Mastering MIGS III: LIVE Robotic Surgery on a Cadaveric Model
Originally Broadcast: Thursday, February 2, 2023 | 7:30 PM ET
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Objectives
Demonstrate in a cadaveric model a safe & efficient approach to TLH with robotic assistance
Analyze potential obstacles to effective uterine manipulation, from patient factors to bedside assistant
Translate the surgical principles gained from this webinar series into real world applications
Presenters
Arnold P. Advincula, MD, FACOG, FACS
Chetna Arora, MD, FACOG
Welcome and thank you for participating in tonight's event. My name is Doug Kay, 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 60 minute time limit with interactive questions and answers with Dr Advincula and Dr Aurora. Throughout the live demonstration at the end of the demonstration, they'll participate in a dedicated Q and A session. We'd also like to expand a special thanks to our colleagues from intuitive that have been great partners in bringing this program together our program, part of a three part webinar series on mastering minimally invasive gynecologic surgery. And tonight's program is entitled Mastering M Three live Robotic Surgery on a Cata model. We are also particularly pleased to demonstrate our next generation Ally two uterine positioning system for the first time in a live surgical set. Our distinguished presenters from Columbia University Medical Center and New York Presbyterian Hospital are Dr Arnie Avila, chief of Gynecologic specialty Surgery, and Doctor Chana Aurora of the Division of Gynecologic specialty surgery. Now, Doctor Avila and Doctor Aurora. Well, do thank you so much chat. It's great to be here. Finally, I'm not sure if you folks remember that we had scheduled this a little while ago and thanks to a hurricane in Florida, we were unable to do the live webinar at that time. But I definitely want to thank Cooper Surgical for support for tonight's event as well as intuitive surgical for allowing us to sort of dovetail what we're talking about in terms of uterine manipulation and ally with the robotic surgery. You know, we recognize that as we've been doing these webinars, we get a lot of questions about how all of this technology interfaces with robotics. And so we thought, why not bring the two together and um have a webinar that kind of integrates all this and, and chain and I are are gonna basically share with you tips and tricks. Now, a couple of just quick things I want to um touch base on before we get started. One, you may see some folks running around behind us and that's because we are troubleshooting and that's the beauty of live surgery. You can never predict when it's like reality TV. Just stuff just happens, right? And so with live surgery in a lab setting, we may have some folks running around because we're just trying to troubleshoot, getting a grounding pad to actually adhere to our patient to our cadaver that we're using this evening. With that being said, I also just want to take a few seconds chat. And I just want to take a moment of silence just because we are always very humbled when patients donate their bodies to science. And it really allows us to be able to share and teach in a setting that is not high stress like in the operating room where we can really talk about tips and tricks and techniques and field questions. So with that being said, we'll just take a brief moment of silence. OK. Well, uh let's, let's do, let's jump right in the culmination of many webinars coming together in a really cool live demo which we've been looking forward to for a while. So II I to be transparent. Um I mean, we're super excited to get our hands on the ally too because it just finally got through, you know, FDA cleared through regulatory. We're getting our hands on it for the first time over these last few days. Haven't used it yet in an actual live patient. We've worked a lot with it in the laboratory setting, but we thought, you know, why not? Even though we haven't had a chance to use it in a live setting yet with a actual patient, we would share with you some of the new enhancements because we've had the opportunity to work with Cooper surgical over the last couple of years, kind of finessing the things that, you know, we thought could be improved upon from the original ally to kind of make what we do in surgery a lot better. So, do you want to start with, like, it's a big thing for Cooper surgical because they've worked with us throughout the whole process and really taken what we wanted as physicians and surgeons to do this together. And so, and it wasn't just us, uh like, but there are a lot of people involved, but we were definitely. So, uh this is very similar in appearance to the all I one for the Ally two. There's a couple of things that have changed. So as you can see, just like front to back, this is the same place, same kind of design here with the hydraulic system and the tailpipe, the handle is a little bit more ergonomic to grab. So, you know, people are saying it can be heavy, but when you grab it, I'm gonna hold the pedal and pick this up. You don't have to grab it, the blue, you can grab it wherever you can grab it. And it's, it's pretty honestly easy. And ergonomic to hold, this is a position. I would grab it just for demonstration, but you would, you would grab it this way and this hook onto a bracket just like this. The bracket would fit right on here onto the bed and we're going to show you because it's a little tight in this room. And with the robot, we already have an L I two attached to the bed and what we're going to do is show you some nuanced things that you need to pay attention to when we finish the demo with the surgery. So you can see that up close. But we thought we'd start with the device itself. Yeah. And just one thing to really know is that, you know, this is more applicable. I feel like to a lot of different types of the surgery, there's a lot less dead space. There's really a thorough range of motion. You can completely go retro version, you can go all the way up to the top. You can really push it and it holds the pressure and it doesn't lose it. So there's no give back. So let's show the pedal though. So for anybody who hasn't used one of these before, there is a foot pedal and, and you can see that here and let me make sure I'm not wrapped up here, but there's a foot pedal that's here and, and it's covered because sometimes you can get confused if you see this black pedal and might think it's your energy source. But this is for the, for the, the Ally and then you'd step on that and that releases these links. If you've used the original Ally, you'll see that there are a lot more links, they're smaller. And as chait has said, it really creates a tremendous amount of range of motion with, with your, with the way you position your unter manipulator, the other thing that is, is really an amazing enhancement that we're very appreciative of not just the ergonomics of how you pick it up and then having this with a lot more range of motion and reach. But, you know, a lot of us when we do robotic surgery or laparoscopic surgery, often do combined procedures. Right. Yes, a huge one when we're doing Hiss, copy and laparoscopy robotics, et cetera. This used to feel like it could get in the way, you know, this, this tailpipe right here was always a frustration of ours. Exactly hiss. But this actually because it flexes so nicely and it can rotate down. So I'm gonna, I'm gonna step on it and check this out. The tailpipe goes out of the way and when that tailpipe goes out of the way you can do your cystoscopy, do your hysteroscopy and it doesn't get in the way. So we do a lot of myomectomy work robotically and the ability to do top bottom deal with the intracavitary lesions histoscope. Now, we can have this positioning the uterus during the surgery, but we can do our histoscope myomectomy. Then when we're done with that, we bring it back into the field and then we can use it honestly of all the things that's probably, I don't know, maybe that's my favorite part. And then the reach is the second and they handle the third, I don't know, parallel it to the leg and it's really not even in the way at all. And then you don't have to worry about moving under the drapes or resettling it after you've already draped and use it at the same time. So you want to talk a little bit about draping. So, you know, the thing to remember is that this device works with all the cooper surgical manipulators. So whether you're utilizing like a roomy or an arch, and now we won't spend too much time going over this because we covered that in the earlier webinars. But you know, roomy two viar arch viar deline, all those things will interface with this positioning system. This one in particular, I'm holding the deline because that's what we're using during this case, this one has a metal tip. If you were using like a harmonic for ultrasonic energy, we're using the monopolar energy and then we're having the, we have the blue cover. I'm gonna pass this to you, right? Two different drapes. By the way, as you saw chain to put on a blue one, there's also a white one and the white one. It's pretty easy to remember because it's got a drawing of an arch handle and a roomy two handle. So if you're going to use one of those um handles, then you need this particular drape. If you're using the delineated, it's very specific to a blue one. And then you can choose your manipulator based on your procedure, psycho copal pees hysterectomies myomectomies, endo excisions, adnexal surgery. It works for all of them. So coming through here, I just kind of lifted this up to show you the blue, but it actually remain sterile. You hold this little tab and you just literally pull this down and then you slide this while it's sterile. Expose that tip here. I'm gonna give you a little bit of a, you have your pedal here. Oh Yeah, I'm going to give it to you. Here we go. I give you the pedal. You know, it's always good to have the person manipulating the arm, holding the working the pedal. Because if you ever step on the pedal and you're not holding this, it's going to go right to the ground. And because this is much longer and has a greater reach, you'll probably end up contaminating it. So, and if you're attached to a manipulator, you certainly don't want that to pull out of the patient inadvertently or end up maneuvering the uterus in a way that you don't want. So always hold the, the, the arm if you're gonna, or the manipulator that's attached to it, if