Chapters Transcript Maximizing MIS For Benign Gynecology: Large Uterus Tissue Extraction Dr. Devin Garza reviews extraction of large uterine tissue as he maximizes MIS for benign gynecology. 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 30 years, Cooper Surgical has worked with health care providers to provide highly effective clinic and practice based contraceptive surgical and obstetric solutions to complement our portfolio of trusted and reliable medical devices. We have also broadened our offerings investing in the areas of reproductive genomics and in vitro fertilization. We are fully committed to helping improve the delivery of health care to women and their families. Cooper surgical manufacturers. 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Thank you for joining our program with Dr Devin Garza this evening, Dr Garza is the director of minimally invasive surgery for H C A ST David's North Austin Medical Center, Saint David Surgical Hospital, the Texas Institute for Robotic Surgery in Austin, Texas. Dr Garza is also an assistant clinical professor at the University of Texas at Austin Dell Medical School. I'll now turn the presentation over to our speaker, Dr Garza were now so happy to give you presenter privileges. Well, thanks everybody for joining us tonight. I know there's 1000 places you could be, but you chose to be here tonight and engage with the rest of your colleagues and hopefully, um you'll be able to get something, some tip or trick that I'll be able to leave you tonight. Uh Mainly we're kind of raising the awareness and if you're at this presentation, I know that is the way you think in terms of minimally invasive surgery. So tonight, what we're gonna do, we're not gonna have one whole night talking about the ally uterine positioning system or the roomy cup, which I love personally, all of those things and you are going to hear why I like them and why I think they make a big difference in how we can continue um as a group to elevate the minimally invasive surgical approach in teaching masters courses and advanced courses. For so many years, we see a recurrent theme and one of the things that most of the surgeons who come want to learn about is getting bigger, getting those, those you terry that are bigger than what they were comfortable with. And there's a lot of ways to go about doing that. Uh straight stick, of course. But tonight, what we're going to talk about are some robotic tips and tricks which, which really do um I can translate them into a straight stick tip for you if you want and, and maybe at the end when we have our question and answer session, we can do that. But tonight's really gonna be revolving around uh the use of the robotic platform, um which is truly the best, I think toolbox that we have much less, the best tool in the toolbox for managing what we're talking about tonight, elevating minimally invasive surgical approaches to the complex cases. Tonight, we're paring down on the large uterus, whatever, whatever relative large means to you. Um it means very different to me, but when I was, you know, 15 years ago, large was a lot smaller than it is now. So the the cases that were able to tackle um especially on the robotic platform or what we're gonna be talking about tonight. Whatever large is for you. 18 weeks, 16 weeks, 24 weeks, whatever it is. But then we got to think in terms of not just disconnecting everything but how to get it out. And so we will spend a little time on that. Although I wish I had the same amount of time that I did it in advance for a master's course with you to be able to really tackle this over a few hours. So let's get into it for my disclosures. I typically put it this way. I don't speak for a company or a product that I didn't already believe in hundreds and hundreds of cases prior to them ever asking me to mention it in a talk. So as a disclosure, I'm on the Speaker's Bureau for not only Cooper surgical, but intuitive surgical and applied medical, which our products will be looking at tonight. Certainly, we want to thank our sponsor Cooper Surgical uh for putting all this together. I appreciate the way that they reach out to their surgeons to be able to continue to engage them with surgeon education. The things that make sense, the things that are practical for our patients and their best outcomes. So, thank you, Cooper. So our goals tonight, why minimally invasive surgery? Of course, we're just gonna basically realign around the same goal. What are the obstacles to a minimally invasive approach to that surgery? The uterine manipulation, which I think can be one of the biggest places, the biggest blind spots that surgeons don't recognize when they want to get into these larger, more complex cases. And then I, I liken that to uh running a marathon but not tying your shoelaces. It's a basic pillar to the actual remainder of the case, not only who's manipulating but what manipulator you're using and some of the advantages and then of course, the general tips and tricks for a large uterus. And we've got a lot of video to show you tonight and we want to be able to have some practical and efficient tips on extraction. So we're just gonna go over the excite or extracorporeal cold knife tissue extraction method. Near the end of the presentation, I give this slide often because it's, I think it kind of sets a little bit of the tone for the evening um perspective is, is everything my perspective is I did um laparoscopy with the eyepiece before we ever had video. And once we started having video, I started doing laproscopic work there. Vaginal work, obviously, abdominal work for when things got much tougher. Once I got to, to robotics pretty much after it was FDA approved, I just realized that was much better on the robotic platform. The better surgeon in me came out, so to speak. And I was sold on it early on for all the reasons that all the robotic surgeons that are listening know that just the ergonomics much less the wrist, uh that scales down into an area about that big when you can see three D uh 10 80 H D, I mean, it's, it's amazing. So my perspective is I do everything robotically and I know you may not and that's okay and I have my reasons and I certainly have my numbers which will give you the outcomes for mostly complex work, which is all I do. So as I'm giving tips and tricks, just kind of knowing that where my perspective comes from private practice in Austin, Texas. Um I do mostly complex referral work. A lot of enemy trio cyst excision, a lot of large you Terry, essentially a lot of the cases that my colleagues thankfully send to me because they just don't feel comfortable doing. So as we go through these tips, this is really from years and years of experience where I tell where I tell my colleagues, you know, your learning curve should look a lot better than mine because I should be able to give you the value of the places that I made mistakes and you can learn from there. And then I just challenge you to do the same and teach others you're gonna get best at what you do the most. So when I say pick a horse, that means just, you know, choose one thing that you can be really, really excellent at great at as opposed to um you know, doing some laproscopic, some robotic some vaginal. I mean, it depends on your, where your work. I mean, obviously you might be in an academic center and you have to do certain things, but the reality of it is you're going to get best at what you do the most. So tonight these complex, um, large you terry and some of the stuff I'm telling you, I'm gonna show you, uh, it takes time and a lot of effort and energy and learning wherever you can, but you just get best at what you do the most. So I think it goes without saying and now we're going to get into the more clinical tips and tricks. So we'll start with the plain and simple come, patient comes to your office and you're evaluating her and you recognize immediately on your abdominal exam that her uterus is essentially up to our umbilicus or well above that, whatever is uncomfortable for you, whatever would make you right now say, oh that's a th we're just, everybody would do a th like that. Well, I definitely tell you, not everybody, there's a lot of us who don't, but how do you progress through that? One of the things is you are shaped differently. I call one of them an ice cream cone and the other one, I call a snowman. And I use these kind of funny little terms like that. So you kind of remember the thought process in that an ice cream cone is where you do your examination and you actually see a cervix, you can actually feel the cervix and the lower segments, not too badly distorted snowman, so to speak, or turn that ice cream cone upside down. And what you then have is a lower segment that has the predominant amount of pathology. And then the uterus itself is kind of sitting on top. So those large lower segments, cervical fibroids that take up the entire pelvis. Um We're not gonna cover those tonight. That's definitely doable. We still do those weekly. But what we're going to focus on are the ones where people really don't understand that it's actually a lot easier than they think. And so