Objectives
Develop a framework for case-based device selection & trouble-shooting
Demonstrate assembly of the various uterine manipulator platforms
Demonstrate proper use and setup of the ALLY® UPS
Illustrate clinical correlation with video vignettes
Presenters
Arnold P. Advincula, MD, FACOG, FACS Levine Family Professor of Women’s Health Vice-Chair, Department of Obstetrics & Gynecology Chief of Gynecologic Specialty Surgery, Sloane Hospital for Women Medical Director, Mary & Michael Jaharis Simulation Center Columbia University Medical Center New York-Presbyterian Hospital
Chetna Arora, MD, FACOG Assistant Professor, Department of Obstetrics & Gynecology Division of Gynecologic Specialty Surgery Columbia University Medical Center New York-Presbyterian Hospital
greetings, everybody this evening or I guess people hatching in from various time zones around the country and around the world. But thanks to cooper surgical again for sponsoring this event. And really, yes, I'm really excited to be with doctor or again, I know a couple months ago we did a program together. So it's it's great to be with uh former fellow and now partner. Yes, definitely. So, um this is gonna be kind of um really free form, um, we have a agenda here that we've outlined for ourselves. A lot of things we want to try to cover over the next 60 minutes and so please feel free to send in your questions. Doug's gonna farm away at us as they come in. Hopefully we'll be preemptively answering these things for you. Um, We have so much we want to share. Right. Well, why don't we get started? Let's do it. Um, do the room me. Yeah. You know what, one of the things that I think people often forget about with regards to, you know, manipulation is that it isn't just for hysterectomy, right? That really it's critical to anything that we do in gynecologic surgery, right? I mean, we get the advantage that we get to move the target organ, right? And so whether you're doing a hysterectomy or a conservative surgery of fertility surgery, arguably the most important arm in the surgery. Absolutely. I think for hysterectomy, whoever's down below manipulating your uterus is probably more than half the case. That's the value of that. So we thought we talk about the platforms that are available and start with the historical kind of the tried and true the O. G. Which is uh the room you to handle. Um And then then after the roommate to handle came the arch, so we have the arch coefficient and then are roomy tips. And then the most recent member of the platform is a delineate er uh now delineated is very specific to hysterectomy. So what we want to do is just sort of talk about the importance of just setting yourself up for basic user manipulation. And we're going to talk about the roomy to handle and the arch. So you know what I mean? What's the what's the most important thing when you're getting yourself set up right? Like if you're just having the right equipment, having the right setup and knowing how to use your equipment. I mean, it's a really understated that typically, you know, the most junior person in the room is getting things ready and the one who's setting up the from below the foley goes in, the manipulator goes in. Everyone's ready to go at the top of the belly, but Half the surgery. The most important part is in the 1st 10 minutes of setup. So it's just about getting your equipment. There's only a few things you really need to do. A manipulator replace one. That's right and we'll talk about that with a model that we have, how to do that. But you know, the important thing when you utilize like a roomy to handle or an arch is you have to do a tip selection and I just want to talk a little bit about how you use the roomy tips. So there are a variety of tips. Um I'm gonna start with the ones that are most commonly going to be utilized and that's going to be the, the six inch tips, uh six centimeter, I should say. Uh there's a much more narrow diameter or caliber to the purple, but that's six centimetres. There's a white one that's six centimeters. Then you go to eight. You can see here um with the green, you're going to 10, yep in the final of the 12, 12. Exactly. So the way you place these um are obviously the setup here is its dual. So you've got one funnel that you're going to use to blow up the tip balloon, which is going to hold it in the uterus after you've sounded it to make sure it's truly a trend. So you use your 10 cc syringe and you're just going to use Saline. We have air here just for demonstration purposes and as I fill up this balloon at the tip, you have your balloon filling at the side right here. Then you just clip this shut because the moment you pull this off, the air will come right back out but that retains the air within the bubble and its side opening, which is important and that's something we'll get back to a little bit later. It's the location of this balloon when you inflate it. And then the other piece that you're going to see tubing wise is for criminal motivation. So the nice thing about rumi tips is you've got a way to secure it in the uterus and you can chrome up our debate. But let's go ahead and release this and talk a little bit about how we attach these. So when you attach this, for example to Rumi handle, I'm going to go with the white one. Just gonna pick this one. Just, you can see the whole range of sizes. This is also six inches or six centimeters but of a slightly thicker diameter. Place this on the end. Can you pick