you're gonna step on the pedal and I kind of fixed it in a position just so that you can have two hands so that you can hold the manipulator. This is just an easy seat and there's a natural curve of this. So all you do is you kind of see it into this position. That's it and then you close the door and this one just has a little, a little piece there, little piece, just kind of, there we go. Perfect. And so then we just close it up so then you can open it, take it off, etcetera. But what's nice about it is that this whole piece then can just move so you can go all the way in anti version, you can go all the way down retroversion, you can push to the side left and right. And also you can retract it back into the pelvis too. And so you can get full range for all different types of procedures. Now, honestly, I would say in our division, we several of us do a lot of robotic surgery and also a lot of laparoscopy. And I would say probably half the division uh at least utilizes this almost every surgery that, that, that we do. We, we utilize the ally. Now we're super excited to start using the ally too. But, but we basically use the this positioning system every time we operate and I just want to show them chana like what it looks like from a side view if you can step on the pedal. So this is what it would look like when it's in the actual patient, right? Um Again, we're ghosting this because it's going to be hard to see here on the, on the cadaver. And again, I forgot to mention this earlier, but if you have questions for chain and I as, as we're going along, please feel free to fire those things off. Doug will pass those off to us and we'll try to answer them as we go. But if you can step on the pedal, oh, I'll step on it here. So you can either try to move this with just the handle of the manipulator itself. But I like to do both. I kind of, I don't know what you do chat there, but I grab the handle and that way I get even greater range of motion by doing this by moving it. And like chain said, you can even while it's in, if you needed to rotate this, you can rotate it and push it in fully. That's the beauty of this range of motion like different pathology where you really need to see kind of the cup in a different direction or an angle that that retro version is so key. Yeah. And you know, obviously we're doing a, we're going to try to demonstrate a hysterectomy here or at least some highlights of a hysterectomy. But we also use this depending on the type of manipulator that, that we have to just position the uterus for myomectomies, endometriosis resection at neal surgery because you can just literally park it and then you just forget about it, right. And, and it just sits there and you don't have to rely on somebody down below. And I don't waste. Then my fourth arm, if I'm going to use the additional arm on the robot that actually serves me a purpose of providing active dynamic kind of traction because this is doing my static positioning. I mean, even what's so nice about it is if you can put a sterile glove, a blue towel, you're at the robot, you need a micro position, move, you can quickly reposition it yourself. Get right back on the console and do it all on your own. So when you don't have that support, maybe in the room to do everything together, you can really be an individual, full surgeon. I love autonomy and surgery, especially with robotic surgery. So this is like my favorite tool to have with the robot. OK. Uh 22 quick things. First doctor a there was a comment if you don't mind that you could project a little more towards the microphone, right? So yeah, so there couldn't fully hear you. The second thing the question did come in just when you set the ally on the bed repp, right? With the current ally, there's like a sweet spot. They've got to hit just that perfect sweet spot when they set it up. The question was, does this give you any more flexibility in in the bed rail position? I would say it would because it's the reach, that's the, that's the thing like with the original ally, you really, you had to be at this sweet spot because there were some dead zones that we, that we used to refer to. But because of the ability for this thing to reach a lot further than the original ally, you don't have to be as precise. But again, the key thing is that this bracket that gets used with, this is needs to be mounted behind the bracket that your stirrup is on. You know, so we'll show that once we get the robot out of the way, but it's got, it's got to be behind that, that, that, that stirrup. And that's kind of what allows you to kind of for the most part, be standardized with your sweet spot that we, we call it any other questions? No, that was it. All right. Well, we're gonna wheel this out of the way and we just gonna start and dock the button. So, just for the sake of time, uh, we always feel like time goes by so quick and I, I don't know which way to, I think you can, um, it is getting ready here. She's deploying for dock. What we actually did is we took the course and what you can do is come on this side after you deploy it and let's just talk about our place to leave it, leave it here. Ok, great. So we are putting all the arms in and, um, now granted this is a cadaver and we have a very, very small uterus. And so what, what we, what we typically do is we enter with an upper quadrant in the left, we use a needle to start get new and then visualization here. Uh I, we go ahead and put our lateral most ports. I usually, once I put the uh upper quadrant port is the first car we, we typically use a five to put our little in when we're in the or let's just kind of get a nice survey. We look inside and we'll place roughly at the level of the emboli and along the A I roughly about four finger breads up. Usually that's what it measures out to. We'll place our, basically, if I was only doing three arm case, this ends up being my right hand. But in this case, this will be, this will be the fourth arm. We'll place that first and then what we do is we triangulate with the umbilicus and not in a straight line, but a slightly recessed line that we triangulate, we'll place the additional troll car which becomes our active hand, right? Like a scissor. In this case where a needle driver is going to go here can report always at the umbilicus no matter the size. Yes, no matter the size pretty. I think I can't remember the last time I had to put a port super umbilically, but regardless of the size of the uterus, we live in the umbilicus and then we just mirror image the left hand here. Again, it's roughly in line with the um about, you know, four finger breads above the A I in this particular torso. And you can see that even though this is a very petite sort of torso, in terms of not a lot of real estate ribs are actually here. The rib margins, I don't know if you can appreciate that, but it's just like a half a piece of paper. But the spacing of this with the semi circle kind of M formation gives you all the range of motion you need. So without collision, so we'll go ahead and dock, but we did this just for the sake of time. How am I looking? Uh Keep coming. Let me just, oh, you know what um hold on one second. It's because our laser line is blocked here. Yeah, perfect. OK. Go ahead. Keep coming and keep going. You're good. Let's go towards the feet and keep going. You're good. You're good. All right. So, you know, you don't necessarily have to target if you get good at bringing the robot in, but we're certainly gonna target. We just need to bring the monitor around so we can see. So I'm gonna go ahead and grab that and turn it, position my body so you guys can see. I always kind of loop the cord in here so that you don't have any kind of free cord hanging. Give it a second to calibrate. Then the scope of the target anatomy. Make sure it's flashing button and then enter into the pelvis. I'm just going to move that screen a little bit so I can see you. Ok, Arnie? No, I can't see but all the matters that you can see. Ok. Got it. We're gonna pull this back on the mayo stand. Here's our uterus. We already have the uterine manipulator actually inside for the sake of just speed. So we can show a lot more during the case. Now he's holding the targeting button, bringing everything down. Perfect targeting doctor remaining armed. So we're gonna go ahead and quickly dock here. I'm just gonna put my air seal pressure up a little bit here. We had it down. I need my bipolar. Now, I'm just going to shout out to my team that did we troubleshoot the grounding pad situation yet is Dave around. I just want to see if he's able to give us an update. So then we kind of fan out the arms just to make sure that you have enough space. The camera is a little bit close to two. So we're going to move it over to three, a little bit onto that side. I was standing on the court and now I'm just going to create some clearance between these arms. So there's a clearance button here. And so I'm going to drop that down being mindful of the knees when you're in lithotomy here just to continue out that fan. Ok. I just bring the instruments in. All right, we're going to go ahead and bring the scissor in. Perfect. And while I'm here, make sure we're burped, bring this one, I'm gonna bring our progress in and I'm just gonna try to see that as well. Come on in. Just see. There you go. Oh, great. Awesome. All right. We're good. We're all burnt. That's just lifting up this just to give it a little bit of extra space and take tension off the abdominal wall. And we'd like to make sure that we tweak everything that needs to be tweaked now, so that we don't have to do anything during the course of the surgery. So I've got my arms spaced. I've got lots of room. We've got the cables plugged in and we're ready to roll right. And at this point, the only thing that we'll need at some point is potentially some suction needle driver at some point to close the vaginal cup and then, and then suture. In this case, we use a barbed suture to do that. But I'm going to go ahead and get started. And I don't know if you remember earlier, I mentioned to you all that we were having some issues with just getting the grounding pad to adhere to our patient. So if you're wondering why you won't see any energy on my scissor, it may be because we haven't been able to troubleshoot why our grounding pad is not working and letting us activate our monopolar scissors. But nonetheless, we will improvise and we will, we will make this, make this work. We need to see what's going on with our air seal gas. Can