manipulator. So here what we do is actually blow up the balloon. So while he shows you, I'll hold this, you grab it. So I'm here going to the fun of the uterus and you know, the idea is that not placing this at the exact right portion of the uterus, you're not going to get the right elevation or the traction counter traction. Being able to use this as your accessory incision lys laproscopic arm. So let's pretend we blew it up. And I didn't I didn't blow the balloon up all the way just because I didn't want to block our view here, but we would blow up the balloon and make sure that the tip is at the fungus. But we would have sounded it and that is sounded to roughly about 10. Okay, So that's what that's where you want to place it. So once you sounded, you want you want to place it at the 10 centimeter mark. And then as you know about 10 centimeters because you get that feedback, you're gonna push in the cup and then as you do that and you can feel that here that 10 centimeters is giving you back the feedback on the handle that's external to the body so that you can directly correlate it to what you sound. You click it in place so then you just click this piece down and now this is all one unit. So the manipulator doesn't go in any further. The only part that pushes in is the cup against the cervix. And we say against the cervix really mean against the cervix is situated inside. So that's really how you want that to look as you want. That tip really at the fund is but you don't want it through the fungus and you want the cup to be situated nicely around that cervix up into the for nix. If you know if we back this up and I just want to highlight this because this happened the other day when I was in the operating room doing a really difficult big uterus. We just had trouble getting manipulation and I made the mistake of not checking the placement that was placed by my trainee and I realized that they had had this this backed up too far down down in the lower uterine segment. And so even though they had the cup up against the for nick's every time they manipulated the uterus fell fell backwards and it never went anywhere right and it really made it very difficult. So just getting it sounded properly so that you locked this down at the appropriate position so that it sits correctly. It makes a huge difference for an affliction and lateralization of the uterus. I just can't emphasize that enough. That's why change. And I wanted to really focus on that is make sure that you're you know, in this cross section you're right where you need to be at the fungus. You've sounded appropriately and you have the right cup size because this this is your gps for the surgery and it needs to be up there. I mean I don't about you but I always check, I do a sweep after its place just to double check that it's situated in the right location because you never have to check it during a case. Because trying to make any modifications in T. Bird with a robot docked. It's harder just to show you here the importance of why it needs to be in the for next. If this were for example pull back, pull back a little bit, let's say it was locked here and this is as far as when you pushed it in it didn't perforate. But the cup was never up in the forex completely and you didn't know that and you're doing the surgery and you're looking at this from above, you're gonna dissect so much more lower to do this. T. L. H. And you're gonna you're gonna make a Koopa to me that's very coddle. What does that mean to me effectively? Yeah. But what does that mean to you? That's your bladder is at risk and the other more critical structure, right? They come in they come in and they start to realize as you get lower so just can't emphasize enough sound correctly, pick the right cup, make sure it's in the for nix. Okay so we're gonna go over to the model will go straight over to the actual model itself to show you the steps of a th and what's nice is the breakdown for our program today is we're going to do segments of the T. L. H. So we're gonna do a segment here and we'll break it down with a video in real life so we can directly compare what we've learned. One last thing we want to say is, you know, once you have this manipulator in place and in this case we're using the delineate er is we don't normally blow up the balloon. I had a time for the new mo clutter because this has a built in numerical order and you can go and blow it up so they can see it. So the valve is open. So there's your conclusion right here, right. Um I think that this sometimes distorts the vaginal vault when you're doing a dissection particularly, you're doing robotic surgery where you don't have haptic feedback and I really want to see the pop of the lobotomy cup. So we both don't inflate this until we're ready to do the Koopa to me. So that's just something to think about. If you're trying to save time, you can always have this loaded and this blocked and then right as you need it, just inject it and release it. So we would keep this thing on flat. I don't know about you guys, but in the Northeast we've had issue with CO two shortage. So you definitely don't want to be wasting your CO two with escaping vaginally. So definitely utilize your balloon during Koopa to me and vaginal cuff closure. Alright, let's go to the go to the bottle. So you have the dinosaur model all set up here and we're gonna take you through the next set to start. So basically what we're gonna do is here, we've got the ligature for our bipolar device and we've got some grasshoppers. So Arnie's gonna go ahead and show you how we load on the ups. So I'm gonna hope they're not blocking the view here. But I'm gonna just quickly again, we didn't want to go into like the whole placing the manipulator. But I'm gonna go ahead and we have a uterus system, the ally here and I'm just gonna go ahead and drape this that you can see how we do this. It's it's fairly straightforward, There's a drape that gets attached here and we're just gonna use that to hold our union manipulator so that there's a couple of tabs where you can pull this down, stare li to drape the arms. There's a foot pedal here that allows us to adjust this. We're gonna go ahead and we've got the manipulator in this guy Nissim model and I'm gonna go ahead and place this so that we can there's a nice little groove that basically just kind of lays itself in and then it closes like a door. So once it's once it's mounted there's only one way to really attach this. So once we place that and I got my foot on the pedal, I can adjust this anti flex it. And I'm just gonna and I'm gonna which side you want to start on? We can just start on one. And if if we put it this way we can show you some ergonomic techniques which if you want, we'll do it that way, I'm gonna lock this in place. It's holding the union positioning positioning systems holding the manipulator, it's giving me the deflection, cephalopod pressure and lateralization of the uterus that you want when you're doing a T. O. H. Okay. And then why don't we walk through a little bit of anatomy because, yeah, let's do it point model. So I'm gonna come in with why don't I come in with a little you got a pointer? I'll use the ligature too. So I'm just going to come in with our trackers here. So we have a kind of really nice lifelike model. It's all food grade as Arnie described. Here's the uterus with a big bundle. My oma. There's the bow on the back, The pelvic curvature. Here's the ip. Yeah, promontory, this is the ip. This is the tube right here. There's an ovary underneath. Perfect. And there's your ovary with some lifelike follicles inside. Similar aspect on this side with the the tube on this side and the ovary here to these are the peritoneum just like in real life and underneath you have vasculature. So you have the ureter, you have your uterine artery and ligament here. Perfect. And also the round right here too. And what's nice is it is translucent and has feedback back. So you get to see your cup too. There is a nice anterior my oma as well. All right, you want to get started then? Yeah, so we're doing a three part hissed. So this is just like a typical standard production, right? You have your camera here. But this is a nice self contained camera. So it's gonna hold itself here and our knees on his side. So ergonomics of A. T. L. H. I think you know when we go in through and we're taking the next to it's nice to go to the contra lateral side because you have such a beautiful angle. So I'm really leaning across the ups is helping me fully here and I'm going to seal and I'm going to burn from the U. Oh we're going to do an ovarian preservation surgery. So that's a key point that I made. Is that a lot of times people say well I'm on I'm on the left so I'm going to do the left side. That doesn't mean you have to do everything on that side. You know the lay of the lay of the instrument. It's all about looking at the ergonomics of a of a rigid instrument and once you lateral eyes, the uterus contra laterally like this. You can your cross table surgeon can actually take the tube in the ovarian without a lot of difficulty or over tension in it and then tearing it and getting bleeding. And basically I'm on my own to be honest at this point right? Like I don't need our need to do any retraction here because it is a relatively straightforward T. L. H. But you know if you go on the same side you do have to do a lot of work. She can take it all the way to a certain point where then I can comfortably take over and then and then do the dissection. So she's going to go ahead and just keep taking this down