this based on, you know, sounding the uterus and then the diameter you can choose based on, you know, the caliber of the cervical enteritis are cervical. You find this is helpful a lot in patients who you need, you know, manipulation. But it's a reproductive aged patient. Um, you know, you don't want to, you want to struggle to dilate and you can get this in a lot easier. Uh, the rest of the roomy tips are all the same diameter when you start with the white all the way on up but you just twist on to the end and then you have this and there are channels on the sides that you can literally place the tubing just to keep it out of the way neat and organized and I don't know if you want to show putting it on this one here, like getting a Yeah, sure. So why don't I take, I'll take the eight tip and I do the similar setup. There's channels for both sides of it equally as well. Yeah, what's nice about it is this part here is kind of a soft cushion. So all you do is you place the tip of it in through here and there's a little channel that it fits right in and you just screw it right on top. Then on the sides there are the same channel. Sometimes I like to use like a dilator, something on the side just to roll it in so you can just fill it in the spots. Then I just slipped fingers all the way down. Then there's too little grooves that you just are able to stick it in. It's important that they go in the grooves and we'll talk about that later when we um particularly show with the co cup coefficient cup and then attaching it to the ups. So the uterine positioning system. So there are different groups on the sides that help you place this to keep it on the way. And I don't find it as critical when you're not doing a hysterectomy with these handles because I sometimes find it's easier just to let the tubing hang off to the side. But certainly this is the setup. Now this is important when you're just doing straight out, you know, manipulation, you're not taking the uterus out but you need to be able to move the uterus back and forth. The nice thing about rumi to handle is you can articulate at the distal end at the level of the, of the cervix and and the whole device can then also be so a lot of degrees of movement does require a bit of a learning curve to definitely master that. But once you do um you got a lot of degrees of freedom with this and then with the arch it's it's more following just the curve. Yeah, just because as you know, the pelvis, the with the uterus itself, it's kind of sitting in that whole sacred bowl and the whole purpose of just getting to those vital structures, you just have to push to lift and it has that natural curvature. Now let's say you want to do a hysterectomy, you still have to do the same step. But the next piece to that is then choosing the copa to me cup. So both of these work with something called coefficients but their specific to either room to handle or the arch. So I'm just for demonstration purposes. So after you've put the tip on so you've already sounded the Uterus, you have your 10 Akron, you have your speculum having been placed first, then you're going to assemble your manipulator. So we have the arch with the roomy tips selected this, then goes in through the side so this piece will slip in pretty readily. Then you just push this through so that the peace now is free floating within the device. There's a little piece here that's blue, you make sure that's lifted and released. There's a groove in the handle and that's why it's important to have those pieces clipped in so that the tubing stays external to the coefficient cup, you clip it in, it's pretty gentle right there. It'll slide then with one hand, I typically just slide this in until it reaches the cervix itself. Sometimes when you're holding this, you can kind of use your left or your non dominant hand to hold it and use your dominant hand to kind of slip it into the vaginal enteritis, sometimes either lubricating it or being able to just kind of navigate it by moving it slowly. And the key thing here is that um again, um the beauty about this is it's back loaded, right? So, uh you always want to keep this, this is the setup when you're going to place it in a uterus that you're gonna do a hysterectomy on, right. So you have to go through all the same steps as we showed you earlier. With the exception that you've added a coefficient and now you're in the process of placing this, you got to put in the uterus inflate the balloon, get that situated, get all your stuff out of the way and then you're gonna slide this down as as as chicken. You said it should be a sweeping motion and you're going to feel this, there's inaudible and almost a palpable click. And then once it's in, you have to remember to lock it in place and this when you'll feel it, this should be if you've sounded correctly, which is truly vital that will make sure that this is accommodated for the length of the cervix, but all the way up to the funding of the uterus. So this is flush with the cervix, which as we were discussing hysterectomy culpa to me, you want this as tight and close to that for next as possible. In a similar situation occurs with the, with the coefficient for a roomy to handle right? You do all the same steps, you gotta sound, get the right tip length on there, then you're adding this piece, right, you're going to add this piece that again is similarly back loaded, right? So you want to make sure that this, this goes in the proper location so