we, uh, give us one second? We're gonna see what's going on with our gas. We get a new tank for the gas. We were troubleshooting so much. We used up a tank. All right. So give us one second here. But maybe we can field some questions while we're getting, getting the gas to. Yeah, there was just a question about, um, the, the arm and the ally when you guys are introducing it. Um, what is causing that additional range of motion? You know, why are you able to get that broader range of motion? Oh, ok. Well, for, I don't know if we can, uh, go back to this view here, but while we're getting some more gas, um, the range, the additional range of motion, I don't know if you can appreciate this on the, on the links is they're a lot smaller than they used to be and there are a lot more of them. And so that's what really got rid of a lot of that dead, dead zone that you would run into. And it's just, there's a little bit more link that you get. Like you can get a lot more reach. I think the other part of this also is the cleaning of this instrument used to be very specific. And now you can use kind of like alcohol, sandy wipes, everything. And so they don't get sticky in between. So you have a little bit more range of motion there that you're not having to kind of forcibly move the links a little bit apart. It doesn't, it's not going to get gummed up the way it had in the past. So you're going to get a lot, a lot more range of motion. And then the other thing we can do is while they switching out the gas, as we can show you what the Drake looks like with, if you're going to another manipulator. So let's just take this one off. There's also, there was a question that came in if you don't mind leaving the linear on for a second. There was a question that came in from a delineated user asking that in the past when they wanted to fully retroverted the deline, they had to separate it from the ally. Can this fully retroverted? Still stay attached? There you go. That is fully trover still, you're still, you'll notice that the full of this didn't change. So you're not like swinging the uterus in the body as you do that, you're actually able to control the movements and spin it on its access without giving a full swing of the entire. See how this part is your colpotomy and that part never changes. Yeah. And you're just rotating it like this. So it can be very delicate internally. It looks more aggressive out here. But that's just to give you that range. And that's really key because, you know, if you're trying to see the anterior cul de sac really well, and you're doing a bladder dissection or let's say your bladder is stuck by being able to flip it like that and then, and then push it in like this kind of retroverted and then pushed in. You're going to see that an interior cul de sac a lot easier, right? And we do that a lot when we're doing either conventional laparoscopy or robotic surgery to give us that view. But let's take a quick moment to just show the other manipulator real quick. We can take this drape off. So are we good in the gas? So then there's a little thing, you just pinch it slides right off. So this is the, the white adapter and that's gonna go on the, on the arm, you grab the little tabs, same concept, little door here that opens. There's a nice little key, as he mentioned before that shows you which way is up. So just like you see here, there's the side here that matches the roomy tip. Oh, sorry, the, the arch, right? So we're gonna use the arch, it's going to be positioned this way and then this is just gonna sit right here. There's like a little groove and it just clicks. Right. Yeah, it's kind of honestly, it's like a tactile thing. Uh, I always say I tend to jet it in there because I just feel it and then I just put it in there but it can be a little bit finicky. I'll give you that. Uh, but you know, whether you're just using a roomy tip to, like, for a conservative surgery where you're just doing fertility sparing type surgery. You can, I typically use this. Um You can certainly put a coefficient on here if you want to do a hysterectomy Pei tip, like a sacred tip certainly works fantastic on here. So a lot of different tips that you can use. And then of course, if you're using the room two, you just rotate it, sit at the corresponding image here and then this one is a lot easier to, to, to know because there's like grooves to know where to place this and that's it. That's it. And of course, you have not only do you have this movement, but you also can get some articulation at the distal end as you know, with the traditional roomy two. And of course, you can put a roomy tip on there or as I said before, if it's not a roomy tip that you're using by itself, you can use a roomy tip with a, with a coefficient. So I think hopefully that answers folks questions. There was another one that came in just while we're setting up, came in from our team in Rockford, Illinois and they want to know if the Ally two that's on the bed rail is placed, seal or at him on the bed. I'm assuming that's to the bed, you know, to the stir up. Yeah, it's, it's cephalad to the bracket that holds your stir up. So, um, so that's, that's what, uh, that's typically where you want to place that you don't want to put it in front of, in front of the stir bracket. Yeah. Ok. It, we will drop the pressure a little bit here. Hopefully we won't chew through our gas too much. All right, let's get started. Ok. So I don't think we have. So if you, if you, if you're tuning in now and you don't see monopolar activated, it's because I can't seem to get the ground to work on the cadaver. So I'm gonna demonstrate some highlights here in terms of how we kind of utilize manipulation positioning, not just for hysterectomy, but for other types of surgery. And then we're going to try to see what we can get through here in the next half hour or so, in terms of just important things to keep in mind when you're doing your surgery. And hopefully, we can demonstrate, demonstrate that just with some cold scissors and chain is going to go over some of the things that she's doing at the bedside and then hopefully, we've not done this before on one of our webinars. But we'll see if we can create a coot toy without any heat. So we'll see how that goes. We'll see how it goes. All right. I'm mostly here just to kind of demonstrate the motions a little bit and I can kind of demonstrate it a little bit higher. So you can see, but you really don't have to have someone access to this view here on this camera or there is standing in the, there is a camera. What I'll do is I'll kind of move this way a little bit after I position. How does that look? Is that gonna work? All right, great. And we thank everybody for uh sharing with us as we try to like give you the angles and, and troubleshoot and kind of show you the things we want to show you. So can we go? Um Are we losing guest? All right. Gotta love life surgery. All right. That's why it's a good thing we're in a simulation setting. All right. So I've got all my arms here. I'm using a 30 degree scope now, you know, for the sake of demonstration, this is not a, you know, we, it's rare that we get a small uterus like this to work with in our practice, but it'll be nice to just be able to demonstrate some things on this. So I'm going to just start by saying that this is a great tool. Notice that is not doing anything and the uterus is just sort of parked. And so if you were to hypothetically want to work in the post year cul de sac, I'm 30 down. But what I'm going to do is I'm going to just go 30 up right now and I got a much better view. So if I wanted to excise some endometriosis here, if we were doing a dissection, like in a sick or poop pei, I really have some great perspective here. But what I'm going to do is, and again, we have a very small uterus. So we had to be very careful when we placed the manipulator not to perforate but Jane, if you can show me deflect it over in, into the patient's left, I just want to show you like what like if we were to open the retro meum, for example, like how that actually helps you the position her, right? Because I she's got nice tension to the contralateral side. Now, granted this uterus is so small that even our 2.5 cup is looks very large. But you know, I'm going to just open this coal because I don't have any, any scissors that are, that are working with heat. And I'm just going to open this along the length of the, the up to the pelvic rim and it just shows you that you can with the aid of tension like this, I'm trying to be careful not to pop through the through this window here because technically, that's just going to create a window on my IP I technically want to be more out in this area here to try to develop my space here so that I can try to, you know, if you were going to find your, this is really technically where you want to be. Now, you know, I don't want to be 30 up at this point because I can't see as well. So I'm going to go and I'm going to go 30 down. But again, this is why, you know, when I do surgeries where I'm just working with a P, for example, I don't have a fellow. I don't have a resident. I just hook up the ups and then I just, you know, start my, start my dissection because I can actually, you know, see really well because I have my automatic retraction, right? Like my, my, my, I call it the iron intern. It's never going to get tired, you know, that's what we sort of nickname it. And I just, again, I don't have any heat so I apologize for that. You can take the round if you want at this point. I didn't, I opened it from the round to the Pelvic Brim and that's if you were, for example, not doing a hysterectomy. Now, we will be doing a hysterectomy in this case. So typically you would want to take the, take the round ligament So I'm just going to cut through that here. And right now because it's a small uterus. You don't really need to use your 3rd 4th arm, but it is available if you wanted to. Now retract the round ligament just so you can see a little better hold the tube out for yourself to let you do a self inject me. There's a lot of benefits for it, especially when you're learning and beginning on this, you should always have your fourth arm that's dr or telling me I need to help myself and use my third arm there. So I'm doing that right now and I'm almost down to the cup. But, you know, again, I'm just going to kind of open this up whenever I open the retro parent, I, you know, my advice to you is if you're going to do that is don't be afraid to open