and I can retract if I need to while she's doing that. So important things to know with the model. We're just taking down just like the broad broad ligament, I left the tube, we can get the tube later. You know, that's something a little bit more straightforward. So we're going to relieve that one behind. I'm gonna zoom in a little bit here just so we can get a little bit closer with the view. And so our point here is, yes, this isn't an actual hysterectomy case. But what we want to highlight to folks here who are trying to pick up some sort of efficiency tricks for their procedure and tips is key parts of the hysterectomy that I call nuanced um steps that really allow you to become much more efficient as you do the procedure. And here's a little bit of that posterior broad ligament that she can take down if she wants. So when in this model particularly, its imp important to know that they just have to kind of seal the perineum a little bit around. But as you can see we've taken down the you've taken down the corneal aspect of the fallopian tube and now we have the round ligament left here to right here, that's a little bit of a little bit of it. Yes, so I'm gonna grab it and you can always see it just like the ligature and then cut. And what's nice is I'm on my side so everything has been completely off tension with enough counter traction. And then if I want to I can come across here and I can now switch with her with this uterus tilted over this way and I can I can go ahead and zip across and zip across this. What we can do now is I can do an instrument exchange and I can come without even moving the uterus, right? This is just one quick instrument. And what I want to mention is that although china mentioned a three report technique, my philosophy is if you need an extra ports, put it in right, you don't need to be a martyr when you're doing a middle invasive surgery. It's minimally invasive with cars already to begin with. So if you need to put 1/4 1 in there, go ahead and do it. But as you can see here we have easy exposure. She's already taking the tube in the unit bearing down and I'm just gonna go here and I'm gonna just take this entirely for the broad ligament and I'm just going to stabilize here on the instruments using my instrument itself and then he's going to be able to take the round. It's nice when you're doing a. T. L. H. To leave a little bit of a pentacle on the round. So say you've got a bigger uterus, right? If you go right close to the uterus, you won't have a nice handle to be able to pull that uterus over lateral if you need to. So sometimes it's nice to kind of pick a space and make a connection. So if you have the utero ovarian and you have the round almost make a game plan in your mind, your trajectory right before you take it so that you already are just leading right into where you want to cut right now. One of the things that I think is really important when you're managing the CSA is not to come across the tube and the utero ovarian and then and then undermine it off the round ligament going laterally. Right? Because if you do that, if you come across tube in utero very and then come underneath the round here like this what you essentially do is you've created this sort of floppy skeletonized. Yeah. Medical what we do typically in our cases is we come across two beauties ovarian and we line it up with a portion of the, of the round ligament so that we keep this triangular area intact. And what happens on most most of the time in cases is that as the round ligament is released off the uterus it's gonna retract, its gonna retract and it's gonna elevate the the next out of the way and up against the side wall right? Because you preserve the I call that the golden triangle that we utilize when we try to enter the retro peritoneum. So we've done that and then notice that I have an easy shot while she's retracting to take my round ligament so I can come across right now and I'm going to take my round ligament, but I've kept that golden triangle intact. So I don't know if this is a good point now to the other side or go to the video. I think we should switch to the side so it matches and then we'll be able to do it. And what's nice is that Arnie already has the ligature on his side. Right? So at this point you're not doing a million different exchanges. He we're going to have the uterus moved over to that side. He's going to optimize his ergonomics and his economy of motion and not do another switch. I'm already ready and set to retract. So say the ovary or the tube or something is in the way whatnot. I have my retracting grasshopper and he's already at the right side to go ahead and take his you Oh, I'm just going to start taking my until I get to that point where I can stop and then switch over so that the chain that can do it on the lateral side, Right? The remainder of this dissection on the lateral side, just giving them a little bit of tension so you can see through that peritoneum, see if there's anything left. Remember we're going to connect the dots to that round. I will say, take your time sealing this vessel. This is probably in my personal opinion, probably youtube. The utero ovarian is a pretty bloody ligament. Especially if you've got like a big fibroid uterus. There's a lot of collateral vessels that are on that side. And so take your time taking each aspect of that cornea individually. Take the uo separate from the tube and separate from the round ligament. So everything seals. Okay now I can switch to you and you can get the round. Perfect. I've gone through my side and I have the camera in the screen just showing me exactly where I need to go and I can already see my round ligament here. So just the camera. Perfect. What's nice about this is you have your camera here. So if you are teaching yourself on this model, you're able to have your camera all on your own and you can do a contra lateral surgery. So I'm here grabbing this round ligament, holding it. I'm gonna give it a burn. Can grab if I needed to in a larger uterus. Hold that tag of around that she's left me so I can pull without bolting it. My philosophy when you do the medicals and the upper part of the of a hysterectomy is to leave yourself some some pentacle on the specimen side so that you don't get such a huge retraction into the into the uterine corpus where it starts bleeding and you can't control it, right? You want to split the difference between you know you don't want to hug and hug and pray being so close to the uterus? You don't want to do that? Why don't we jump to the video? I will tell you this, here's the video, we're gonna let it go on in the background. This is kind of just what Arnie and I just did um uh this is a retraction from just like I was on the right side, Arnie was on the left side. He came in with a ligature because he had it perfectly on there. He took the utero ovarian, we have some demonstration, we already cut the round ligament. This was a teaching case. So we were showing that you basically we want to show to connect the dots. So we took the round here, they took it here and they knew the direction to go because sometimes you can end up hugging too close and you get into bleeding or you go too far out and then your bladder flap is really wide. But you can see here the economy of just being cross table taking the contra lateral cornel structures because the instruments lay comfortably, you're not twisting and doing any kind of gymnastics to get that done so perfect. I think we can probably move from this video and you know, we can go ahead and get it going so we'll switch over and we'll go back to perfect case, let that play and then we'll go back to the case. Okay, so I've got the ligature on my side. So why don't we go ahead and take the rest of the posterior down? Yeah. Or do you want to do the bladder flat, posterior and bladder flat important structures like taking once you get through the round ligament for us, A big step in the procedure to really optimize things is getting that broad ligament and turn post your leaf separated and developed, dropping the post early for the broad ligament because you want to lateral eyes that your order as you push the cup cephalopod right? And then and truly developing it to the point that now you're starting your own reflection and doing all that then leads to the skeleton. Ization of your uterine vasculature, like all kind of falls into place as you do each step properly, you know? And as we do this, I will say it's so important to do the same thing every single time. Even if it's an easy case, apply the same principles and do it again for your hard case. So I'm gonna go ahead and take this post to your perineum at this point, just so you know, we can isolate and find the ureter here. The ureter is right here, it's coursing pretty laterally on this side as we can see it's water under the bridge. There's a gray structure that right way down here, just lateral. Ized it right there. So I'm gonna go ahead and kind of zip across ideally when you're in this position, you'll zoom in with your camera and you'll have a trajectory where your cup is and your goal is to go right along where your cup is reaching that spot. So I'm just gonna do a little cold cutting. So the key is when you develop that broad ligament, think about where the call pottery cup is, watch people sometimes do this and I'm like where you're going with that because you really want to, you want to skeleton eyes where you're going to be taking you to rise and you're gonna be clamping along the cup. So, you know underneath here, you can feel it, but