that when you're, when you're placing this, you can you can slide it, it's back loaded, right? So that you can have this pull back so it's not in your way, anybody has used the original roomy handle knows that you had to front load the device and that would make things really complicated because you had a cup sitting on the end and you're trying to place the room a tip and the cup all at the same time. Now it's it's back loaded. And similarly you're going to slide this forward and it's going to be a similar situation where it's gonna, once it's in the right location, it's gonna click into place. There's a lot of different little there, it's almost like palpable and audible that you have it in the right location. You also can see on here that there's an arrow that shows you where everything should line up, right? So this is properly placed and it is really key as we mentioned here with the clip, this clip cannot go down if it's in the wrong location. Right? So these are just little things that when you have trainees that are down below or somebody's new to this, that you don't appreciate that you could dislodge the coefficient. So making sure that you have these sort of audible, click, it feels right. It looks right, Same with this. And what could happen, say if we didn't have this clicked in and it was wrong. So if you don't have it clicked in and you're putting a lot of pressure on the uterus and you're lifting up, you could actually inadvertently slide this cup downward and it's no longer as flesh. And then when you get to the point where say you're making your copa to me, you have now made space where there shouldn't be and vital structures just like the uterine arteries that are there and the ureter so that click is good feedback. Yeah. You don't want the copa to me cup to migrate Caudalie during the course of your surgery. Because if that happens then it means that you are creating a coupon to me that much lower than you should be. And what does that mean closer to bladder? Closer to your nose? Because as the your orders come towards the midline that's happening neither lower down, right? So you you definitely have to be careful that but this is the proper setup but you can see and you know, we have both. You know, it takes some practice to get really down to like where it's like you're doing it like without thinking about it so much and it goes really quickly. But these are the sort of the key things to keep in mind. The question came in just the coefficient from the roomy to the arch look different. The question was, are the cup and the tips, are they the same or are they different as well? The cups are the same. And just to segue with cups which is I think a great example here is this is a hard cut and so there's some different types of cups that are out there. So there as you can see some of these have different kind of coloring on them. This is a metal external. So this is important because they say like you're using an ultrasonic device that will you want to avoid spark and melting that cup itself. And so that this is designed. So yeah, it's designed for the particular device you're going to use. So I think the first thing you take home is that the roomy tips are the same. Whether it's arch or roomy to same roomy tip coefficients are slightly different, but the material on the cup is the same. So for mono polar, it's an old time cup. This is the there's a blue cup that you're going to use for ultrasonic energy. You're going to request the metal cup because otherwise you're going to melt these with ultrasonic quickly. And then the other thing to keep in mind is there is a soft cuff. Um and that's that's this version here is a slightly darker blue, but I know a lot of john oncologists like to use this because for a much more narrower in troy Davis or trophic or postmenopausal. Sometimes it's easier to be able to squeeze that. You can see I can squeeze the cup here. Um That's that's more significantly more rigid. Yeah, you can't really do that, but that's the main thing with the company cups. And then the one thing that we didn't touch based on is the delineate er which is the sort of the newest generation reason we save that for last is because, you know, these two products, Yeah, these two products can be used for hysterectomy and non hysterectomy cases. Um whereas the delineate is really exclusively for hysterectomy, right? You're you're going to use this when you know you're removing the uterus, um it's designed to be, again, it's the coefficients already added in, uh it's ready set to be back loaded at the same principles, you've gotta, you know, um sound, the sound helps you set where you're gonna lock this window lock right here. And the one thing we didn't mention cheating is like picking the cup size, right? Yes, so in your kids comes as cervical sizer um which you basically, if you see on the borders of this right here, it says 2.533 point 54 and four is the max, it goes to so similar, 2.533 point 54, and we kind of have them all demonstrated here, so you can just get a general sense, but so like here is a three and we put it on here and when you stop the bar, the bar stops at a three, it's a little hard to see and appreciate here, but basically when you go in with a speculum, you're able to then just measure the size of your cervix and you're able to accurately objectively measure to pick up which cup you need and I feel like majority of when you have really been, you try, we tend to move toward