it all the way up to the, you know, to the pelvic Brim because, because that way you can really reflect this open much easier, right? That you can really see in here. And I'm just trying to do very careful blunt, the section, the tissues in this cadaver are so fragile because it's, it's a, it's a small cadaver. Everything's nice and thin, um, almost see through what's right here is your urinator coming into view. So you're going to start to see the here coming on the pelvic brim. I'm just trying to, I'm just trying to clean this off. And so I don't have any heat, but nonetheless, it, it, it's opening up pretty nicely. At least it's bloodless. Yeah, that's true. That is true. I'm going to open this up just a little bit more because it just lets me kind of open this a little bit and you can see a little bit better. But I think Taita was pointing to you that you can kind of see the ureter right here. It always looks like a piece of linguini actually in a cadaver because it's flat and it's not vermiculation. So, but it technically, it is going to, it's going to cross over at the bifurcation of that common iliac, um, as it goes to internal and external and you can see that here and I'm just going to leave that ureter attached to the, you know, to the, to the medial leaf of the Perrine here and you can, you can see it right here. That's, that's your ureter right here. Can you see that? I know it doesn't really light up that well, but that's it right there. That's what you're in. Cha, it has the, has the, um telestrator on. I don't know if you can see the telestrate line, but there's the, there's the right there. And again, you can see when you go all the way to the pelvic grim how that really helps you. And of course, you know, you can always retract your head neck So this way, you know, whatever you need to do with your, with your additional arm, I'm, I'm going to create a window underneath here. You know, if you're going to take your IP, it's always nice to have a lot of running room here so that you don't take it too close. You need at least two centimeters back from the high to make sure you don't end up with a remnant. Right. So, because there's been studies that have shown that you can find ovarian tissue if you're much closer to the ovary. You know, a lot of people like to hug and pray and like we hate that you want to do that. So even for risk reduction purposes, you know, getting as far up the IP as you can. Yeah. And so this is your IP ligament right here and this is where you would seal this, whether you want to use a bipolar or you want to use a vessel seal or whatever you want to do. This is where you would take that. And so I'm going to go ahead and come through that. I don't have any, you know, I can seal that with this obviously, but the bipolar works, but I don't have any, any monopolar, but certainly once you, once you bipolar something, you can certainly just cut it cold. There we go. So we have our neo freed up and then normally what I do is I try to have the uterus position so that it's more like in a mid and pushed in over to the left. So I can, you know, see on this side, um develop this poster leaf. I like to see the broad ligament separated, don't you? In terms of, I got to stop myself from stepping on the pedal, its force to habit. Um All right. So I'm going to come back to this, but you can see that, you know, we have the side wall open, we got our IP with nice pedal here. Let's go to the other side. I'm just going to demonstrate some things. I'm going to basically do this hysterectomy down up to the itself and then, um chain is going to show you some tips and tricks with how we close the cuff and the value that the manipulators give you when you're, when you're doing this, using these, when you're doing a th so, um, any issues with the range of motion that we have up there? No, I mean, honestly, the, the I'm putting minimal effort here to do any of these things every time you ask me to park it somewhere, I just push it and leave it. It's holding pressure too. Yeah. Can you talk about like the, the issue with the legs? Because I think that sometimes you know how you and I harp about like making sure the legs are positioned properly because you can see how they're positioned well here for good use of the the up. Yeah. So I will say that you really need to make sure that the patient's legs itself are not hyper flex hyperextended. And what's really nice about the UPS is it fits under the groove here. And so we have right here the, the stir ups, we're able to kind of make sure that this patient never rotates outward. And so what's here with the, with the manipulator itself? You can just grab the handle and I can get full range with the legs. Not even an adding point being a problem. So you don't um you don't want to be abducted. If you're abducted, you're going to lose that space. I mean, if you think about it here, if I bring this leg in, I don't know. And then if I bring this in, you're going to hit the manipulator here and you're never going to be able to get that good space. So you just need to make sure that when you do this, your hip, the legs itself are in that kind of need a shoulder position. That's right. And then making sure that you're not hitting your, also the the elbow of your robotic arm because you know, sometimes it can rub on the knee cap of the patient or too. So just be mindful of the drapes as you do this and mindful of where you place it and to be quite frank, you really don't have to move legs very much. Once you place it the first time, once you're docked, you can drop the legs down once this is in and then you're set. Yeah, I would say alluded to this ankle, knee opposite shoulder, if you kind of have a little bit of hip flexion, I don't know if you can see me, but a little bit of reflection. Ankle in the opposite shoulder, slight external rotation that's really going to open up, open up the legs in a way that's comfortable. It's not going to put your patient in any kind of an awkward position. But that's like a huge thing that I just, I'm glad I remembered it because that could certainly falsely give you the sense that you have a limited range of motion when you really, when you really don't. It's just really, especially when you have a bigger patient that and also really important is making sure that the buttocks and the per are properly positioned at the bottom of the bed. If you don't have the bottom positioned properly, right where the sarum is fully lined with the base of the bed. But the buttocks are kind of slightly off. You're not going to be able to drop the wrist of this actual curve of this manipulator all the way down and you're going to limit your ability to Antivert. You're not gonna be able to push in as far as you want to, particularly with like a heavy multi fibroid uterus or even like endometriosis where things are more rigid and fixed. And so it's really important. Positioning is everything. Docking is everything and then the case should be smooth. Yeah. No 100%. Um Somebody asked earlier about, you know, the ability to rotate the uterus upside down and if the buttocks aren't far enough off the bed, you are going to have trouble and forget about even just using the ally two ups or any Ally. It really gets difficult when you're hitting the cushion and the buttocks have slid back. So, you know, you're going to not be able to move your manipulator in general regardless of whether it's hooked up to a UPS, if the, if the, if the patient slips back on the cushion. So yeah, you can actually, you, you were able to really flip that upside down and maybe I'll step out of the way. I think I might have been blocking it. It, yeah, I'm being ginger because this uterus is little and I don't want it to poke through. But basically, if you notice what same thing that Arnie had mentioned before, you hold this, so I'm holding this piece here and I'm holding the handle. And if you watch the colpotomy cup, the colpotomy cup itself is not going to move very much and there it is, it's fully retroverted. I have a great view. Now, I can push it in if I want to, I can pull it back out if I want to and I can still give motion all the way back in. Uh, there you go. I can go. Yeah. And then let's see what it looks like when you park it, see it's like upside down and, but, but it's upside down successfully because we're, we're, we're not retracted back onto the bed. So I think that's key. All right, we have two questions coming in. Both related, one was related that you mentioned before going from 30 down to 30 up. Um You know what exactly steps in the procedure? Are you doing that? And why? And the second part is how do you do that without removing the scope? We're getting the s out of the way. Oh, yeah, I mean, the beauty of the excise system is that you can control it from the surgeon console. And literally, I use, I mean, now you're a 100% 30 degree person. I'm 100% 30 degree. They open an A zero by accident. Yeah, you use the 30 wherever you feel that you need an improved vantage point, right? So actually, if you use it all the time, you don't even realize that it's a 30 because it's so seamlessly adjustable. I guess you should say, I honestly, I feel like I can't operate with a zero anymore because I'm so used to operating with a 30. But like, you know what, I was looking in the retro perm, you can just go to go right to the surgeon console and there's a, there's a, a touch pad here and there's a 30 up 30 down. So if I look inside here and I want to, I'm 30 down right now. If I want to go 30 up, I just hit 30 up, goes 30 up and then I just readjust. Right. So I'm going to have to write the uterus. You just cut your fingers as you move so that you don't end up moving your instruments as you change the 30 degree scope. All right. So if you could tilt it this way a little bit, yeah, that's great. So, what I'm gonna do now then is just talk a little bit about, uh, if you're not taking, let's say we're going to do a his and, and we're, we're not taking the next. Um, you know, certainly there are a lot of things that you can do to help yourself if you're, if you're, um, not going to take the next one of the things I'm a big advocate for is trying to preserve this, this sort of anatomical relationship of and again, not the tube, but the utero variant and the round ligament, right? I try not to undermine this so that when I separate this from the uterus, this allows the ovary to retract. Now, what I'm going to do is I'm just going to reflect the ovary on the ova, the tube to the