that's where we want to develop that broad ligament and it lateral eyes. Is this, your order is not attached to the paranormal because it's difficult to do in this in this simulation model. But if you can imagine the ureter would be up against this post, the broad ligament right here. You want to lateral eyes this by and sizing it and that lets the urine or go to the side right away from where you're going to be working on the cup and sealing vessels. And we'll show you a video demonstration of exactly what we mean to Arnie was just gonna lift this up. And then what I'm going to do is just kind of zip across and take that post to your parents. I looked it up as much as I can perfect. It's kind of a bulk of uterus and then I'll let you hold the poster. Perfect. And I can see I can come right across here and I'm going to just take it all the way to your side since it's got a nice view. What do you think? It looks good? You know what I would say? Take what the defense gives you? Just keep going, see it, take it because you know what that just adds for efficiency in the surgery. So we always do that all the time. So you're releasing that poster broad ligament that post your leaf. You're coming across parent post eerily and then I'm gonna drop this down and you can see that cup right there. That's the bulge of the cup and I'm going to drop it down so you can start entirely on your side if you want. Perfect. Perfect. And see that view. So also once you've released your round ligament, you'll notice you have so much more mobility because that initial part that's holding that uterus forward is released so the motion is going underneath, showing yourself. It's clear. So I can see it's clear underneath. I'm just gonna hold that corner and I'm just going to take a bite. I have perfect ergonomics. I haven't picked up my shoulders at all. And I'm able to just simply come across here. You can see my bladder showing up underneath and making sure my bladder is away. No c sections on this model and then we can come across, you know, the other thing is whenever you make a bladder flaps. Okay, so let's review, we've dropped the post early for the broad ligament. Here's my cup right here separated that entered a poster leaf. We're coming across to make a bladder flap when you have that uterus pushed in and you push the cup all the way in the place to make the bladder reflection is right over the fat part of that cup, the middle of the middle of it. That's where you're going to see that slide. I think there's a tendency people are afraid of the bladder making it too close to the corpus of the uterus, along the uterine cirrhosis. That's where it gets sticky, thick bloody, right. If you make it right over the sweet spot of that, right over the cup as you push in. It's a vascular, that's like where you see that sort of the wispy cotton candy, you know, champagne bubbly looking tissue. That's what you want, right? That's that's the right plane for your doing your dissection. You think, yeah, totally. And to find that, give yourself some feedback you're gonna have, even with the ups if you just give a little poke right here, you can feel that resistance and that's your cup and that's where you're headed out. And for this model, it's really nice just for visualization purposes, that's exactly where your uterine artery. And there's the uterine right there going into the, you know, exactly. And this is where, you know, you would skeletonized this because I always think it's important to skeletonized the uterine. Like my philosophy is you want to create your surgery so that by the time you're ready to do the Koopa. To me, you've got a naked cup completely jump to another video. Let's do it. There's a couple of short clips actually when the videos we have showing down to the post air cup and then the vesicles uterine reflection. And once we do this, then I can jump quickly do my side. Let's do that. Perfect. So I have a video here. I'm gonna go ahead and give it a play. So we've taken down the annex on this side. And um what I kinda wanted to highlight here is you're showing the round ligament gonna be taken. But I wanted them to point out the cup. So in this you have such a beautiful view of the cup interior early, then the cup posterior early. So you know where you're headed. And so the round is gonna be taken here. The person on the contra lateral side can give a little bit of traction if needed. Once this is completely sealed, then the idea is that you're going to tunnel posterior early to the level of the cup. And what's nice about this is that you can apply this principle to like say an obliterated and to your culture triangle that we're keeping we're leaving the round attached to the next because that's going to retract off to the side as soon as this is released and then we're going to get into that broad ligament you want. Important. Don't keep sealing your broad either one. Once you get a little filming part show, make sure you're separating around, see that beautiful champagne bubbles. Like we're talking about now you're going to able to go in there and you're on the right side of the same side of specimen. That's that's like the best view right there. And that's we have to be communicating with your assistant. If you're not the one holding it at the bedside, your assistant needs to recognize that that's the view that you want. You want to be able to see that if you're not seeing that and it's not on tension, then they're not doing their job right? Because that's like half the surgery right there and look at that, she's taking down all that releasing this posterior broad ligament. Let's that ureter lateral eyes when you push that uterus in. And honestly this is so critical and a big uterus and a big uterus. If you don't do this on a really big uterus. What happens when you push things in that ureter comes down and it j hooks back up and then you end up accidentally desiccated that ureter and this move is so important. You know, it's easy to kind of sometimes let this part go because you're just like, oh I see my uterine, it'll be fine. But then when you have a big uterus, you are going to be worried you're going to pull something in the next. Yeah, I think so. Here, let me go ahead and play the next one. So the next one is showing the vestibule uterine reflection. And as you're showing this question came in on the obliterated interior cul de sac. How do you address that? If you see that perfect, it's a perfect segue. It's actually exactly at that point. So instead of, you know, you look at an obliterated entire cul de sac. Your first instinct is taking off the abdominal wall. Stay away. Save that for last act. Actually, what you should do is go where it's known. So that typically in those cases uteruses plastered to the upper abdominal wall and that post your cul de sac is free for the taking. So first take your Alexa, take your round ligament and then start going posterior. Really identify your cup and right where you see your uterine artery, That's where you're gonna feel right above the cup and you'll start tunneling under into that virgin territory. And the idea is that a cesarean is never going to be at the level of your coal pottery cup, it's a little bit higher on the lower uterine segment, that's where all the adhesions are. So if you tunnel getting that feedback right on the cup, then you're gonna be able to get right into that territory, you do it on both sides and then you connect the dots in the middle at the end point here. And so you're seeing this coming across the midsection of that, the fat part of the pottery cup with the obliterated entire, called the sec 100% don't go after the infusion first because you can always take the next down, that eliminates two major blood supplies. You can always open the poster leaf of the broad ligament and get to the uterine posterior lee. You can do that bilaterally and you can get rid of the remaining two major blood supplies at that point, the uterus turns purple cause it's a scheme. Make so much easier to start doing the dissection. But but again, the doctor Aurora's point because somebody asked that question in the in the viewing audience, when you're looking at that lobotomy cup, you're technically where she's talking about making that space. Once you know where the Utah rides are. That space that you want to get into on the, on the, on the rescue reflection is, is on the, on the lower end, right? So this is the uterus is up here. And I'm looking at the cup, I'm entering, like, almost like I'm below the cup because that's where that, that that sweet spot is gonna be, where there's no scar tissue, right? If you're making it on the cup or towards you, you're the worst part of the deception. That's where it's going to be sticky bloody. And once it starts bleeding a lot, it's just so hard to do the dissection. You really kind of over shooting. And that's the one time I will say you want to be a little bit lower on the cup. You do, that's the sweet spot. And use the part of things that help you can always back fill the bladder. Put a little methylene blue in there. If you see blue, you know, you're not maybe in the right territory, but use what helps. And I mean, we're talking back onto the making the bladder flap on this dissection. We didn't have any, you know, wispy tissue or anything stuck like a cesarean. But take that bipolar down to as far as you can and then use your monopoly for that finer dissection in this model here, we're just taking down the wispy parts of the bladder. The coal pottery cup is actually here way up here. This is a bit low, but