I always say stack a few more ice cream scoops on there because it's, it's gonna be a lot easier than you think. So let's get started. What manipulator are you using currently? And I know half the room's gonna say V care, half the room is gonna say roomie, um half the room. Um you know, is like, I don't know, whatever they have for me that day. Well, you don't have three halves in a room, sorry about that, but I know that you don't give a lot of thought to it. Sometimes a lot of colleagues I've met don't give enough thought to it. So I am going to spend some time. Obviously, Cooper has this here tonight, but I really, I love this product. I don't know, 10 years before they ever asked me to, to even give a speech or anything about that or why I like it or anything like that. Probably even 15. So one of the things I find extremely beneficial is the ability to articulate the uterus, essentially 90 degrees anti version and 50 degrees retro flex. So a 50 degree retro flex puts that co ring so easy to identify for your anterior cul pa to me. But you can also in those positions or, or somewhere in between, then you can manipulate the uterus laterally or some oblique angle, whatever it takes. But I do find that articulation very helpful for smaller you terry 100% of the manipulation and actually use less robotic arms, make it a little more um reduced port type of a technique. But on the larger ones, of course, it just really starts to help me see that ring in a, in a oblique way that I couldn't have seen before. So the delineate er which is really um hybrid between the V care and a roomy arch provide some of the things that I find very helpful, the co cup itself. What I, what I found difficult personally in my hands when I found difficult was with the V care is that the basket is kind of shaped in a way that frequently didn't allow for the cervix to come all the way to the bottom. And what I find on the co ring, it's a little, a lot more robust, but it's also finished rated. So kind of a fatter more patch list service can kind of fit a little bit out of those ministrations. And typically we always get that cervix to see really nicely on the bottom of the basket or the or the co ring itself, which translates into having practically never that the cul pa to me posterior Lee will ever really need to cut through the utero sacral ligaments. What I found personally and maybe you have as well with the V care product is that the posterior cul pa to me was frequently uh a little more distal in the vagina and below where the utero sacral ligaments insert, which we'd rather keep that uh for the sake of the patient's cuff suspension. So the co ring itself, I like it's easy to see. It's easy to feel the um I think what most people would tell me about the V care is that it's easy to place. And so the delineate er, has kind of taken a lot of what we liked about the V care. It's easy to put in. Um it's, the delineate is gonna be more robust in your hands. It's gonna be a lot stronger, it's longer and um it has a built in uh vaginal occlude, er, which I'm gonna show you a couple of things in, in a little bit. I like to make pottery is very early for various reasons, mostly cause I wanna, I wanna know where that ring is at the beginning to have a good anchor point for my vision on where I need to take my uterus and where I need to make sure my ureter is out of the way and all that stuff. I like that visual of my ring and then I love to be able to isolate my uterine vessels when possible by making my posterior cul pa to me. But we'll get into the tricks tonight where it's kind of like, you know, the uterus is too big to actually get beneath it to find a posterior cul pa to me, what do you do? We'll get there but by and large. Um I think that if you love your roomie too, I don't see a reason to change if you are um already very facile with a different tip sizes, which I'm going to show you in a second. You understand the value of that, that that the um single length of of care on a larger uterus, the baby care goes up pretty high up in there. And then a patient with a higher B M I which you essentially get is kind of this little white handle sticking outside of her glorious area. And so it's not, not all that helpful on a larger BM I larger uterus. So at least I think in terms of there's other things like the delineate, er which is gonna be the value of the co ring and then a heftier V care, think of it that way. And it's placed just as easily. Personally, I like a roomy too, but the roomy too, it takes a manipulator, meaning the manipulator of the manipulator, you have to have somebody on that that knows how to use it and it takes five minutes with your Cooper rep. If you don't fully know the value of, of how to use that device, it's, it's really very simple, but I've been in plenty of operating rooms where I, I saw them struggling with it and I had to actually kind of help out just to help them understand how the product works. So anyway, uh it is important but you get good at what you use most. So I think there's value. So the different size roomy tips are gonna be super helpful depending on the size of the uterus. Now, tonight we're talking about large you Terry, but you don't, you know, have 24 weeks on every hysterectomy and there's times where you're gonna actually need to do that, try to collect a me and there's tips that are perfect for that size, which still allow you to provide the cervical vaginal junction being very well established visually from the top of the field, you know, laparoscopically, robotically. Um And so I, I found those tips to be very, very helpful because you get different sides of you two right now. Again, the cups also come in different sizes based on uh not all services, the same patch, a list multiple cervix versus a no Liberace patient. And so the cup sizes do vary as well. So one of the probably coolest new things that has applied to my daily. Uh oh our um tips has been What I remember seeing a long time ago which was gonna be a uterine positioning device. Um and at the time and I think there may be many of you in the same boat. I didn't have a very good assistant. I have a world class assistant now who's with me, 90-plus percent of my surgeries, um who's an amazing manipulator of the manipulator. But I also like to free him up to help me on the top of the field. And it's, it's a nice thing to have that uterus exactly where I want it and then it just freezes in place. So the ally uterine positioning system is the upgraded version of the older uh uterine positioning system by cooper. Uh much less expensive. I'll just say that. But what I'll also tell you, I use it, I use it on every case. I do a lot of endo a lot of uh deep exceptional work. Um Segro Koval Pixies, Myomectomy. There's just I know that you're operating and, but I know that you've also been an assistant before and you know, it's painful to have to keep that uterus in one position. And and not switch your, your, your weight on your chair or whatnot. And, you know, as well as I do when you're on 10 times zoom and you are, you know, developing a space to get your ureter out of the way. One big movement like that, of a big 26 week uterus can mean damage. So from the safety perspective, knowing that that uterus is not gonna move no matter what you're doing. Or frankly, if you have a Lester experienced person doing the manipulation, you may want to get up off the console. I know you'll be frustrated. I am too from time to time, but you get up and you put the uterus where you want it and then you let go. So it's electrical, you push a, you step on the pedal, the arm becomes um kind of limp. It's multifaceted, kind of like little armor plates that have multiple articulating areas and it just will freeze when you take your foot off the pedal. So I find it very, very helpful. We actually, so for some of you that really want to save money in the O R as, as I do, we don't put somebody between the legs and just waste a single person sitting there holding a uterus for an hour or, you know, for longer for some of these cases. So we know that a lot of O R s have kind of gone. Wow, we could save that staff f t. Um So anyway, I like it for the reasons. I like it. It frees up my assistant. Uh You may like it for other reasons, but I highly would encourage you to talk to your Cooper rep if you haven't seen this particular product. So as we start diving into the actual robotic component of the um large you dry, you know, you, I just, it really surprised me how many people don't ever use the fourth arm. So we call it fourth arm. It's actually arm number three. Um I know that there's some things that are so important about it that you may think you don't ever need it because you've got two assistants or something like that. But what I will, you know, try to get, you understand, when I say, you know, master the whole platform, uh support placement, the camera placement, all of these things are vital because if you can get more of you this version into the body, then the patient will be better off because who should be the best person in the room to operate. But you sew laparoscopically, I used to have a