corn you love because we're going to, you know, we do our opportunistic self inject toy. So I'm just going to, instead of leaving the tube attached to the ovary for the sake of time, you know, I'm going to just, I'm going to enter in the, in the miso south pinks here. So this is your meso south pinks. And I got the, I got the third arm here giving me some traction. And if you notice his third arm is wrist up and out of the way, that's how you don't have collisions. That's how you give your range of motion to your monopolar scissors. And you're never going to have any effort exerted on the actual instruments itself. So I make this opening in the mess. If I don't have a third arm, I basically do the same thing, right? But then what I do with my scissor is I call this a purse handle because then I just kind of use this to, I'm retracting for myself. So I can, as I open the miso cell pinks distally approximately, I end up naturally skeletons this. You see that now I'm to the distal end and I can just buzz this, you know, and I can cut this. So, so if you release this part first, it's a lot harder to manipulate this tube. But if you leave a handle, you can do that if you don't have your third arm. Now, I got my third arm So I'm just gonna grab that and come here. And so there's that and then now it's a lot easier if I want to reflect this towards the, towards the uterus. Right. So I'm just going to cut this again. I would normally be using some heat to do this, but we're just, I apologize. This looks a little bit awkward and that's because we just don't have any working energy on the scissor, but we can still get the surgery accomplished. And so I have my tube here and I just want to demonstrate for you then with the tube reflected, I've got access to the utero variant and the round ligament, which is right here, right? So I'm going to leave these two things. I'm going to kind of seal this like this. I'm going to drop this down because I don't need that here. Sometimes, even if you like introvert the uterus and you have a bigger uterus and this very small one and you park it, the tube will just stay up to the anterior abdominal wall. Yep. So, you know, you'll, you'll desiccate this, you'll cut through here. And essentially what I'm trying to do as I'm keeping this sealed here is I'm preserving this sort of attachment here, right? Because there's no reason to, if you're leaving this behind, there's no reason to separate this. And the reason I do this is that especially when you're dealing with big uteri, for example, as this stretched out round ligament is released. Now I'm in the broad ligament here, which is what I love to see that, that, that wispy tissue here. Notice how my ovary is naturally suspended off to the side, right. So I'm just going to, I usually just come in here and I use monopolar heat, but I'm just going to cut coal. And you can see here, I'm separating the anti and poster leaf of the broad ligament and that's so that I can actually allow access to this poster leaf. So I can incise it towards the coot cup and lateralize my ur right. So normally we we'll position this in such a way. So I can see going into the anterior cul de sac. So if you can give me a little bit of a mid position, but over to the patient's right. That's great. So now you can see that I can drop this tube down here. This is the view I want. Now I'm 30 up. So I may want to go 30 down. I don't know what you would do in this circumstance chana, but I'm going to go 30 down. That gives me a better view, see same concept. So 30 30 down, I have a better view here because this is where I'm working, right. So I'm going to work and develop my bladder flap. I like to make my bladder flap from a left to right, just because I'm, I'm um I like to use my scissors on the, on my right hand. Um, even though I'm a lefty aide de so I, I cheat and I use my scissor in my right hand and I keep my bipolar on my left and I use that so I can lift and undermine like this and help develop my bladder flap. What do you do? I kind of give what the defense gives you or offense gives because I just want to make sure I can get into some of these big old uteri. But same idea. One thing that's really nice to note is that when you do push in, you're into the broad ligament and you've made that space, what's nice about the ups is if you push enough pressure, a lot of the new mode just starts to fill in the broad and then you're going to end up kind of developing these, both these spaces almost at traumatic and then you can follow the anatomy and follow that space as well. So this is where, you know, you leverage your instruments in surgery. So, you know, this is one of the most beautiful things to be able to see is your coot cup, right? Like, and the goal with T is to make this coot cup look naked. That's what I always say to my trainees is that you want to see a naked cup because you want to be able to see that there's looks, if it looks like there's a lot of tissue here, then you probably haven't done the dissection completely and you probably have some bladder attached or maybe you have like bowel pulled up poster. But the key is, I'm not sure why people often seem to gravitate up here to make the bladder flap. I like to make the bladder flap right over the fattest part of the Colpotomy cup when it's pushed in. So we always want to make sure that you're communicating with the bedside assistant. Now I have the luxury of having my partner, you know, doing manipulation. So she obviously knows what needs to happen. So she's already got it pushed in. But you can see how all that tension helps and it definitely helps getting that tension too when you're doing a difficult like o like obliterated anti cul de sac cha. What do you do when you're doing those cases? How do you leverage the manipulator? I mean, I like to push it in as far as I can and give it a slight movement, you know, left and right. So I can try to, especially in our obliterated anti cul de sac patients because you know, the Cesarean numbers are so high that you can actually park it. And really see, I also follow right on the bubble of the cup. I feel like if you work in the internal os, all you're doing is creating more work for yourself because then you have to drop your bladder that much further when you drop it on that natural area of tension, that bladder will just almost push itself away from you because the Colpotomy cup will enter the perit even deeper. And, you know, one of the things I look for you see this view right here, you see that sort of, it looks like, um, cotton candy, sort of like, uh, like, like champagne bubbles, wispy tissue. That's where you want to be. I, I love that view because that's the view that you want when you cut here. What that does is it allows you to get into the bladder reflection, um, very at traumatically without getting into a lot of bleeding, right? So I hold the bladder edge firmly like this, elevate. Look for this, especially if we're not dealing with a super stuck bladder, you'll see this, you know, and then notice that when I lift it, you see the bladder edge now, right? And this slides down really easy. And I like to make my bladder reflection just past the drop off of that car poom cup. Um, because there's a fest here and then that lets me know that I have adequate space here. So, you know, these principles that we're talking about, it doesn't matter that this is a tiny uterus because from a technique standpoint and a a nuanced perspective from principles that we practice in surgery, these are the same things you're going to do whether this uterus happened to be 20 weeks or in this case, a normal sized uterus, you're going to want to develop these planes in these areas and then use what the pneumopar helps you identify to open up these spaces and then you end up and avoids you getting into these bladder pillars, then you agree cha them. Yeah. And also like thinking about cuff closure if you're doing this with trainees too and creating that adequate space, you know, they can even use their third arm to hold that bladder away. And then that the cup is so visualized that closure of that cuff becomes so much safer and you can rest easy, know that the bladder hasn't been incorporated fistula issues, any bleeding issues, even kicking in and pulling in your ur or having to go dig out the ureter. If you have any issues with your systems, it just benefits you to do the same thing every single time. Reproductively. This is, I love this view. We see the bubbled edge. Now granted this is a really thin vaginal tissue, but you want to see the pubic cervical faster when you come around. And so again, you can see the bladder flap is made, you know, very nicely and you can, you can push that down gently. I'm going to now and again, this is 30 30 down. You can see what the look is if you go 30 up. Um this is what 30 up looks like. Um I, I want to develop my broad ligament. So I'm gonna go back to 30 down and I'm gonna look in here and I like to like hold the poster permiam sweep, you know, I get rid of some of this, you know, fat that's here. Normally I use heat to do this, you know, because my yog is going to be out here laterally. So all I'm doing is as chain is naturally giving me tension. All this is I'm just going to release this post tier leaf of the broad ligament. And that's the beauty of the cup. The cup helps define that for you. That's why I, I can't imagine ever doing TLHS without, without a cup. Now, I'm just going to trans illuminate here. This is just sort of fat that has nothing to do. There's no vessels in here. I'm just releasing that. I want to skeletonize my vessels, right? Sometimes you'll see a little bladder pillar here which you can buzz and you can just kind of buzz it and peel it and push it back. Um Just make sure you don't get your uterine and Arnie. If you have like a big uterus, how would you use your third arm to help you here? Well, if I had a big uterus, what I would do is I would basically use my progress and I call it hugging, I would hug my uterus. I would come in and I would hug it and, and and pull it over and I could even, you know, small uterus, you could even use this to help yourself because you can kind of pull things over. Um But yeah, I would hug it and pull it over so that I can see this. Now, this is all like stuff that you normally would be just extraneous tissue, make sure you don't have any vessels here. It looks like there may be a vessel here. So I might, you know, might desiccate this. But because I'm relaxing this, this is