it's just showing that, you know, you can take this and thin it and push it back as far as you can. So when you close that cuff the bladder is far away. That's a key point. I mean, don't don't skimp on the bladder reflection because when you do it just makes doing a laparotomy harder. It makes your cup closer harder. So my philosophy is I push my bladder reflection past the co pottery cup we're on, there's like a demonstration on the, on the coke up. So I basically make my bladder reflection. So I feel my instrument roll over, roll into defenestration. Right? Then I know I've got an adequate space because once you do the Koopa to me, everything contracts. So I want to know that my bladder is down. I can take a healthy bite on the vaginal cuff to close it adequately and not struggle, especially if you've got like an obese patient and it's all hanging down. It's nice to already have it dissected. So when you pull your vagina to you, you can just sell, I'm gonna switch this over so we can I can quickly try to take my side down. Here you go. This is for you. Give this to you. Great. If you want, just keep questions coming at us and we'll do all we can to keep sharing like sort of how we address clinical things as we use the model to demonstrate some stuff. There's a little bit of the posterior left behind so we're going to take some of those and cut that down. And I'm working towards the copa to me cup. Alright, here's my ureter down here, see that gray structure here and water under the bridge. My uterus is here. But I gotta finish doing my reflection here. I'm going to push this in a little bit. And what's nice is now that if you've created a round ligament medical, you can use it to pull. So if you cut really close, you don't have any place to grab. And you're often just times leaning or you're getting into bleeding back bleeding of the uterus and it's dripping onto your bladder flat. So I'm gonna give you a little bit more attraction this way. Perfect. And there's the bladder right there that he's just rolling off of and I think we're good. Yeah, the bladder is nice and low and the coal pottery cup is right below you. There it is. There it is. I'm gonna take my uterine, my bladder is down and you know, to anybody watching tonight that trains residents, I think this is an excellent model for teaching residents. Just the steps to understand the cognitive steps of A. T. L. H. The finer points and then developing some of the psycho motor skills that are needed to be able to do tlhe effectively, right? I will even say it goes further than that too. And it's nice as an educator too because it's nice to practice what you say and how you teach and so that you can practice saying the same thing every single time. This is my cup right here. And I'm going to take this uterine right here. I like to, I like to clamp my uterine right off the copa to me cup like I'm clamping a uterine vessel off the cervix with like a clamp in an open case, if you've skeletonized this adequately, your bladder is down, right? So my bladder is down. This is just you know, again, it's just some of the tissue that's here overlying the cup. I'm gonna let me just move this out of the way so you can see it. I'm gonna take my my uterine off the cup. I'm just gonna quickly keep coming through this as fast as I can here for the sake of time, it's almost through. But what I like to do is I like to create a pentacle once I come around it, right, So I'm gonna transect it. And then I like to make like a horseshoe incision around here so that I essentially create. I always joke with my my team like a little broccoli florets that sticks out to the side, that's like my my entire pentacle and it slides off the cup. Because if you transact it and get down to that cuba cervical fashion, that's going to allow the uterine to slip and slide off the cup so that when you do your co pa to me it's not in your way. But you also have a very nicely defined vascular medical here. And of course there's the there's the ureter that's retracted over to the side here, this vessel will retract and if it bleeds, I can pick it up and grab it. But if you don't have it defined. And this thing is just like kind of like an amorphous blob here and it starts bleeding with a lot of coagulated bio burden. Yeah you're gonna end up dislocating a ureter here because this is going to retract. So it's nice to be able to create a pentacle and do that and we'll get that on the other side for you. What's also nice to say is you know like it's important to know that with A. T. L. H. You don't have the same ergonomics as a robot, right? So you're not wristed, you're coming in at an angle and you don't have a flexion point. So what I'm gonna do is I'm going to take my uterine here and that see motion that kind of bite he's talking about to isolate sometimes it's nice to take it from the other side. So I see I feel my cup right here. It's a nice visualization. I can come right across. I'm gonna come and seal right over my cup. I'm gonna take it here. The uterine artery and vein holding here. I can feel myself roll off the cup buzz just creating that that releasing it off the cervical fashion and letting it develop into a pentacle and lateral eyes is off to the side off the cup slides off the cup creates the naked cup. It just it allows for a cleaner cleaner Koopa to me and your vessel will steal a lot better because if you don't come across it all the way and it doesn't release off that off the cervix. It's hard for that to collapse the vessel for your vessel stealer to work or whatever energy do you want to show what I'm talking about with that. See motion maybe on the north side so you can finish it off on his side. So the idea is like, say it's a big fat vessel. And so I'm going to push the uterus over. And so are you just going to release the last bit? Come on. Yeah. And he's just gonna take that see motion here do like this. Exactly. And now he has it where it's flush against the cup. So if you're having trouble at all releasing and getting that medical to come off. It's nice in the model because the model is released it and it released beautifully released. Released very quickly on this model. Right? But it slides off. So again, remember the ergonomics of how you're doing it switch sides like, like, oh, okay, I'm going to play a quick video. We're doing good. We're at 7 38. A couple of questions have come in and on the same topic. So let me group them a little bit together. They're all about large. You terry, right? And, and kind of different topics around that. So there's um, one about more isolating larger you terry. And there's one about dealing with larger you terry after the hysterectomy to place it into a specimen bag from isolation. So there were two on those. There was also something about the approach and how you approach, How do you approach it differently when you're dealing with a larger you terry? And then there was also one on with the Koopa. To me, do you started posterior versus anterior based on a larger uterus. They're a bunch of came in around. Let's address the bagging and extraction stuff at the end. Let's save those for the end because we're going to do the Koopa to me shortly so we can address the copa to me one. But let me play the video what you're doing with cleaning off the cup and taking the uterine. And we can kind of allude to this with a bigger uterus here. So here I'm having, you know the trainee here, show me where's the cup and where's the uterine? And we know the bladder is far away. That is with the bladder. It's really lateral. So sometimes when you have a really juicy pentacle, it can be hard to fit it in this device you feel for either the posterior side or the anterior side grab with the bottom blade here on the posterior sweep up in the neck of the cup, turn your ligature or whatever device you're using ever so slightly feel it bounce off the cervix and you have the full thing. I just have them check the posterior to make sure they got it all and close the copa to me cup. And sometimes people will air on doing it more towards the upper part of the copa to me just so we have a big medical, you don't want to do this like low right? Because if you make a mistake and let's say you tear it, you get into bleeding then you're just so loud you're gonna get so close to the ureter. So you really want to make sure that that's the beauty of the cup. That's why you want to see the cup and you wanna you wanna strip it down so that you can take your skeletonized vessels like this with confidence and know that you closed it off right. And one of the things that we always do when we operate is that you know, we do one side completely, then we go to the other side, right? And when we do one side we get to this point we won't transect that, you know and we'll just seal it so that we don't have to deal with back bleeding during the surgery which inevitably happens when you're manipulating the uterus back and forth, just get everything done and close it off, seal it, finish the other side. And when you do the other side you can transact that uterine, then come back, transact this one, then you're basically ready to do your papa to me right? Perfect. Exactly. And this part we've done all the sides of both sides of the uterus. And so it's being sealed. It'll get cut right here by but that see motion will come from the contra lateral side. So I kind of have this intentionally like on an unedited way to show you that it can be pretty quick. So we've taken it down medical right there skeletonized. And that see motion will be right here shortly. Exactly. And