left hand and a right hand and someone else had to either hold the camera or hold my other instrument or, or my assistant would hold two different things. I'd switch out, but I was limited. I had two hands robotically, you have four, you operate your camera, of course, with your feet, you have a left hand and you have a right hand. So that's already three, but you also have the ability to have an additional hand. Um I'm right handed. I tell my right hand surgeons to put that additional hand on the right side, it makes sense to have what you probably have is a grasping type instrument here. Um Grasshopper bipolar, um There's various instrumentation. We're not gonna get into all that stuff, but to have some traction and retraction and to have exposure like the exposure I'm about to show you on these videos uh comes from not just my awesome assistant using a roomy too and the ally, but it comes from my fourth arm giving me that additional exposure. You only need this much room to operate robotically because of the the wristed application and the angles that you can get. So when you think in terms like that kind of, you know, the perspective of, of thinking in terms of having two of you in the body rather than relying so much on your assistant. I know there's times when you're gonna want to go with less to be more cosmetic. A 24 week uterus is not time to be cosmetic. There are ways to be a little more cosmetic, but we're going to talk about the use of all of the robotic arms. one of the things that catches me off guard when I watch videos is when a surgeon puts the camera in before they, uh, either wanted to convert to an open case or they actually did convert to an open cases. They look in, they, all they see is the uterine fund us and they just kind of freak out. Um, and they open, they punt, um, you know, they never had a strategy, which is what tonight's about. Right. Me helping what you already have as strategies or giving you one more little arrow in your quiver. So I use this funny term. Don't peek and freak, don't put the camera in and all you see is the fungus. Remember we're not operating on the fungus. This is not a myomectomy talk today. This is big. You try. So let's get past the round ligaments on both sides before you think you're going to convert. So, one of the first things And rules of thumb that I've learned over the years is where is your camera gonna go a typical way of thinking? Let's take a look at what this uterus looks like here. This is about 30cm. Uh ended up being a very large uterus. Putting your camera above the fungus can actually hinder your ability to get the range of motion and the exposure that you think you're gonna get. Again, it goes back to what I just mentioned, you put the camera in at the umbilicus and you just kind of freak out we're not operating there. Remember where the pedals are gonna live? Utero Ovarian pelvic um your bladder flap, your lobotomy, your uterine vessels where the ureter Czar, um that's not gonna really matter. And most of the time, what you'll see in videos of large, large you Terry is that the uterus is underneath you? So those think of the ice cream cone uterus, those ice cream scoops are just way behind you because you don't need to worry about them. They're not the pedestals, the blood flow to the uterus. So you see where the X is on that yellow arrow. That's a very tempting spot for people just like I was, I used to do that to put my camera up high like that. When in reality, it's difficult to see over the uterus. Once you're inside, I would also highly recommend a 30 degree scope. I use a 30 degree scope across the board, whether I'm on an X I or an S I A 30 degrees group is just hugely advantageous to a large uterus to see over and you can turn your camera and see around. Always make sure of your orientation. Of course, you want to be purposeful with when you do things like that. But I still like that blue arrow that you see there. That's where I'm gonna put my camera because it's gonna give me access and visibility to all of my pedestals. So again, you know where that blue arrow is at the MBA like is and by the way, we still need an extraction strategy. Well, I'm gonna get to that. But what I want you to think of is building your extraction strategy into your entry. And I'll show a short video on that. But if we can make our extraction site on the way in, it's just an alternative, there's another way where you just make it on the way out. I know that. But if you think in terms of how can I also maximize my ability to see and already have my extraction site. And by the way, already placed my large bag to contain this uterus in all in the first couple of minutes of the case. So another product that I'm gonna show you is this little green device called an applied medical. So if you know, I've never seen it is by applied medical. And I think cooper surgical for letting me talk about the things that just make my day work there, part of it, right? But these are two gel point many is really helpful because your camera tracker doesn't actually have to go into the body. So if you look at that middle picture, the view that you're looking at can look a little odd because it's it's new mo peritoneum. Um And you're looking at the abdominal wall because there's a dome, a gel dome between your tracker and the actual cavity site where you major Exit strategy, which is your entry. I know it's a little confusing. I'll try to keep coming back to it, but it gives me with a 30° scope. The ability to just dip my camera in, Not with a troll card that's in the body, the train cars a little bit outside the body, but I will put my troll card in on the 30 and I'll see the liver immediately. And so it's a, it's a very valuable tool for your camera at the umbilicus, whether that Uterus is well past that or not. Another thing you're looking at is that the Uterus. Remember we have new Mo, right? So new Mo puts our camera higher. So at the beginning of the case, we don't need to have your assistant pushing in on that Rumi or on the delineate. Er You don't need to have that uterus pushed up to the chest yet you do later, but not yet. Your pedals are gonna be a lot clearer to you if they're in front of you and it may be off to the side of those big ice cream scoops, but it's still gonna be visible to you and it helps to push your uterus forward towards the pelvis. So gently pulling back, don't pull out your manipulator, of course, but also I have my additional arm, my fourth arm and we're gonna talk about pork placement, pushing down on the uterus. So I make it as little as possible to be able to get to my early um the fallopian tubes, uterus ovarian. Um started the I P whatever that is. So again, like this for the camera, think in terms of this potential exit strategy as you're entering the gel point mini can be very helpful and pushing your uterus forward, pulling it forward, not pushing in at the beginning of the case, making an 18 week uterus feel 26 weeks Or making a 14 week field 20 weeks. So I think you get my point. So I want to show you a very reproducible way of entry either for a great big uterus that's gonna need an extra corporeal and closed tissue extraction or LSH for that matter. But it's an extraction strategy. All of these are strategies built in for efficiency. The way we're gonna make this incision, it only needs to be about 2 to 2.5 centimeters. And what you're watching is I've got Coker clamps pick what you want. But Coker clamps to help Evert the umbilicus just a little bit and you see the size of that uterus. It's basically right at the umbilicus. I picked this one because it's just pretty common. I'm gonna make vertical, vertical skin incision. And yes, I'm going right through the umbilical plate. And what we're gonna do is we're gonna, I'm not in the body yet. I'm not in the body. I'm gonna re grasp fashion and we're gonna do this uh similar to uh Hassan type of technique, a little bit larger army navy Mayo's put that back on. There you go. And all I wanna do now is to in size vertically. The fashion, I'm not in the body yet. I'm not in the body. I'm only identifying the fashion clearing it off really well, because at the end of this case, we want to close this really well. At the end of the case, we close it with interrupted sutures, I'm gonna make a blunt entry through the peritoneum with my finger. Obviously not gonna be that um uh Cavalier and somebody who has had lots of abdominal surgery, right, might do a left upper quadrant, Hassan, I'm sorry, left upper quadrant palmer's point technique and visualized to make sure this can be safe. But again, you see me really clearing off that fashion and now about 2.5 centimeters and that uh belly button is gonna look very, very cosmetic at the end of this application of this technique. That's the gel point mini. That's the initial soft tissue retractor. This video is not sped up. I mean, it takes just a couple of minutes to get all this ready. You see that bag, I'm gonna show you this at the end of the presentation and how to do it. But this is our strategy. It's just, it's just a strategy, but it's the one I like and find very, very efficient. My