right off the cuff, I can seal all this and then release this. It's, it's lateralizing my der further right. Here's more of this sort of extraneous tissue here, supposed to leaf a broad ligament here. And basically, what I've done is I've got, it looks like I've already transected my uterine right here because it's so small. But normally you would take your uterine right off the fat part of the cup right here. It's all skeletonized and you just want vessel right here. So that's basically my vessels. It's not, they're not very visible in this case. But I like to, you know, make sure I seal it on this side like this and I do it right off the fattest part of the cup. And I don't go below the, below the edge of the cup, right? Like if you, if you start heading this way, sealing things, you're going to get your right. But if you're right on the cup and you've skeletonized, this is your vessels, you're just gonna, you're gonna seal this and it's a tiny vessels. This is a 2.5 cup. So if that kind of lets you know how small this uterus is, and then I'm just going to, in this case, normally, I don't cut it until I do the other side. But since we're here and it's a small uterus, I'm just going to cut it just to show you're going to cut your pedicle and you're going to let this vessel release. I'm almost already, almost in the tissues are so thin. But that lets this lateralize. You want your uterine notice my uterine is lateralizing right here. You don't want it to be on the corner of your cuff because you want to be able to bring that around and do your coot without running into your vessel. So I lateralize it off the corner of the, of the coot cup here and let it slide. And that keeps that nice and nice and protected. You have a clear peta you can grab. If it starts to bleed, it's not going to get in the way when you make your crot cause bleeding. And again, you're just following the anatomy and that's where the manipulator and again, changing just has the thing positioned it and you're able to do what you need to do. I will say, you know, it's super important when you take that uterine artery to make it truly its own peta make it like dancing in the wind so that if you ever need to isolate it, you can really just burn it again. Say the tension from the UPS is released, it starts kind of oozing a little bit. You can literally just grab it and burn it and you know that you don't have the go to the other side question that came in just as you're working on the vessels is this is a smaller uterine? Right. Right. Do you have any tips you would give in particular if you're tackling large uterine and uteral ovarian vessels, you know, and you're dealing with a large uterine, any different tips from what you're showing now, I mean, we do the same thing we skeletonize. We find that, you know, I like a fine dissecting. I use a long bipolar grasper and a monopolar scissor and I like the way it dissects. And so we just isolate the and then we don't, we don't rush taking the pedal, we take it, we take it in sort of sequential bites and we're able to control it. Alternatively, you can use a vessel sealer, which, which, which obviously for this demonstration to be a bit overkill. I think with one vessel sealer swipe, I think we have this to be done, but you can certainly do that. But I like the finesse of a nice sector. So I can kind of develop those planes. What do you think? I mean, these vessels are typically in Gorge. It's basically what you need to know. You're going to have a lot of pelvic congestion is the term, right? And so often what I'll do is it's just sequential dissection and f duration and then cutting right in the middle of the pedicles. So you can catch it if they do end up leaking and then shrinking down the size of the vessels, like decreasing the caliber. So really just intentionally shrinky dink all the way down and then cutting it in the middle and you won't have to worry about it. Yeah, I like the term shrinky dink because that's basically what, what, what, what, what we're doing. Let's get the other side done. I'm going to quickly release this here and then see if I can make a popoy and I'm going to tag you in chat to talk a little bit about like some principles with cff closure that we want to take advantage of when you are doing your, your tl you notice I just swung the manipulator very gently all the way over with minimal effort. Here. It's parked, he can see both the anterior poster aspect of the cup and I'm not doing much and he's sitting here, the patient console is here. Yeah. You know the ally, how are we doing on time? We're at 8 25. 0 God. You know, the the ally is great for if you have a dual console because you can, you can set things and as the attendant, you can sit with a trainee. Uh So it really facilitates to me even more. So the dual console, so let me um so we would seal here. Um The bladder is nicely taken down already and I'm just going to cut this already just real quickly because I didn't realize that the time goes by. So darn fast question while you're doing that just came in from our team in South Texas said two things. First, they appreciate Dr Aros football reference. The second thing was, was what position and what degree of Renberg are you using here? And is there a standard that you always use or does that differ based on? That's a question, to be honest, I feel like we're all trending toward more obesity in patients, you know, keeping the pneumo perit as low as possible for ventilation and also the T burg at the lowest amount of tea that you can tolerate to get the bow out of the pelvis and see what you need to see, you know, with the tables, you can see kind of the degree of the rende you have and it's like, you know, about 30 degrees or so, even less if you can tolerate it. And we have patients where we just kind of work with the anesthesiologist in the beginning kind of temporize where is the sweet spot for ventilation where we can see the best the manipulator will do the rest and then we can use our fourth arm to park things away. So, yeah, less is more. Right. Right. 100%. I mean, and we also like, what's our air seal on it? Like it, it's not 15, but we could probably drop that even further just for the sake of demonstration, we could probably drop it down to Lake 10 even in this case because, you know, it's, it's you can run the new and you can keep your T bird pretty minimal. In this case, you know, question on dissecting the Urs that came in. Do you find and dissect Urs uh like you did on the right side or you or do you dissect a broad ligament without dissecting the s like you did in the left side and every hysterectomy, especially, especially if you're with, you have a big uterine. Yeah, if you have a big uterus, it's all based on what the anatomy is presenting to you, right? If you're dealing with a very difficult case where you have a lot of adhesion, scarring, bad endo stage four, endomyosis or big uterus, and you need to see that der then you may do a uteral in order and then even isolate the uterine at its origin, you know, but typically, if it's fairly straightforward, you go to the other side, chana. Um I'm going to, I'm just going to do what I did here, which is develop the broad ligament that's gonna lateralize my, I'm, well, everything's lateralized here. Right. I think the most important thing is you need to be able to comfortably do it even on an easy case or a hard case so that you can find it if you need to. And so he's gonna start trying to do the coot and I can chat while we do this without a little bit of cold. We're just cold cutting it, but I will. Ok. So there's a little balloon here attachment on top of the manipulator itself. I prefilled it. This vagina is very small. You may want to be careful to this tissues tearing without me even doing much. It's so fragile. So I'm a big believer of doing the kopy on the bubbled edge. Um because it keeps, it gives you a nice uh cuff edge when you're done. Um So she's doing the new balloon and I don't, we don't inflate the pneumo until we're ready to do coy because I don't like it to distort my anti de sac. So I'm just gonna reach underneath here. I'm just going to follow this. I have really nice sharp um My scissors are very sharp today. So brand new monopolar hot hot shears that are working coal. So I'm just going to keep cutting around. Coming back to that question. I will say that you just need to be able to find it, you know, when you have a small uterus. It's actually like the more important that you know, where your ureters are because your round ligament, your uterine, your, everything is a lot closer. So if you do this big chomping bites and just kind of hug the uterus, you're more likely to damage something. But if you have a bigger uterus, arguably things are more lateralized because of the bigger fibroids and you're able to see into that parent a little bit better and transparently even view it. But the ters tend to be a lot lower than the pelvis. But I would say that, you know, if we're doing ovarian preservation surgeries, I actually don't find the Ator, you know, very clearly by opening up the retro para every time I personally feel there's a benefit to keeping those spaces closed, swing to the other side. And, you know, if we had heat, I would be going very quickly through here tolerating a little bit of bleeding if I had it. Um And hopefully people aren't annoyed by the little smudge mark I have on my scope, but that's OK, we can drop it down a little bit. Um And I'm just gonna, now I have it on 30 down because I was trying to see the, an cul de sac. But I'm um because I'm trying to, I'm trying to just see this part of it right here. I'm, I'm not pushing in as much because I don't want to naturally just this. Yeah, because the tissues are really, um, really weak. I'm gonna dynamically hold it for you here too. A little bit because we don't have the heat here while, while you're doing that. There was a question that came in on any tips on developing the bladder flap when, if there's a lot of scarring from previous C section. Oh, yeah. That's a good question. Do you want to take that one? Yeah. I mean, I feel like that's probably now becoming one of my favorite things to do just from like, you know, keeping things interesting. But ultimately, you know, you can get scarring as little as a partial obliteration to uterus fungus all the way to the um like small uterus even yanked all the way up high and it's plastered and, you know, the key is then hopefully at that point you have posterior access. So you