the thing about that is unless you're dealing with like some crazy sticky adhesive hysterectomy or maybe like a stage four endo case most like hysterectomies that are that are that are not complicated even when they're really large you try there should not be much bleeding really should you could essentially do a bloodless hysterectomy because most of the planes we work with are all a vascular planes. Right? The only thing that should be charged at the end of the day are the two uterine vascular vascular medicals and the two variants. Or you're too I. P. S. If you're taking that next this is more of a teaching point just to show the end of public fashion that white end of public fashion. It's nice to have a clean case every time. And so this is just pushing off every bit of the bladder to make sure that when you take it it's far away. So they finish this portion of it and then they go to the other side and then they seal and they do the same thing, there's a comment about a big uterus when you do so in a big uterus case you really have to use that uterine manipulator to help you. We have a report hissed for this case you can always add another ports but giving yourself that hard traction over so that you can create that tension, those triangles. So having that round the utero ovarian on this side, if you have that angle and you can see it, you can follow the same principles. Just have bigger vessels. Typically with the same thing again on this side bouncing off the cup, you can see the cup outlined in the in the cartoon drawing and then the vessel sealers coming and clamping that vascular pentacle. You know, some key things with a large, you know, if you're doing conventional laparoscopy, it's really helpful to have a 30 day the scope, you know, to be able to look 30 up. 30 down. That gives you a better view on things live at the umbilicus. It's the same thing we teach with robotic surgery. Now I do my hysterectomies robotically. But I live in the umbilicus because once you push that uterus in and you've got a 30 scope, you're looking right at all your critical structures. And we were talking earlier on the way here today to this program that as long as we can see that cup, then we can get that surgery done just a peek of it and then you can get started so that we can manipulate that uterus and work our way down to that target that we have. So they sealed it on this side. And now we're coming over just to do that. See motion. And it's so nice from the side because there's no there's no angle issue. You can feel yourself roll off the cup and you can isolate that uterine artery so it just sits there perfect. And you can just, once you'll see it, it'll pick up and it'll be almost floating in the breeze. So that's that's releasing it off. So that when you do the whole pot, I mean you come around, you don't hit that right now. You can do that with mono polar scissors. If you're operating robotically, if you do it with a vessel sealer, but it just lets it lateral eyes. Right often people do a cop autumn and it's just bloody because they haven't done this step and they're literally coming across their sealed uterine pentacle. You should just lateral eyes that get it out of the way. So the only thing that you're looking at is the cup, the cup with the pubic cervical fascist surrounding it bladders down vessels are lateral ized that that, to me is is a clean technique. And it's it's what I call the naked cups. When I'm watching people do a T. L. H. When I see a lot of tissue attached to the core pottery cup and it doesn't look crisp, doesn't pop. I get a little concerned that you know when the people are starting to say I'm ready to do my co pa to me and I'm like wait time out reassess just make sure everything is the way it should be before because once you start the Koopa to me, not that you can't rescue parts of that and fix things, but it's a lot harder. It's a lot harder to do the bladder flap. For example, once once you cut the specimen out also I say it again, it's so good to do the same thing every single time. Even if the case is easy because if you make a habit of fitting it out every single time, it'll come really naturally and quickly. And then if you are in like an endo spot or a big broad ligament fibroid in your way, you've already isolated it so well that if you can't see around the corner, you know, everything above it is isolated, right? So we'll probably do the Koopa to me. Now, let's go ahead and we're gonna try to get through as much of this case as we can. I mean our focus was to kind of show you some best practice techniques. What are we doing on time. Doug? We are at 7 45. Okay. So we got about 15 minutes while you're about to do the Koopa to me a question came in on the occluded balloon. Um if you have only one assist, right, is it okay to fill the included balloon earlier in the case, you know, if you have a hard time going back and forth. Right, Well, but I mean what we do, maybe we can just you can leave it just hanging or just like here, it's ready to go. So this is kind of how we have it set up exactly. So like if I take that and I put that on this particular model, what I do is I normally pull back the plunger, I screw it on the on the tubing, that is the new, more clutter tubing and I leave it, leave it unclipped, right? And I just let it hang there so that at the time that I need it in the dark, anybody can reach down, grab it, drop the plunger and then pinch the clip in your, in your set. And the only reason I say that is again, um you know, probably most of the time you can inflate it and not have any issues, but I've I've just been a big believer that sometimes when I used to do that ahead of time, I think I threw my dissection off because I wasn't sure what I was pushing on that. Is that the cup. Is that a balloon include er especially when you're doing robotic surgery, so if you can just leave it flat because again, the only purpose of the balloon is to maintain Newman when you make a hole in the vagina. Okay, alright, let's see here, grab this. Okay, hopefully this will work. We sometimes with the model it can be a little finicky, you have to ground it to use the mono polar, but you can see the cup. So here's the cup right here. Our bladder is nicely down the ureter going inside it. You have a nice view of the vagina here too. There's a suture line here, that's just like kind of how the vagina is brought to the cervix. And this, here's my cup. So I'm just gonna come across with my energy and my goal is always to see the blue. So you make a long stroke in your first go and I think I can kind of get a sense of blue underneath. Now we have the settings on this in case you're wondering why we're seeing a little bit of sparking because I think that's something that comes up. Sometimes. Normally there's the cup. Normally we do, I do 30 30 and the key to doing and we have a little bit higher just because the way this specimen works, it cuts a little bit better on this simulation model if we if we crank the the wattage a little bit and normally we'd also zoom in a little bit more. But the nice view from this end maximize your movement, You can see go, don't move your uterus, get every little bit you can that's safe if you know your your bowel is low and if he's pushing over this way and grabbing this kind of round ligament again that you've isolated. Perfect and I can get around this bend. I'm just perfect to give me even just another centimeter of space. My uterine artery is typically over here completely isolated. I'm staying medial to that. You always want to make sure that you never take more than you should. The important thing to keep in mind when you're doing a Koopa to me is you don't want to bury that tip into into the copa to me cup. You want the energy to arc if you're using monopoly power to the to the to the copa to me cup, you don't want to be stabbing into it. You want to paint basically over the cup with your energy and let the energy a little arc subtly to it with cephalopod pressure that's going to come apart. If you if you're if you're getting divots into your co pottery cup, that means that you are really bearing your monopoly or scissor or your hook into that specimen, gonna come from your side and also share the wealth, pass it over to the other person. Don't have to do the whole cup on your side. You know, it's going to be much harder to try to get around the angles of things. Just use the manipulator and your assistant to your benefits to help everybody. I'm going to go back to that question that somebody asked that we're having a little bit difficult. This is a kind of a bulky uterus, so um so this brings up some things that we think about that we do when we're doing these cases, somebody asked about you start anterior start posterior if you have a really large uterus and you can see posterior lee relatively well, I would suggest starting posterior because once you release it and clearly first it's a lot harder to get mobility right so if you can release the post here it's always easier to go anterior afterwards right at six o'clock is always the hardest when you leave it. So I definitely like to like to start posting if I can. The other thing that I do, where's our cup? You want to be able to see that little anterior aspect of it just a bit, I can't see where we left off, give it a little push down below, zooming in a little bit in a little bit, you can see the cup there just to show it to you on that side so you can follow it and go from known to unknown, I'm going to give it a little lean can get in and with the 30 degree scope it's nice