prepared bag is going into the body. This is a very specific bag. It's the applied medical contained extraction system, bag, very specific. The gel point is now going on the top and it will create our new mo seal and then you just hook that up and we're done. And this is common, common, common. I mean, if I operate probably 10 times a week, I'm using that probably five times a week. Very, very common. So when it comes to ports placement, we will have placed the gel point, extraction site bag is in the body already. And my assistant's gonna stand on the left of the patient. He's right handed our robots, whether they're ex I or S I doc from the right, we dock uh s eyes at a 45 degree angle, not parallel. And then the X I can come in really whatever angle you want to because it's gonna get so versatile, it can kind of dock with whatever position you have the patient, but the ports themselves, where will they be placed? What we want is enough room between your troll cars so that they don't collide more than they need to on these large complex you try on a small stuff, they never collide on big ones. There's gonna be some finesse that comes with practice, but I typically never have my lateral troll cars higher than the humble like this. It's just, it's just never and those, no matter how big and those truckers are going to be in line with the mid Axillary line above the ASIS not medial. And what I'm not going to do is put my hand kind of right next to the belly button and then put my truck are there. If you do that, you're gonna short circuit the whole process of strategy because then you don't have room for that additional fourth arm to be in the right location, which may be why you don't like it. You may have done that in the past. So this is a very, very common typical port placement for me uh camera, the belly button, the assistant upper left palmer's point basically. And on my far right arm, which we would call the fourth arm, that's gonna be at the level of the umbilicus above the ASIS in the mid mid axillary line. And then that puts my kind of my my right para median hand in the right upper quadrant. So upper quadrant kind of split the difference between where your to your camera is and your lateral arm and split the difference and go to the upper quadrants that'll give you the best chance is if you can get that kind of 8 to 10 centimeters X I, you can get a little bit closer. But if you put the excise straight in a line for some of these cases, it doesn't really give you the benefit that you think it will. Um This is a very, very reproducible and common port placement technique. So some of the quick and easy. Pearls on strategizing is getting past the round ligaments starting at the round ligament if you want to, I don't find that quite as helpful. But if I can get my utero ovarian fallopian tube, round ligament or open the side walls and, and leave my um tube and ovary for later. Um I can do that as well, but I don't like that very often because I like to have that point of attachment to the uterus as well as to the near the side wall to pelvic brim. I like those two points of attachment. Um That traction helps me. But if you can get past your early um pericles, tube ovary, I typically take tubes out of the body as quickly as I can. So they're not dangling in my field because it's already hard enough to see coming across the round ligament. It opens it up like a Mack truck can drive through there. It's just so much better than you would ever have thought if you never got past that point and you don't have to get past both the round ligaments. You may like to do that. I don't typically go left, right, left, right, left, right. Um If you do that's fine. I think it's hard enough to get your, your exposure and your field of view so that if you can see something just keep working, that is more of a common sense application when you've got lots of cases that day, you don't have the benefit of saying, oh, I've got three hours for this case. They kind of need to be done in a very efficient fashion. So I found it efficient that if I get a view and I know a certain aspect of the case needs to be done, I'll get it done with that view in mind. Use of um, Lupron, I mean, it will kind of shrink your uterus down. Not, not, they don't all respond. But I mean, for three months, if you want to get a 24 week uterus down to 20, that might work or 22 weeks, down to 18, you know, 18, down to 14, if you can talk your patient into that more power to you, I don't typically use it. Um the use of a super A cervical um like you're strategizing for this T L H, you're gonna take a cervix, but you can't see much, you can't see your co ring. Uh So you may strategize that you're going to do an LS H leave the fungus up here. And then you've got all the field of view in front of you to actually see to be able to do a tracheal ectomy, which essentially will be a very large service at that point. Sometimes the size of an 8 to 10 week uterus. But it's a strategy. It's a strategy of saying I can't quite see it all, but I can get my uterus is up very high. We've identified where the Ureter Czar and then I'm gonna transect the fungus and then I'm just gonna go ahead and get the rest of the cervix because I've got my ring clear now. Everything's right where I need to see it. Another thing that happens from time to time is you have these enormous, you try with, you know, one great big fibroid and sometimes de bulking that fibroid can help you to see. Now, you've only got a little 20 week uterus left to manage and you can see everything really, really clearly doesn't always happen that easy. But it is another strategy. So Mri's can be helpful really looking through your your ultrasound reports to find out. Can this be done? Is that something that we can can do? Alright, let's get into some video because I know that's where we really can make our points come across a lot more easily. Now, I want you to watch, we're into the hysterectomy part of the video here. I want you to notice what my that arm on the right that you see is me. That's my fourth arm, that arm on the right you see is also me. So what I'm gonna do is just, you know, the tubes can come off in 20 seconds, just make a little window in the Missus South. Things get through these, these as quickly as you can. This is just uterine ovarian. Make a nice big footprint with your whatever coagulate, er, you're using. I don't care which one you're using. But the main thing to notice here is how big the space opens up when all we did was to get our initial pericles and get across the round ligament. Now they're gonna push in and look at my fourth arm. I could have my assistant do that. Of course, I could. The problem is, and there's my backfield, double check. Where's that bladder? Right? The problem with my assistant doing that is it's going to take him out of the field. So instead of suctioning smoke right now, he would need to be holding that uterus over. And if he's holding that uterus over, he's not gonna be able to help me if I get into any trouble, any little bit of bleeding. Remember the camera is up close. That's 2.2 centimeters right there. I'm already gonna make Michael Potter me. I'm not, I'm not gonna try to redo this. And if my assistant wasn't right there with that sucker, that could have been a very difficult situation. So I want you to remember I throw in all these lifelike things because that's not her uterine vessels. Guys. That's just the vaginal branch. Look at the manipulation and exposure that my fourth arm can do while my assistant is doing everything from below. You notice that ovary over there is kind of dangling out in the middle of nowhere. It needs to be pecks it at the end of the case so that it's not just kind of sitting there and has the chance of having an actual torsion with one small cyst. What are we doing? Well, we're on the posterior leaf of the broad ligament. Gotta remember guys, I'm sure, you know, but I'm gonna remind you those your eaters take on a really common hockey stick candy cane maneuver. They look like they're headed to the pelvis. But with that traction and towards Cephalon, towards the diaphragm, what happens is those urinals frequently take a hockey stick or they come right back up towards you and you think that they're out of the way. But if you don't actually know where they are and you don't see that you're going under the uterine on these large you Terry, it's gonna cost you a you're a literal delayed thermal spread. At least you notice how I have my uterine vessels isolated really clearly, really clearly from the ureter which we left in the left pelvic sidewall. I have a landmark. That landmark is my ring. I know I don't want to keep blasting stuff out lateral. I wanna stay medial to the ring and of course, my assistants pushing up like crazy towards the head right now. What we don't want to do is to simply do what we call a hug and pray technique where we just kind of get as close as we can to the uterus and just vaporize and cut because in this type of a situation with large you terry, the, your editors do not do what you think you're used to seeing them do, which is to kind of go