do everything with the intention and I'm going to just park this up for you and you can see 30 I'm going to flip, so I'm 30 down. But if I want to see that really well, this is the beauty of the of a 30 scope on the, on the robot on the X I is if I go 30 up, you're going to see that view really nicely. Look at, look at that view. See that's my view at a 30 up on my poster coot, let me go back to 30 down. So you don't see it as well, right? But as soon as I go to 30 up, you can really see nicely and I can see now both ends of my, of my, uh the blue, which is like the, you know, it's like follow the yellow brick road, I would say follow the blue cup, right? So, and really preserving your utero saris here, which is just such a nice thing. And a poster vagina. Exactly. And you mentioned before about when you inflate the a cooler balloon and you wait until it's just before the coy. Um Do you still use the ACLU balloon? Um, even if you're using the air seal to protect. Oh, yeah, there's no reason to be sputum into the, into the room. So she's probably going to unhook this. Basically what I'm just gonna demonstrate here. I've now just brought into a bit of a neutral position and I'm going to go ahead and just undo the door of the manipulator and then I'm just gonna hold this manipulator and I can honestly, you can just move it out of the way. It's completely out of my way. Now, I'm just gonna slowly bring this out. Do you mind grabbing me a lap pad just for the, just so we don't have it all come right here. There you go. Ok. So all I'm gonna do is I'm gonna pull this this out and then it should all just kind of come out together in one piece. Oh, this uterus is so it's so small. It oh I drop this in the bag. Give the specimen away and I can put this on the table just so that's a little bit more. I'm gonna tag you in after you bring in the suture. Let me grab that too and um give me a, give yourself a needle driver. So we just want to show you what the cup closure looks like If you've got, if you've used the coy cup to your, to your advantage because you, you, you have nice edges, right? You just have to make sure you don't over distend the vagina. You know, you don't want to stab into that with the needle. Um I'll let you, um, let me switch out that needle driver while you're doing that. A question came in just about the foot pedal. And was there any change with how the foot pedal attaches? Is it? Is it detachable? Now, from there was a request that come that be detachable from the allied two unit? Oh, yeah, that's a really good question. Actually, we didn't share with you that nuance, but maybe I can, I can if we can go for two seconds here while cha is getting situated in the robot because chain has got to adjust the settings because she's got the nice baby bump. So, um, if you look here underneath, you'll see that the, the there's an electrical plug, but there's also the now the pedal comes with a detachable plug because that was an issue in the past where if something you'd have to send the whole unit back, now, you can just take this off and send the pedal back by itself. So that's been a huge, huge plus to be able to detach that plug. So I think that's a very nice addition just from a maintenance standpoint. So one thing you can do here is say you have a particularly obese patient and you're struggling just with visualization. I'm kind of, I'm always 30 up when I close the cup here, it, you, you don't want to like look down, let me show you what 30 down looks like. It's, it's not as big in this pelvis just because she's small. And so you can see, but now you're kind of like looking up into the bladder and kind of looking up into the cuff and only seeing the post to your edge. So I really like to set it up as a 30 up view. This is helpful. So you're not kind of staring at the rectum and this just gives you a great visual and this patient is not particularly big. So I don't really need to have this parked up, but I do that with trainees every time I do this, I always grab the mucosa here, making sure I can see the mucosa on the other side. Then I'm going to go. This is where my uterine artery is here. I'm going to go into the corner. My bladder is fully pulled away here. I can sometimes use the back of the bubble of my needle to show it then to go, push right through here and just load it as I'm right here. This is small enough, but I'm gonna go through the motions. I would normally do. I hold this load it as I'm right here, pull this through following the curve of the needle, grabbing the other corner and now I'm just going to drive this through, making sure that I get the uterus, take Ros in that post perm and that'll help do for suspension. What's nice here is that I just kind of follow this. I go back, I'm keeping my needle this way and you can go past the camera here. You're not gonna hurt anything. This is all dead space here. Safe space. Here I go as far as I can. Then I let go and I pull back and I just thread this all the way through until I get that corner of this. And we're using, you know, the barb suture here just for closure of the cup. It's pretty fast. We have a pretty long suture here for a 2.5 cup closure, but it's just the standard, you know, 12, 9 inch, whatever you feel comfortable using. I run it back twice. I run it back the other way. Now you just go through this loop here. I then load my needle and I just pull this here because it's a lasso. You don't need to really like, set it. You get this through, pull it, lock it in the tissue. Even if you're in your loop and locked here, it doesn't matter as long as you're conscientious of what you're doing. I hold this up. Show myself, I have the mucosa, the bladder is so far away here giving myself a little bit of slack, pulling this through. And just for the sake of time, normally, I would have the trainees loaded again and you know, make sure you have a good bite of the needle getting here, getting this and then grabbing that post to your per meum. Now, in order to not make sure that you don't lock, you just grab underneath, pull it through again, you can pull all the way through here. One nice thing about using having a third arm here is that you can use your third arm to help you also just for speed of the case. So you want to make sure that you never pull in that lateral aspect that you really lay that stitched flat and then it, it should be medial to your uterine peta. Never let it go lateral. That's never let it go lateral. That's definitely how you get a ureter for sure you'll kink it. You'll have kind of a choking kind of appearance on the system. And then you have to go dig it out and barb suture can be harder to pull out. So, what I'm gonna do now is I'm going to grab this here. I'm gonna go through the tissue. Same thing looking before here taking a peek, kind of slowing it down. So I can show the movements, grabbing here, grabbing the post to per Now, what I'm gonna do is get you load it and then use your third arm to kind of pull the suture through. So do you see how I purposely? Now? I have my right now. I have my needle already loaded and it's parked in the view. It's not going to be a problem. Now, I'm using my third arm to just do all the work that my other needle was doing. And now I'm gonna hold this here and I can literally pull this aside, drop it out of my view and I'm ready to go. Same concept now, just grabbing this here, grabbing the vaginal mucosa, making sure I have both pieces here grabbing the inside. This is the cup edge, making sure you really look in can see both sides have the post to your paum again. So what I'm gonna do now make sure I'm not locked. I'm gonna grab my needle, pull it up to the ceiling. It's out of my view, switch gears and I'm literally just gonna pull this through so that I don't have any of this stuff in my way to give it a pull. Hold on. I think I gave myself a little tangle. Thank you a lot. Yeah, I did. But what's nice about it is that you can stay in this position and then not have to worry about reloading your needle. Well, that was a little bit of a fuss. But when you pull this through, keep yourself stable, keep yourself stable, drop your needle out of that way, don't do that and then pull this all the way through until you can give yourself a nice stitch. Use this to pull this to lock it in place to make sure that you don't end up kind of laying a stitch over over each other. OK? And then you just park this away again and you come back down and you keep going your closure. So I hope you're appreciating the value of the Colpotomy cups. The Coke cup is really, it's, it's, it's such an asset in your cases because it gives you a clean vaginal cuff edge to work with minimal char an actual case when you're using your heat to create that pulpotomy. And you can see here how that really just allows you to, you know, to close the cup pretty expeditiously. And what's nice about this is that you really want to make sure that you can pull your suture and pull that from the side. So I, I personally, whenever you're using a larger suture, you can use this to kind of pull through and then you can use your third arm. However you like to, I, I have a habit of personally pulling for myself and teaching the residents to help themselves pull just because I, I have that bladder kind of pulled up for them. I have this all beautifully twisted for you guys just gonna show you some troubleshooting and then you pull this, lock it down, really? Then cinch it shut. Make sure you line up the edges come in and always use your needle driver to be what is pulling because that's your stronger suture and you're not gonna break the barbs and pull down with whatever your alternative graphs are for us is the lung bipolar and this is just a big old stitch, but we're using it for this benefit. When you grab the corner here, I always kind of use the bipolar. Sometimes you have to use the tip of the needle to dig it out to make sure that you're really getting the corner stitch closing this here. I took tiny bites just for demonstration. This is a really little cuff. You probably could have done this in smaller, uh definitely like larger bites. But you wanna make sure you're not traveling too far, take this, pull this through and then you just run it back. I have a few minutes left. And as you throw that last stitch, what I'll do is I'll quickly undock so that we can demonstrate like what it looks like on the side real quick here, Doug the, all that looks like that interaction with the stir up and you can run it and we do have