because you can go around the bend, right, still right there. Alright, let me activate this, I just need to get this thing down a little bit there, you can come over that way and see if I can get down there. Alright, normally you'll see that blue of the cup and you'll try to match the blue to the blue. He's feeling the cup again, the cut edges right behind it. I just thought I could see it right there. Let me just get my position here. Your camera would zoom in and go around that corner. I still can't see it that well because just so bulky. Well this is a good point when you have a bulky uterus like this, so here's here's where I'm struggling right to see because it's bulky. One of the things that I'll do when it's really bulky, like this is I'll do a super cervical because you can often see to do an amputation. And so in a case like this when you've done your uterine and I know I can retract this way and I can see where the where the where the sort of the isthmus of the cervix is the corpus and then you see the cervical neck. What I'll do is because you've already taken the uterus and everything is the vascular rised. I'll just amputate like I'll take my monopoly on robotic surgery and just take the corpus off now when you're doing that, you're going to have to withdraw the manipulator at one point as you're doing it but don't pull the cup back just in this case where the delineated, we can we can unlock the shaft of the, draw it back until we see ourselves hit the part where we've kind of come across the manipulator because when you do a super cervical, you're gonna hit the shaft that manipulator. So once I hit that shaft and I can see it, I draw back, pop into the enemy into the peritoneal cavity, which just barely the tip of it. And then I anna flex and that that cervix goes up and the uterus goes backwards. I can finish amputating once that's done, I can make sure I reposition the cup well into the for nix and then do your co pa to me, and it's so much easier to see. So in a case like this now, I don't think we have time and I don't I don't want to try and look at the posterior. Maybe we can try to elevate it. So I'm gonna push in, I'm gonna lift up and then you can see the blue of the cup. What I can do is I can switch with you because you have a good view from your side again side back and I'm gonna retract for you and I can hold this up, dropped out of the way, there's the Economy cup. So that's a post the review and I'm gonna try and zoom in a little bit with the camera, a little bit better sense. I tell you probably, I would say there's Michael Potter me underneath? I would say probably, I don't know. Seven out of 10 times on a very, very large uterus. I will end up doing a super cervical and then coming back and taking the cervix because it's so much easier. Michel platini cup is right there, It's underneath. So, I'm just going to come across, I can see my pelvic sidewall on the other side being mindful not to shove my device in too far and then losing control and then getting into vascular chair where you shouldn't. It's releasing kinda nicely here. He's lifting up for me to give me just an angle underneath. It would take my 30 degree, I would be able to go right underneath it. And the nice thing about using a lobotomy cup. Now we're a little bit lower than we normally would be just because of the bulk of this thing. We're just trying to trying to visualize it. Um is that when you, when you use the Koopa to me cup to enter the vagina, it preserves the uterus cycle ligament attachments, right? Which to me is extremely helpful to be able to like not disrupt that. So it's it's an inter factional hysterectomy because your motorcycle ligaments stay attached to the poster vagina. So when you repair it and you close it, then you're gonna you're gonna restore that anatomy in many ways. So why don't we, why don't we? Instead of trying to struggle through this right here. Why don't we go and video. That's probably going to demonstrate some of this technique a lot better because I think I'm starting to tear at the model a little bit here. So what we'll probably do is have dan come in so we can prep this so that we can kind of demonstrate some key things as we round out the program with the vaginal cuff closure, you know? Yeah. And so here's one picture of what we ideally wanted to show. So I'm just gonna kind of pause on this part of the video that and give it a play. It's not the time. So on this thing, I have a demonstration of what the anatomy looks like. So I haven't paused um intentionally. So this is what we're trying to see right before we showed you Koopa to me, right, so you have your uterine vessels isolated hanging on the pentacle. Your new mo clutter balloon has now been inflated. You have your line of your coal pottery cup, you're gonna go ahead and start and make your dissection right there. So what I'm gonna do is I'm gonna go ahead and play the video fully and we can kind of walk through it. So um this is just kind of like an idea that now you have, we're using a spatula here, which is your monopoly device. I can see that white endo pelvic fascia really beautifully right through here and I'm gonna go ahead and start activating the blade. So on this, the monopoly lurker is you you have it on whatever setting you're using, trying to just basically lightly touch arc on the tissue, looks like it caught nicely caught up. So we're not losing any of the feed, a little bit of smoke in the spot, you can use your section just intermittently, give yourself some section or you can open up event just to get that smoke out of the way, looking for that. Give that beautiful blue cup. So what you see here and you're following the internal bubble. I think sometimes what people do is say traverse too far and then you end up taking going farther down than you need to. And you don't have that same resistance that when you're pushing the cup in, when you push the cup in, that's the part you cut on. If you cut behind it, you're taking a little bit of the top of the vagina here. You see your you terrans are fully out to the side. They've been completely isolated. And as you do this a lateral eyes further, you're going through the vaginal mucosa. I tend to use cut across the whole thing and then go on a little co ag toward the corners because that's a little bit more of the juicy or spots. But yeah, this is a nice thing right there, there's that floor it off to the side and you don't even hit it. It's a clean co pa to me and notice that there's not a lot of div ID creation on the co pottery cup because they're just sort of dancing on it and not pushing into it because you're relying a lot on on letting a little bit of the, of the parking to it so that it doesn't as you push in it doesn't the pressure and our king to it is what allows things to separate. So the idea is that on this one here going around the copa to me I think just taking every bit you can see before you move the uterus. That's right. It's like it's so hard when you've got that one centimeter of tissue that's left and you're like painstakingly trying to get it and it's just so hard to reach if you maximize it as far as you can, you can just do one swipe and it's over. Like I said, take what the defense gives you. You can get a lot entirely and a lot of pasta really just just keep going. You know, I mean to me that's what really is ideal when you're doing your lobotomy because you also don't want to dwell. Like one of the things that that I find people struggle with is they spend a lot of time I called dwelling leaving the the energy in one location and just burning, burning burning. That's where you get a lot of thermal effect. And then with that you end up, you know putting yourself at risk potentially for things like vaginal cup distance, right? If you have a lot of char in the vaginal cup and of course if you don't take adequate bites because you didn't make a good bladder flap, then you're really suturing through the vascular tissue. Right? But I have everything set up for the sake of time just for just to demonstrate highlights for closure. So we have a couple of needle drivers and we put the ports. So we're kind of show another technique here just for the sake of time. I'm gonna just drop the future in. But I tend to like to do um use the same three ports. And so what I do is I just I hopped the camera to the side I'm not at. So the camera went over to the left, lower quadrant court. I'm gonna put my left hand in the umbilical ports and then on my right side I will use my right hand traditionally in the pork. That was already created. And so what I'm gonna do, I'm gonna go ahead and place my instruments in. So it's a way to allow yourself to gain an IPs lateral configuration for some people like to suture. Whether super pubic and in the lower quadrant, others like to do cross table. If you have like long arms and you're tall, you can do that with summer Ghana me showing me the vagina kind of in the center position there. Let me fix the scope here. That is I think I just bent the sculpture. There we go. How's that? That's the vault right there. I think I distorted it when, when we teed it up just to demonstrate some key things with the closure. So it's nice to sometimes all you can do is you can just lean on your needle on a piece of tissue, grab it right here. It's nice to focus in for you here. So you can actually see it. That's okay. And then you can just pick it up and it's already hopefully will be and you can lean on it to give it a right angle. Um and then I'm gonna grab the tissue at the corner of the apex. I'm going