straight down the side wall. They actually curve back up. What you're seeing here is I'm not gonna ever be able to get the view behind that big old uterus. And by the way, can you even remember how big a uterus that is most of it is underneath my camera and you notice how high my camera appears to be. It's because it's inside that gel point, very high but not well above or umbilicus again, right side, just to reinforce some stuff. Don't worry about getting that created end of the tube and trying to get that perfect angle, you're not gonna get it just make a little window in the missus South things and then use whatever device you're using go proximal, go distal and then I would get the tube out of the way Now, depending on your tracker. So I'm sorry, depending on, yeah, your tracker size of your assistant. Um you don't want to lose those tubes. So make sure you know what? In my case, I'm using an assistant poured out of my gel point and it's 12 mm, it's enormous. So any needle, any structure can kind of come through that again, getting across the round ligament. What am I worried about now? Reminder, who knows how big dad uteruses at this point. Well, I'll tell you what, see those vessels, you know, that's a big uterus because the vessels are enormous. So, remember all of your collateral vasculature on a large uterus needs to be taken seriously, be mindful. Look for the bleeding before it ever happens. Even that vaginal branch surprised the heck out of me. But I also knew my assistant was there with the suction Irrigator because that's just how we do it. So what am I doing here? It's just the simplest posterior leaf dissection in the world. You probably do this when you do th S so develop everything you do with the th in terms of what you do robotically or laparoscopically for that matter, don't change how you do things if we were to open, there would be nothing easier about what I'm doing right now. In fact, to be harder, it would be harder to see a large B M I I have only one focal distance by standing at the side of the patient where in this case, I can go slow enough and gentle enough with great exposure that I'm providing myself and isolate these vessels without bleeding, isolate my ureter. Nowhere my ureter is, it's just a very simple posterior leaf dissection. We're not really unwrapping the ureter from the pelvic brim down. We have plenty of cases where we need to do that. But these are the things that help you find confidence you're not just applying your cut seal device against unopened peritoneum. It doesn't work like that the ureter would have already come back up underneath where we're at. And if I had my bipolar with the peritoneum in it, it shrink wraps the peritoneum into the jaws and that brings the ureter into, closer, closer to where you're doing your, your Katari. And by the way, the ring is visible again, I have a real easy landmark. I like to kind of undermine these vessels that Endo Pelvic Fascist. So I can kind of get a little bit underneath those uterine vessels because that way it kind of sticks up like a little rosette like a little pentacle. So if I have to go back and grasp it because it starts to bleed, I'm not actually gonna be worried about the ureter. Number one, I have my ureter clearly visualized and separated and isolated. But also because I do this little undermining of the um uterine vessels through that end of pelvic fashion. Now again, I'm never gonna be able to get to the back side of this. So what do we do? We just rotate, just rotate the ring and were able to get that entire call pa to me, not because we can see posterior li like get underneath the uterus like you do on a smaller uterus. But because we're going at the Koopa to me ring, which is a huge target and we're rotating that co ring around so that we can actually rotate the uterus and see it. Plus my fourth arm is also pushing the uterus wherever I want it to go. Closure of the cuff. I don't think that's really what most people in the room need to see. It's, it's obvious you need to take big bites and you don't want to over cauterize. There's, there's, there's my ureter, they're easily visualized. You don't want to over cauterize because that's tissue that can become ischemic. And if you don't take a big enough bite, what's gonna happen is you're gonna get uh higher risk of A D Hisense because the tissue is not viable to begin with. But you also want to take great big bites and knowing the size of your instrument tip is my favorite way to teach Um on that particular instrument from the tip to the Crotch. It's 1.7 cm. So I know how big a bite I want to take when I do this. Always want to double check your urine as you can see my urine right there to the left. And that's because we did the dissection, we made the anatomy more normalized. And if I need to grasp that, it's not a problem, it would be a big problem if I didn't know where my ureter was, you can't just be grasping out there laterally. I also have traction with my future. Now, the question becomes, oh, by the way I wanted to make sure you knew I was gonna do this. I went back and I texted my ovary back to the round ligament because otherwise it's just kind of sitting on the infant pelvic. You get one big cyst on that, you might, you might have a higher risk for torsion. So with these large you Terry, it's easy for them to get very distorted on where the ovary the I P is and where the round ligament. So realize I put that bag in at the beginning, I'm still on the robot. We haven't changed the patient's positioning whatsoever. We don't have a bunch of people standing laparoscopically trying to figure out how to put a bag around this monster. This particular applied contained extraction system, bag is always open. So you have to kind of what we say tame the bag or put a couple of sutures on the bag so that it doesn't, doesn't open up until you're ready for it to open. At this point. My fourth arm is holding the bag stable. This is unedited right here. All I'm looking for is to put that uterus on top of the bag which is 17cm. You see that little loop, I'll show you how to make it. It's a genius maneuver of my assistant. We used to try to close the bag with a stitch and we just kind of started to morphing into this way of doing it. He's gonna bring that uh tether that black tether up through the gel point and were bagged and the bagging part on that, the Hysterectomy was edited. The bagging part was not, usually takes us right around two minutes, 2.5 minutes to put, um, you know, 22,000 g, 2400, 2800 even, um, into that bag. So what happens when the more slater comes off the shelf? I mean, most of us would have used three different more isolators to try to get that one out of there or more. Um and they're expensive. I mean, those things were $700 a pop for that matter. But we have new techniques and that's what I want to show you is my favourite one. We're not gonna cover all of them. Don't forget about your vaginal tissue extraction. That's still good stuff. I'm just gonna show you another way something new to put in your armamentarium. So tissue extraction obviously, don't forget your vaginal more isolation technique. Um Sometimes we make small cap autumn is to be able to take out fibroids, redneck cell structures. But this excite technique in in um obedient management. Doctor Advincula turned this excite enclosed, extracorporeal see incision, tissue extraction. It's cold knife tissue extraction from the top of the field much faster than I ever was with any morsel later on the market. This is just one example of what it looks like to take out large structures in long unbroken strands uh sometimes they come out in fragments which is okay too. But the more you limit the fragmentation, the faster the technique goes, we're typically taking out tissue 200 g a minute on average. So that 1400 g uterus that you just saw or this 16 50 is gonna come out roughly, you know, half the size. So this will come out in about eight or nine minutes, maybe. Um That 1400 g comes out like five or six minutes. Um depending on how hard those fibroids are of cars. Of course. So you remember that little loop I put on the bag. This is the way we're gonna put that on. You just take a needle driver because you need a needle driver to throw a stitch, you need suture. So take your suture, tie it around the needle driver and now you've made the loop. Now we're gonna put it in a very strategic location. It's gonna be exactly opposite of the tether that comes on the bag. So using that same suture, we're gonna take the bag again. Applied. Medical makes the bag. If you have never seen it, it is always open and it's 6000 ccs deep. And so we need to make it smaller so that we can actually work with it and then deploy it in the way that we want to when we want to. So he drove that suture exactly 100 and 80 degrees from the black suture tether that comes on it, it comes with that one, but it doesn't come with this little loop. This is we're tailoring the device, but we're only putting it through the plastic rim, not through the bag itself. We don't want to denature or hurt the bag. Now, the other thing about the bag again, it's, it's, it's large