a question on that. If they wanted to see where it is on the tape, you got it. One of the questions, we're gonna go ahead and do that. We're just on the question came in. Uh How do you introduce suture to the field? Is it normal vaginally? Yeah, I, I apologize if that wasn't a, a visual here. We have all eight ports and so this suture, this needle is too large to uh go through the itself and because they cut it, sorry, I'm gonna go ahead and cut it. Ok. Yeah, great. So, what we did is we just dropped it in through the vagina. So I had it preloaded on a ring force and I just had it on the bottom table where you know the all the equipment is. Then we just kind of park this here. I'm gonna drop the needle so you can give it to me. I'm gonna pull it out with the troll car. OK. Great. So he pulled out the bipolar. He's gonna grab this with uh you know, a needle driver or whatever and pull that stitch out and pulling the troll car out at the same time. Let me grab that through my work. So basically, I'm going to grab that and pull it out with my troll car. Always make sure your instruments are up to the abdominal wall and a safe point and then they can just pull out an undock with safety. Can they see this, um, doctor to find out if they can? Is that camera? Let me move this out of the way. Um, the robot went out of the way here. That camera there can see this, but you can see the interplay of the stir up bracket. Yeah, they can see that is on the front and the, and the Ally is here and I'm going to get the, see if I can grab the Ally. Well, you know, it's going to be hard to get the carrier in here, but cha is stowing this. So she's stepping on the pedal and leaving the arm placid down. So let it, let it, let it drape down. So when you step on the pedal and let the arm hang down while you're stepping on the pedal and then you turn it off, it lets the arm stay loose, which is how you want to store it. Like if you shut this off, that's going to wherever that arm is, that's how it's going. If you, if you're not stepping on the pedal, it's going to lock. So you got to step on the pedal, let it, let it while you're stepping on the pedal, let it dangle, turn off the energy, the power and it, it'll be, it'll be loose so you can manipulate it. So I'm going to go ahead and undo this so you can see kind of how we just lift this up out of here. Ok. Now we're still a little bit of Trendelenburg, but I, I loosen this up. I've got the handle. Um, I like to hold it blue, blue and I just lift it up and then I typically, you know, I try to do this in my or while people are closing, helps the nurses out and I just put it on the, on the little rolly cart. Here's the rolly cart here just so we can demonstrate it. So there's, it's kind of got natural grooves and you can just fit it right in and then the wires remain safe underneath. Then this pedal just sts under here. I'm going to lay this here right now just because we don't have the cart here. But, and so again, that bracket sits in the back and typically you want this to be forward and, you know, with like Yle ins, for example, you don't want the elephants to extend beyond the rail. This is not a great example. This is a different kind of stir up, but the yin need to end at the rail and then, then that sets your sweet spot for your ups. Gosh. Yeah. So we, we had just, I'd say there's just if we could take a couple of more questions, right? One of the questions just came in. There were a couple of ally specific questions. Have you seen a difference post COVID as we all experienced staffing shortages has ally helped you, you know, in those cases, are you seeing staffing shortages here as well? And has Allah had some impact on that? Yeah. Yeah. I mean, we, I mean, there's nursing shortages, there's all our staff shortages. I mean, honestly we, I mean, I like to operate a couple of times a month. I'll go down and operate at one of our, one of our sites where it's just me and a P A and, and I don't have a fellow, I don't have a resident and it's great. I mean, my surgical P is at the top assisting with suction or whatever needs to be done. And I've got a ups down there and it makes me feel very, I can function autonomously, but it's also just great in the, or in general, even if you have nurses there because it just frees them up to do other or just residents. Right. It also, it just helps with teaching. I mean, like you can then get on and do the teest administrations, you can stand next to the console, have them pop their head out, teach them how to ergonomically position their arms. You don't have to be locked down here where you're talking from a distance and trying to explain something that may be difficult for them to not visually understand. So I just, I feel like it really frees you up from being stuck in something that would otherwise keep you there the entire case. And again, you mentioned it earlier, like we do this sterile glove technique. We're at the console, dual console resident or fellow. I'm sitting at the other side and I need to tweak something I can certainly jump up, grab the, grab the UPS, position it and then go sit back down. And so it really does. I think, you know, if anything, it improves my ability to teach because I'm not having to be scrubbed and stuck here, I can do other things, you know. So there's a question, there's a question I'm going to take the liberty of answering today and one last clinical question I'll direct to you. The question was, is the Ally Two Ups available for sale or just the Ally one, right? So I will answer that question. The Ally Two Ups now has FDA clearance. We're going through some final FDA validations before we can make units available for human use. Right now. I would say talk to your local sales rep, they can get you a, they can get you in the queue for when it's available. So you're ready to get it first thing first and it will be coming soon. So I said we are able to do quotes, we are able to do purchase agreements and you can get in the and get in line to get it. So last question, I'll direct it both to you is um what was the explanation for making the coot closer to the bladder rather than closer to the uterus? You mean the bladder? Not the co yeah, the question said Omy, but they may, may have been bladder. Yeah. Yeah. I, I like to, I like, I just think that, that there's a tendency when you're making the bladder flap to hug too close to the uterus, the corpus of the uterus. And then you get into the cros of the uterus and it's thicker and it doesn't develop and it's bloody. So, like I said, with tension inward, you want to develop that over the fat part of the cup that gets you into that sweet whisky space that lets you reflect the bladder properly along to vascu uterine reflection. When I made the copay, your coot is always going to be made away from the bladder on the beveled edge. So I made it on the beveled edge of that Coke cup. I would either, you know, I normally use heat obviously. And again, I apologize tonight that we didn't have, we could not get the cadaver the pads to work on the cadaver for some reason, but you would use your, your, your energy along that beveled edge that's facing you on the Colpotomy cup. And if you notice when chana was closing, there's a lot more vagina to work with because you're not so close to the bladder, you tendency if you, if you make a small bladder flap, you're once you do the coy that's going to and then you're not going to know where the bladder edge is to your cuff edge and you're going to take less, you know, less aggressive bites, you're going to take smaller bites. And I think that's the risk because you're not getting in the fascia with the vaginal epithelium. I want to particularly highlight here that you're not even doing any upper vaginectomy. We took it where we took it, but there was no extra vagina that was removed. It's a little hard to appreciate here, but the cervix is just completely bare, it's skinned out. So when you do use, when you do make the colpotomy at that distance, you are not taking up a vagina, you're not leaving cervix behind, but you're just creating a safer distance for closure. If I could just insert one thing in the last minute here as take home points, even though, you know, we're working with the very small uterus tonight, I think principles that I think chain and I would like you to go home with when you're using the UPS the L I two is that it's fantastic for giving you autonomy. But certainly when you're in the actual case itself, that the exposure to traction, countertraction, if you notice we leverage that all the time to like open, open things up so that you don't have to waste your extra arm and you can see things, right. So it's great for that, whether it's a big ute or small uter whatever procedure you're doing is that exposure is key. And with that additional range of motion and reach, that really helps when you do the hysterectomy, just pay attention to the planes, open the planes, open the broad ligament, develop your bladder flap adequately. Use the cup as your guide, right? Like can't emphasize that enough that when that cup looks naked and is popping right at your face, that's like the best thing in the world. It doesn't matter whether it's a stage four endo case or a routine big hysterectomy for fibroids that is like your safety zone, right? They're seeing that in full view. Um And then it helps you with your cup closure. Anything that you want to add chain as a take home, those are all very good. Same thing every single time, even if it's easy, an easy case, do the same exact steps and don't cut corners and then apply those same principles when things get rough and you have to kind of troubleshoot becomes easy and a lot less stressful. Yeah. So thank you includes, thank you everybody for tuning in. First of all. Thank you Dr Vila Dr Aurora. This time went amazingly fast. So it's a pleasure to watch you do the procedure. Thanks again to our partners at intuitive for supporting the program, our partners at the Columbia Simulation Center for supporting the program. So we appreciate all your support as a reminder for helping with the visual and the whole thing. So yes, thank you everybody. So, um and again, if you'd like a follow up demonstration from your super surgical sales representative, please put that on there and we'll make sure they connect with you. Thank you again, we look forward to hearing your feedback and have a good evening. Good night everybody. Bye bye.
Arnold P. Advincula, MD, FACOG, FACS
Chetna Arora, MD, FACOG