to operate away from me. So I'm coming towards myself. You don't want to end up operating from close to you then going far away because it becomes harder to drive the tissue. The needle in the tissue. I'm going in perpendicular at the level of the apex. My uterine arteries are super far away. I drive this down prone, ate my hand fully here. I'm going to actually just grab my needle. Now the nice thing a couple things I want to highlight is when you when you start the suturing definitely get an adequate bite right. You want to make sure that you have both. The fashion and the vaginal epithelium because if you don't have both and you're just getting for example vaginal epithelium you don't have any any strength basically setting yourself up for for potentially distance but also an interest because you have no fashion coming together. You're not restoring that anatomy. So you want to make sure that you get both. And like when I when I pass the needle I like to make sure when I come through the posterior side that I'm also getting apparently um on the back side you can just use your needle. If you're if you have your needle here you bring it to your ports. You know it's safe. And then you can just pull your suture through all the way. And I'm trying to be a good assistant and like put the scope where it's steady and she can see Now normally with laparoscopy now we're using the built ins um camera on this, on the goodness in model. But if you were you know working with somebody and you're doing this laparoscopically you would bring your laparoscope in. So she so she can see a lot more closely. Right? And so essentially the things that we want to highlight here uh for the sake of of of the of the educational session is make sure you get the corners, make sure you get the corners well make sure you get the fashion really well and make sure you get the vaginal epithelium really well. And then for this part when you're using the Vlach and I thank God, I've got I'm going to focus in younger than our knees eyes. Hopefully I can get into that little space. I need my reading glasses for this kind of stuff. Okay. So I'm on, I'm on I got it so it's a little bit harder to demonstrate. But you can use the scope and kind of pan in and then you know, you can have another assistant if you wanted to to help you navigate your needles. Notice the one thing that you did that made threading the thread in the eyelid a lot easier is that she brought the eyelid down to the tissue so it's stabilized it. A lot of people try to thread that in midair. That really gets complicated. So I typically like to bring it down to the tissue. I need all drivers are unfortunately a little loose on here. They're a little loose. It's okay but we're all right for the sake of Okay, well, I mean, I think we made the points that we wanted to hear. I don't know, we have the video up but we can do is talk through. That video is not up. What we can do is perfect if you want to finish your questions in the last few minutes and maybe I'll put the call pa to me back up and have that one running in the background and then we can always have the cuff closure to follow, which is just a nicer demonstration because it's, you know, real real tissue too. We have that plane. So I know there was a question about tissue extraction. I mean typically what we'll what we'll do is, you know, once we have the specimen and we know we cannot deliver it vaginally is we'll leave the specimen in the upper abdomen and eventually bring it back down into the pelvis. And I love, it depends on the size of the uterus. Right? So you're gonna select your bags whether you want to do a bag on a stick or a free sort of freestanding bag that you have to tie close to introduce. It's always about, you know, bag management, right? You want to make sure that you don't have your bag like opening up in the middle of the abdomen and pelvis before you can get your specimen in there or stuffing a huge specimen in a tiny bag too. Right? So pick the proper bag size. You know, make sure that you you have an organized way of doing it. I know that's beyond the scope of what we're trying to cover today, but uh we typically will either do that with, we're doing a robotic case. Uh use a robot to facilitate that or if not um you know at the bedside for a conventional laparoscopy or you can undock the robot come to the bedside and do that whole bagging technique. But typically for us, I mean I think you're the same way we typically tend to take our specimens out trans umbilical e they're pretty large. I mean when we're doing our 20 plus week, you know, it's just a painful I think to go back down underneath the legs when you already are ready to go and you can dock on the robot really nicely. Just lateral eyes, one of the cameras and go right to Giambi. That's right. I just find where faster trance ability with the exciting technique than we are going down below extracting a very large uterus fragile. But you can you can you can you can come down and here's where we kind of left off. And so do you see on the lobotomy here we're getting around the corner that's at six o'clock. That's going to get really challenging. Just get as far as you can reach safely. You see your ovaries here, your public sidewalk or whatever it is on that side you're trying to avoid. But you can go up just until you're so close to it. You're not going to hurt it and then jump over to the other side and you can see that the cup looks fairly pristine because we're not digging into the cup, right? That's one thing you don't wanna do, you wanna use just enough of a setting that you're not getting like you don't have flame thrower in there, right because that's where you get, you're gonna get a lot of thermal effect, you're going to get an injury. Um to not only the tissue that you're working on, but potentially to the bladder, right? Um And so you want to make sure you have some control over it. I know it's a little hazy, but we intentionally put the camera right up to the spatula so that you can see really nicely over here lateral is here yet. And then what's nice is here. So you've done basically from 12 o'clock to five o'clock, then you're gonna go from 12 o'clock counterclockwise to about seven o'clock and all that's left is that little space underneath. So what you do is then you can go in with someone to help you, they can lift you put the uterine manipulator and you lift it up to and divert the uterus. Someone pushes up on the fungus, which I'm actually gonna be able to demonstrate here, that angle is too hard. You can't really see that and you can't connect the dots, just take a step back. And what we'll do is we'll be able to see the rest of that little part and it comes right off. And as you can see at this point we've placed the new mo clutter balloon already, it's been inflated before we started this whole process, but there you go. This is where a 30 degree scope is very helpful. So 30 up or 30 down, depending on where you are in the lobotomy, lets you see this really well. Right. So again, just a lot of stuff, a lot pressure helps complete that and maybe we'll just let the cup closure playing will take the last few questions as I know we're rounding out the I can't I know I feel like you're trying we have so many things we want to say but just like this, it's the same setup I was trying to tell you is that the bilateral we just put the camera over to that side and you can be, it's a lateral so you don't hurt your shoulders. Other techniques you can do is air planing, keeping your ports contra lateral and turning the patient a little bit over to that side. Getting on a couple of steps, anything to save your shoulders. A couple of questions came in really just about on the same topic. So I'll try and group them together again. Right. It was that surgeons are seeing a lot more patients that now have had multiple c sections, right? And that seems to be a common theme. So in those cases there are a lot of questions about what you do there. But but a lot along the lines of um do you cut more cephalopod? Is the bladder is the place or what other tips and tricks do you have when you've seen those multiple c sections? And again, I mean I think thank you to the people watching or sending these questions because this is validated what dr laura and Jason and I were talking about earlier, I think we really need to demonstrate like a real obliterated entire cul de sac like sort of live surgery because I think that's been that's one of the toughest cases that we see all the time. Right? High c section rates obliterated, enter kolasinac. I think we said it earlier. That's the worst thing you can do is tackle the adhesion first, ignore it and do every other particle that you can see. Like upper particles on the cornelia post here. Broad ligament. You can always see that and take that down safely. You can always see the cup posterior. And you can always take the uterine vasculature post eerily right before you even do anything with the bladder or any of the adhesion to the uterus. But the worst thing that you can do besides starting on the adhesion first is cutting two cephalopod, right? Because you're cutting through the worst part of that case, right? It's thick, it's going to be completely bloody. It's really nice to go into territory where you haven't cut for a C section, your c sections are on the lower uterine segment. They're not at the level of that cervix in that cup. So that's your spot to aim for. So I typically like I said, once you get all that, the upper particles down the poster lead for the broad ligament down and