and you need to be able to tame it in a way that it's not gonna be in your face. Um You saw in the video how I kind of brought it out very strategically at the end of the case opened it up, had plenty of room. And the way we do this is we're going to kind of scrunch the bag, you know, very scientific term, scrunch it up like an accordion. Don't wrap it around itself. That's what I'm trying to get across, just scrunch it and then we're gonna tie it closed because the beauty of the bag is that it's always open, but it's a problem if it's open when you don't want it open. And so these are what we call our little taming sutures, you can put one on, you can put two on whatever you like. Um You can, if you want to put more sutures in the plastic to be able to lift it from other sides, there's a whole lot of fun things you can do with this. I'm just giving you the more reproducible version that I use all the time. So now the bags just kind of ready to go and um it's not gonna be all in your face as you're operating, it's going to be sitting and just waiting on you to deploy it at just the right time. So let's get into the actual technique. Many of you have one, I'm sure many of you do it faster than I do it. But I'm just gonna show you a reproducible reproducible version. That is just the best thing we look forward. We have fun to the tissue extraction component these days. So you've got your specimen in your bag, you bring your bag edges out like I just did and you put the gel point or if you're not using the gel point, you, you use another product by the same company which is simply another o soft tissue retractor. You see how it gives us exposure so that the bag is not in our face. It also concentric li takes that 2.5 centimeter opening and makes it more like 3.5. Or if you have a patient with a larger B M I and an extremely large uterus, sometimes I actually make it 3.5, makes it four centimeters. So it's a still cosmetic and tissue will come out very quickly. I apologize for looking at beef tongue, but that's what that is. It simulates uterine tissue if you've got a Denham aosis, right? It doesn't really simulate all your fibroid textures, but it runs about like this. What I want you to notice is a couple of simple things. The knife is not cutting all the way around. There is an area on the back side, we call the no cut zone. And, uh, if you look to your right, you see a plastic guard that I could be using right now and I encourage you to use that plastic guard. So you don't cut the patient. Um, hundreds and hundreds and hundreds of these in. Um I don't use the guard because it just narrows my diameter. So the knife is making small c type almost a guillotine type incisions. And you're gonna need to change knives frequently, just have those other knife handles with blades loaded so that you don't get 200 g or 300 g a minute. When you're waiting for your tech to change blades, the knife handle needs to be handed to you as soon as this is dull right now, I get another knife. The other thing we're using is thyroid leahy clamps. They really do work better. They're shorter, easier to handle. You have a lot better leverage on your tissue. Notice how I'm grasping the tissue in my hand so that, that tissue is not obscuring my field of view. I don't have a lot of room to work in here. And the last thing I need is for the tissue to be kind of dangling in the field, you notice it's a lot of exposure. And again, you're noticing my left hand do more of the work than my right hand. Although I know you've been focusing on the knife, look what my left hand is doing. It is uh one of my friends, Darren Swainson always calls this the slot machine technique. So he the left hand is doing almost like a slot machine maneuver, big movement. And what you may not notice is that I'm actually pushing the specimen into the belly of the blade. So I'm not spending a lot of time with a reciprocating motion of my knife in the tissue. And obviously, I'm not core ng the tissue out. No one that looked at this and studied this video, whatever, say your core NG the tissue out. No, it's actually you're making small c type incisions leaving an uncut back surface and underneath you see a rotation of the tissue. So that's the technique. And those are some reproducible techniques that I can share with you in a very short period of time. I would love to see all of you at a more in depth, masters course, advanced course or if you're brand new to robotics uh one way or another, uh it takes more time, but I hope that for some of you uh that are doing this, you're like, ah wow, that's actually something I never thought of and you picked it up like that. So you don't lose either way and I am so open to questions and answers right now um with our, with our remainder of our time. So thank you for thank you for your attention so far. And thank you so much Dr Garza, I will now turn the Q and a portion of our program over to Doug K from Cooper Surgical to present the questions to Dr Garza. Dr Garza. First of all, thank you very much. That was a really compelling uh an interesting presentation. So, thank you for doing that. First question for you is we had a couple of questions about the uh camera access through the umbilicus. Uh two questions there. One is uh does that camera uh right on the uterus impede your view? And secondly, I'll put these questions together or do you see any increased incidents of hernia accessing through the umbilicus? Yeah, great question. So, um the you're always gonna be working essentially on one side or the other of the uterus. So if the gel point or that access through the umbilicus uh sits like my pen kinda, you know, above the opening into the patient, you already have a much higher view than you're used to through the umbilicus. Because through the umbilicus, normally you put your tracker through and then as you're truckers kind of eating up some of that distance where my cameras up here, you're already about 10 centimeters in over here. If you're on the kind of the inferior aspect of the umbilicus. And so I'm already up in a little higher zone and I may only see the fund, the fund is there. But of course, what we're gonna do is slip the camera, you know, to the side and we're pushing down on the uterus, like the video showed will rotate the uterus over to find the pericles. Um It's, it's not, um, it's not often even on really, really large you to ride that your, your utero ovarian or your tubes are, you know, by the diaphragm. I mean, there are, believe me, there's exceptions to every rule But it, it you have to use the 30 scope to gain the extra advantage in addition to that camera trow car sitting outside of the body, the dome, the trucker. And then my camera is the only thing going right in underneath the, underneath the skin. So it sounds counter intuitive and it took me a long time to get to that place because I'm listening to some of my other colleagues talking about that, Doctor Advincula, our late friend Dr Peter. And then I started to realize that actually is very true because I was having more trouble getting to my you Terrans and the more um the, you know, the really big medical, the concerning pedestals. In other words, because I couldn't get my arms over the funding of the uterus and my camera couldn't see down low enough. So I hope that answered the question, hernia wise. So we started doing this particular incision when single site robotics came out. So we started talking to general surgeons that were beginning to do single side hernias. And we were talking to plastic surgeons on how they would make the incision by assistant, you know, every tip I could get from him because he works with so many different types of surgeons. Um And we basically came up with this particular method rather than trying to go around the, the umbilicus and, and do all these kind of fancy techniques. Once we started really getting the fashion to be really visible and closing it with interrupted sutures. The general surgery literature had initially with single site came out with all these, I think it was like a don't quote me, but I think it was 4 to 6% risk of hernias. And I was saying no one's gonna do single site if you're gonna get a 4 to 6% risk of hernias. So a little bit of that later, we started realizing vertical incision in the fashion show, whatever you want to do on the skin, but a vertical incision on the fashion and then uh interrupted closure and making sure you're closing fashion too fashion. That's just good surgery. So have I had hernias? I have um what percentage I think I looked it up just about two years ago and it was somewhere around uh five or six dot percent, five or six out of about 700 of these particular types of decisions. So a little bit less than 1% in there and I haven't seen one in a long time, you know. Uh But yeah, you do want to be careful with that. You want to be careful. Great. There's a couple of questions that came in an ally and I'll bunch them together a little bit. Right. One of them was you mentioned uh you know, freeing up your assistant. But also does it save any time for you? And the procedure? Second question around that was what are the