you can always see where the uterus is. If you have enough stuff allowed pressure you drop that poster broad ligament, you will see the vessels alongside of that Koopa to me cup. You can pinch those closed and once you identify them, the place to enter is going to be above the vessel. More coddle, right? It seems counterintuitive to do that because you're always worrying about the bladder but more coddle. And feel that the cervix and feel the cup and be a little bit more slightly inferior to that cup. The fat part of the cup. You're gonna find a very clean undisturbed space that's curly white. You know you feel it so if this is your uterine and what you're trying to do is you go right over it and you put your device and you literally just spread gently. Not a big wide spread. You're going to get into some bleeding. Just little spreads just where you can feel that cup. Once you have that endo pelvic fascia, that white pearly white, you start developing that space underneath and taking what's thin above you until lo and behold your to the middle. And then you connect the dots from the other side. You do it on both sides, both sides, you'll be able to do that. It definitely tells us that I think whatever the future. Next webinar we're gonna need to really spend some time with some really good clinical footage of the obliterate intercooled attacks that really is like one of those clinical obstacles that we deal with all the time. Right? I think all the viewers out there, you know, that's like the bane of your existence is knowing that somebody, even if it's just one c section, you could end up with a lot of bad adhesions. You know, a quick question. What you might have mentioned before. What monopolies setting do you use? I tend to use 30 30 co ag again and I like I like to use co ag all the way around but I like I use an open scissor. For example, when I do it and I just use the one scissor, both scissors blades closed, but just the one and I kind of just dance around with a lot of stuff without pressure. And for me that works really well, gives me a little bit of coagulation, but it doesn't charm my cuff when you look at it after the specimens released, it still looks pink. I like to see a little bit what I call a little bit, just should look like a little bit, just a little bit like it looks here because that goes away when you close the cuff. Right? If your cuff looks like charcoal briquettes pressing in there, that's not go to hell Well, so when I finished the Koopa, to me looking a little weepy is good because that means that you haven't over desiccated that. And that's all going to stop weeping once you close that cuff with whatever suits you decided to close with. Okay, we have time for two more questions so we'll make it quick the question. And if you come in about the call pa to me say you're starting at 12 basically. Right. Is there are there cases where you would start posterior early, right? In cases where you would kind of go the other way around because of the anatomy, you can just depending on how you decide you want to. So I mean like sometimes I think the angling is just, it's an ergonomic throw to be able to go from top down for future closure. No, I'm sorry for the call pa to me, Right. Yeah, that's all right. So are there times that you start post eerily instead of totally, totally if there's a big old fibroid in the way in clearly or something along those lines, 100% I'll go where it's easy first and that way I opened things up and can handle it, but you know, often times it's just go where you've already started. I typically go like you do. I typically, well if it's not too crazy of a uterus in terms of size, I'll go 12 to 5 um 12 to 7 and then I finished off the 57 o'clock where it becomes really, really helpful to start posterior lee is when you have that very big, bulky uterus and you can see posterior you can see reasonably pastilles really start with the poster cop autumn. And the reason is again, is that if you start anterior early first and you try to do that posterior co pa. To me it's a lot harder that you lose the ability to manipulate at that point. But but but but you can manipulate a lot easier when the anterior still attached and you can see the posterior on a big uterus. So if it's a really really big uterus and you can see posterity definitely start. But what we find as I said before is and I do all my hysterectomies robotically. So for me I find it a lot easier to do this like an amputation of the corpus off the cervix. I just do a quick super cervical reposition the manipulator and then do my co pottery, which at that point takes literally like less than a minute because there's nothing in the way at that point and you don't have to fight this big uterus that's in the way. So a couple of questions that have come in on products, so we'll try and make this not too long an answer, right? But there was a few that came in on the ally, right? Just and I'll take one from a surgeon who said that they are in the middle of trialing Ally for the first time. And just some quick tips and tricks that you would recommend for you know, having success with the allies system. Yeah. Well, I mean a couple of quick things. Maybe I'll just go to this to just show you real quick. So I'll try to do it really fast straight because changing knows this. I always emphasize this when you're using the where's that grab a manipulator at this point so I can show it real quick. So when you're when you're doing, when you're using the ally anytime you have a manipulator, whatever manipulator you have on here, whether it's a delineate er an arch a roomy, it's a two handed operation, right? You're gonna you're gonna step on the pedal and you're gonna hold. And I use both hands to do the manipulation because it's it's somewhat weighty and trying to do it with just one hand. You you don't get the full, you know, I can get other types of angles that if I just do this this is all I'm going to get. But I can do this and I can create some other angles. So it's two hands to do it right? That helps a lot. The other thing is there's definitely a learning curve, right? You've got to make sure the patient's positioned properly. You've got room, The legs are externally rotated and abducted properly patients not slid back on the bed. All those things make a big difference in the case where you're like, my God, I can't believe I'm doing surgery without these things. I really need it. I certainly use it in all my we both use it in all of our reproductive surgical cases because we just love being able to not use a delineate er for that. But like an arch with a roomy tip, I'll park my uterus and reflects it. Do my posterior hysterectomy, do myomectomy endometriosis surgery where you just need static positioning. I think that's the key part to think about your case in advance. And then, you know, if it's going to be beneficial to you, like if you've got an isolated big old post here fibroid having a manipulator sometimes in and of itself is actually not even helpful. You want to fold that uterus forward, put that fibroid right in your face, make a horizontal incision and pluck it out. But then there are cases where if you've got a nice anterior fibroid or a bundle one and you parked it, you don't have to move the uterus the whole case. That's right case selection. But it's also learning curve. And it's also knowing that you can get a lot when you manipulate with two hands. So I think in a nutshell, like two minute overview. Those are the kind of things that we take away from my whole division. There's eight of us in the group and pretty much the majority of us use it in our cases in a wide variety of different ways. So we are at 8, 15 over over. Right, This was great. And as usual it goes extremely fast whirlwind. So thank you dr Advincula thank you dr arora. This was great presentation. Just fascinating. Um great questions from the people who've been watching, keep sending questions in because it really does help us figure out what we should be included, inspires the next talk. Yeah. And thank you to cooper surgical for being just a great partner and sponsoring educational events where we can really just share tips and tricks because that's the only way we learn from each other. And thank you to guide us in for just producing an incredible model that we can use to teach with and of course supplement with the real clinical videos. So thanks everybody for tuning in. A few reminders. Just as we close out, there are a few questions on just what is the model? Right? And that is the dinosaur model. And anyone who is interested in trialing it or training on it, please contact your cooper surgical rep. They could set up a training program for you at your hospital very easily. So, reach out to them and they can help you with that and let us know if you would like a follow up demonstration from your cooper surgical sales representative. Also. We look forward to seeing you and your colleagues at the third session of the man big series that's mastering Migs three, bringing it all together with advanced techniques. So that's gonna be a fun one not to add and prolong things, but that's fully cata Varick with satan and I and a robot and everything and we're going to walk through the whole thing. But with the actual anatomy that you work with, so that one is definitely one. We hope you'll tune in for good. Well, thank you very much. Thank you dr Advincula. Thank you Dr Arora and thanks to our audience. Have a good night. All right, good night, everybody. Bye.
Arnold P. Advincula, MD, FACOG, FACS
Chetna Arora, MD, FACOG