particular cases that you're more likely to use ally on? And the third one was, is your assistant when he's manipulating the ally, is there any issue with sterile field contamination with the ally? So I'll put those three together if you don't mind, I'll remind you if you forget one of them at the end. Okay. So we, we basically were trying out the ally to see where it would make sense. So to me, it's like just go all in and then, you know, subtract out what, what you don't think it's gonna work. Uh My assistant assists the way I assist with one hand between the legs and the other hand up on top of the field. So I'm sterile. Um So it would be the same as anybody manipulating your uterus who is also on the top of the field, you need a lot of either towels. So you, we might get some extra blue towels or, you know, the piece of the uh the flap that covers over the roomy. So if you feel comfortable that that's always covered, that's one thing. Another thing you may want extra gloves so you can take the extra glove off. So there's ways of getting around that, but it's not a problem or a concern. The what cases we use it on. I mean, we, we started using it on all of them. I actually still use it on all of them. The uh the benefit especially doing deep. Uh So for endo deep sidewall, uh uteruses in his position, I know it's not gonna move when I'm in a really tricky uh you know, location, you know, defusing the bomb kind of thing. And I know it's not going to be moving when my assistant has to shift his weight or something like that. Uh For myomectomy is it's nice to have it just kind of stance just to be steady so that you can, you know, operate and do your myomectomy components, you push it in, pull it back, move it over, stays free. Um For large, you try, I showed you that sometimes we will have to disconnect it because the right exact angle I I I need may not be attainable with the ally in place, but that's definitely, uh you know, just in all transparency, it's a real a small amount of time that that is gonna be something that we have to do in the beginning. We were trying to figure it out. We weren't quite sure how far to put it in and pull it back and how far it goes down on the table and all that. But once all that's been kind of smoothed out, um I just find it very useful for literally every case and we're just kind of used to, to using that as a strategy. I think I got them all. Yeah. Good. So question uh when you're doing a robotic hysterectomy on a large uterus uh in a virginal patient, is it even possible if a vaginal opening can't tolerate the insertion of a small co ring for uterine manipulation? What would you do in a case like that? Yeah, that's a really good point. So with all my patients say, for example, um older virginal younger needs endo work or something and, or, you know, public floor dysfunction and hasn't been sexually active for whatever reason. And you know, there's, there's a million reasons why your vaginal and troy, this may be very tiny. I tell my patients it is really important. I think it's important enough. I know I've done plenty of hysterectomies with just a sponge stick and I have some good friends oncology, friends that kind of say, hey, you know, what do you need a co ring for? Well, you know, we're just mere gynecologist, you know, I think it's really important to establish a cervical vaginal junction. I just really believe in having the cup present. So I just tell them there will be a very small um episiotomy, frankly, a small episiotomy. And as long as they're prepared for that and they understand the value of it in my hands. Anyway, I think it's gonna help me protect from a, from an injury. So if I really have to do without it, then I'll talk to the patient as well and say, if I, for whatever reason, if I can't use it, you know, I'll do my best with old fashioned techniques or whatnot. But that's literally how I get around the really, really narrow and choices to make the tiniest of, of like a little episiotomy. But to tell the patient ahead of time, makes sense, makes sense. Also another question came in, how can you fit the snowman type uterus into the room? How does that work with the roomy coke up? Is there any challenge fitting that in? Oh, yeah, the snowman where you have a cervix? That's basically non existent. I can't put that ring on that. That is like, you know, you can't put the ring on some of these. And so we get our top approach and we get to our, our vasculature and we're pushing in um with a sponge stick or something to give me some elevation to get up out of the pelvis when I need to. Um, and those again, aren't the highest likelihood of when we see them. But when we do, and that's, again, it's much more of a complex way to answer the question. But you're essentially doing a myomectomy. So you're going to do a myomectomy off of the cervix and then the cervix, you know, be splayed flat like this. But when you do myomectomy, you'll get, you know, some semblance of the cervix because there is a cervix. It's just that it's super distorted and then I would go back down, put on my roomie. In fact, I didn't have time to show that. I usually tag it onto that other video where it's like a 3000 g uterus. No, no chance of putting a co ring on at the beginning. Uh We do an LS H same little thing but not just the L S H, but you actually have to do almost a myomectomy to then give you some Cervix left to go back below, put in your co ring and a small, you know, it's gonna be a small roomy tip at that point. And then you can see your cervical vaginal junction. But again, those services are going to be very large. And if they're feeding a great big uterus, the vessels to that Cervix are still going to be huge. So, uh there's more steps involved with your ID or a license to get the rest of that Cervix out if you haven't already done that at the case, then? Great, great. So we had two questions coming that were specific to uh robotics was first was how do you attach the robotics trucker uh to the mini Delport at the Umbilicus? And just a second question also related to the fourth arm and, and are you using that in every case? Yeah. So in that video that I showed you that was an S I. So that was an S I and the reason I know that is because the camera support that I had when I placed that gel was a visit court and it was a 12 millimeter visit ports because on the S I I, I really can't use an 8.5 scope anymore. I still use the last S I in Austin. Uh Mostly I'm on an X I but we kind of go back and forth between two rooms. And so I, I know we're gonna get all exercise very soon anyway, but I X I and, or an S I, you just take that dome and you're driving your camera like before you put it on. So you, you, you, the patient doesn't have new mo yet. Here's your cap in your hand. You just take your camera tracker and put it in there and you take your assistant that comes with three that you can put in, but we only have room for the camera which is Da Vinci or on the S I it's gonna be a visit for 12 and then we have the largest one that it comes with and we just put that one in as well. So now my cap, the way I showed you on the video, the cap is coming on with both my camera tracker in place and my assistant tracker in place as well. And then There was one other question after that. Yeah, it was, yeah, the fourth arm and you use that in every case. Yeah, definitely don't use the fourth arm in every case. Definitely not. I mean, we we, we helped to develop single site and so you can do re reduced sport. Absolutely. Just a camera and two. And I've got some, you know, good, good colleagues, friends that are Gabby Moawad. He can tackle these things with just a camera plus two. That's really, really, you know, Mr Fel and unique to his skill set. So I think for most of us that are just kind of mortal, I would say master it with the fourth arm and then maybe don't use the fourth arm. But you gotta remember with your assistance holding that uterus over, he's not gonna be very helpful for you where you may need him. And that's why I put that little clip in there with the bleeding. I mean, I mean, you know, it's a vaginal branch but on a big uterus, it's very brisk bleeding. So to me, if, if I get a 20 week uterus, it's just gonna be forearms. And I'm telling my patients it's gonna be four arms. If they, if they really pushed back and want me to try to do it single site or something like that, we've done, you know, 960 g uh uterus single site before. But, you know, all the other things made it possible mobility and where the fibroids seem to be located. And I told her ahead of time, I may have to put in an additional arm. And so she gave me that freedom to do that. But you know, it went fine. It depends on what you're kind of dedicated to doing at that case. But I would start, the default would be forearms and not just three cause I don't know how to use my fourth, I may start with three and then I go out just put the fourth arm in the middle of the case. Um So you can always start with less add one if you know where it goes and know how to use it. Yeah. Yeah, that's great. So a couple of questions that came in specific to ally and they're kind of related to tie them together. One is, do you put the ally system on the bed yourself? You have an assistant do it. Is it, you know, before the patient gets in the room and then just someone on some general tips on getting the ally system in the right position. So, you know, I'll be honest. Um And I, and I use this as a teaching point. If you're gonna be the doctor who does new things or changes the way the your staff typically prep your patient. Um position your patient, you need to be there physically hands on. I'm not that guy. So what I do is my assistant, make sure that it's the same standard positioning that we always use. The the allies gonna go on the bed. Essentially. I think they put it on literally after the patients already on the bed that gives so there's extra room for you to be with the patient and do what you have to do. Um The uh proper placement of it, your, your rep will go over it. But basically, there's a little power button that needs to be in line with her in Troy this and if you can make that happen, it's gonna be, you know, down on the field enough. You don't have to figure this out on your own. Make sure you have your rep with you to do these first few anyway. And if you can do that on the X I, they just came out with this new thing. Hopefully it's okay to, to say this that it's available for everybody, but it's a, it's a little thing called the uh the buddy or I can't remember my buddy. I'm sorry, I forgot what you call it. But it gave us that extra space because we were having a little bit of difficulty on the Trump 7000 bed Uh making this not down low enough. And so they rail buddy, that's what it's called. So this little device will kind of position it just right, so that the power button gets lined up with the patient's perineum so that it just golden, it does actually sit just right the way you need it. So if you've been using it and you've noticed a little bit of difficulty on the Trump 7000 bed, then that maybe just ask your rep for this particular little device. There are a couple of questions that came in also on your use of the bag. So let me, let me there a little bit longer. Let me read to you specifically what they say. So uh surgeon wrote it doesn't like the expense of the gel point. If I use the large bag without a gel point, I need to remove the political scope. After disconnecting the uterus, then enlarge the fashion incision for the insertion of the bag. But then I'll have a new mo peritoneum issue. How do I get around this? Well, in the beginning, uh Well, I'll answer the first thing. Uh you may have constraints with cost and I'm very cost minded. I don't use a lot of robotic instruments and what, what we end up helping kind of the short the battle is like Well, that thing costs, I don't know, $300. Um, if you use that, but you use it to your advantage to. Number one, make your, your case faster because you can see better. Number two have an extraction site on the way in. So you're more efficient, not having to, you know, dock undock do it laparoscopically. I've been in cases where, you know, the worst part of the case was trying to put something into a bag. So you're saving by your efficiency. That's number one. But number two, if you just, you know, don't want to use it for whatever reason, I'm going to advise two things. One of them, if it's A T L H, right T L H. Uh it's tempting to put it through the vagina. We all did that. We, we all, it's a big bag, it doesn't fit through any trucker. So once you get the bag ready, uh you, we would put it through the vagina, but some of us noticed that we were getting a little more infections at the surgical site of the umbilicus because then that bag is coming up and is resting against the incision. One way to counter that potential infection would be to put a, an additional soft tissue retractor. You buy, there's still by applied medical uh it's, it comes by itself and it's, I mean, 10 times less expensive than the whole gel point system. And you can put that on the skin and then bring your bag up. But you need to put another one in. So you're kind of, um, you're at maybe, I don't know, 60 70 bucks or something like that, depending on your contracts and all that stuff. But that's one way to get around that. But I wouldn't do it on a routine basis because you're probably gonna notice you're dragging bacteria up from the vaginal world. I mean, I don't know if you just dip the whole thing in beta dying and do it. I don't know. You know, I wouldn't, I just wouldn't do it. Um, the second thing is, uh, you can do it laparoscopically too. So you finish your case, you did not use a gel point. You basically lift up on your trow car, your camera is out, you lift up on your camera trow car and you cut right down on your tracker to find your fashion. So it's quick and easy down and dirty way of getting your fashions be open very quickly and then you can drop your bag in and then you know the key is gonna be. Well, how do you keep, you know, how do you keep New Mo at that point? Well, you're gonna have to put some sutures in your fashion anyway. Why don't you put your first few suture, uh, sutures in your fashion then put your camera truck car back in because you've, you've, you've got that closed up. Maybe you don't tie him yet if you want to be super efficient with it. But you're gonna have to do close that hole up while you put your camera car back in and then recreate your new mo. Then you've got your bag in and then a lot of people I know will put a little more than just that loop. That technique I showed you you re dock if you want to dock again or do it laparoscopically, leave your ports in place and then you have maybe a couple more of those little, not a loop but just little strands. One of my friends, Rick Farnham, I don't know if he still does it, but he used to put in Marceline tape, little little things of Marceline tape around the bag edges so you can, somebody can hold that and grab it and then somebody else can put it in, then you're doing it more laparoscopically. I don't advocate for that if you saw how efficient it can be. So that's my favorite way of doing it. But if you don't have that and your department's not gonna buy that stuff for you no matter what case you make. Um Then that would be, those would be my tips to do it that way. And then uh one more question on the bag, right? There was a question about what containment bag you use that for you to ride that are greater than one kg. You have a specific bag that you use for that. Yeah, I just showed it to its applied contained extraction system and it will, we've put 2800 g you Terry in there. Um, it will, it's 17 centimeters. That's, that's the 6000 ccs volume. Now they make a smaller one and for smaller structures if I'm doing myomectomy ease and it's, it's not some enormous thing above, you know, let's keep it low, like four or 500 g worth of stuff. I mean, put a bag on a stick in there, you know, you can use a bag on a stick, but that's what we're talking about tonight. We're getting big like big uterus, right? You can easily get 2000 graham uterus into that bag. Yeah, not to interrupt. This is Alan, but we have time for one more question this evening. Okay. Okay. One more question. Uh There's a bunch of so many have come in at what point? Uh Would you make a decision to schedule a? Th that's a great question. Um I would, I would say never, but I would say one time in about the last, I don't know, 15 or plus years, 20 years, maybe I'd say maybe 15, but that uterus was £24 £24. And the, the fungus measured 65. Now, I do have friends I've seen do some that were, you know, kind of ridiculously large, but this also was, was not um the mobility part is important, you can make mobility happen internally. But, but this was I called in one of my Joanne oncology colleagues. And neither of us can make heads or tails out of it even, you know, through an enormous incision. But that's the, that's the one off, right. That's the one off. Um I just, you know, it's, it's practically never really, other than that case, it just be, um, you know, there's always reasons, you know, there's always a reason um where you are or, you know, in your hands or with your particular people that you have helping you. Right? So, um, but that, that would be my answer from a personal perspective, but I wouldn't, I guess the point of the tonight would be to say, don't do it just based on size, you know, not size alone. Um Two prior myomectomy is that we're open and you can't see. Uh I mean, that's one thing but let's just say mobile enough, it's 24 centimeters, 26 centimeters. Um You put your camera in, you work on the side of it, you, you know, kind of move it over, you get passed around ligaments and you're like, man, this is actually a lot easier than I expected that that was kind of the point tonight. So there's always one offs. But um to answer that question, it's, it's practically never. Yeah, that I would schedule a th good. Thank you, Dr Garza Created by Related Presenters Devin Garza, MD, FACOG Director M.I.S. St. David's North Austin Medical Center and Surgical HospitalTexas Institute for Robotic Surgery, Austin, Texas