the 3.5, 4 cups and I find it helpful to grab the cervix. Do I like to look at and say, okay, I think this is going to be the cervical cup that I need. I do think it's important to always make sure you the right side don't do it one size fits all. I think that that has some issues when you do that, that are bring some element to the case. That might complicate things. But there's clinical reasons why you go for a bigger cup, right? And we can talk about that in a little bit in terms of like sometimes you will intentionally up size, but I think the general good rule of thumb is choose the appropriate cup size for the cervix that you're dealing with. Quick question just came in. If you're using uh Advincula delineate er does that have promo perturbation? And if not, if you're doing a case where you want to check for patent, see what do you use for cuomo perturbation in those cases? Yeah, I mean, the delineate er like I said, is a hysterectomy device. So there's no, there's no coma perturbation to being in here because you're taking the uterus out, it becomes a moot point, but like we said earlier with uh roomy too and with the these two channels, Yeah, we have the roomy tips on roomy to an arch have the ability to come apart just because you probably are seeing three different chords here. So these are the two that came with the roomy itself, you have your coma perturbation and then your tip balloon include er and they're actually labeled on here too, so you can see them. But then there's also one more piece here, which is an important part here. So this is the balloon, it actually is meant for a 60 cc syringe. So after you are taking down your uterus and you're about to do your lobotomy, you have to think, you know, the new mo inside the belly can leak out the vagina. So the whole goal is to block that from happening and keep your visualization. So this is a new molecular balloon. If you hold it up, I can ensure. So basically every one of these are equipped with that, whether you're using it for hysterectomy or otherwise, so that it is a little bit more universal if you hold it this way, so you can use, you know, and then as you can see it inflates and it can go up to whatever size you know, you feel like you need to use and it can be pulled and retracted. But this piece comes off Afterwards too, and we can show that and I usually think 62 maybe, and I'm going to go up to 90. I usually find 60-90 is all you need for this. Um and that's going to hold your normal perineum in an both of us. Like I don't like to inflate this in time. Ready to the company just till the very end. I think it distorts the anatomy a little bit and it just helps you see your plan. If you look at it on the side view here, you see the balloon might elevate the vagina off of the cup and then you blunt a little bit this visualization of the copa to me ring. So I like to just say, you know what? We're going to wait until we're ready to call pottery. Then we'll inflate this right question was why would you use is delineated for other cases, you know where you use roommate or the arch is because of the soft tip on the room in the art because from a probation or you know, why would you focus at just a good question. A little bit of surgeon preference? I'll be honest with you. You know, it's what you're comfortable with. I was exposed to all of these and even a couple of other delineate ear's and I think it's a product of your training. It's a product of what you feel most comfortable with. Some people really love the roomy. I personally find these two devices to be more friendly for me. But particularly if I am going to do a hysterectomy. I choose this one because it is a little simpler. It's all inclusive. I do like this one for if you're thinking about other multiple different procedures, all included and we'll get into that whether you're a guy an application later. But it's really a surgeon practicing surgeon preference. I mean, I'm going to share. We're going to move into a segment of the program. We're going to share some clinical correlations and why we like why I choose and cheating and chooses. Certain manipulate is based on what we're trying to accomplish. But it really is a surgeon preference, what you're comfortable with, what your assistant is comfortable with. And I just want to before we get any further is a shout out to all the people that are done below because that is one of the most critical jobs in the world. So thank you for the folks of all the all the all these years held the manipulator because that's why, you know, we find this is really important. Part of the webinar series is just setting yourself up for success. But we don't want to touch base on like moving into like just a clinical troubleshooting piece. Right? So now, you know about how to construct and put these things together. Um but what about like just placing it? It's that's where there's a model. I'm gonna slide over here and show you some things put some gloves on. We're going to work with the dinosaur model. Uh and it's just been fantastic working with this product because it brings a lot of fidelity to teaching. Um it's about as close as we can get to having to use a cadaver. You know, there's obviously a lot of limitations with using cadavers, there's a lot of benefits of course to, but at the same time that makes things a little bit more challenging. Um you know, this is a great model, we actually cut it in half, we kept the cervix in place, so I know that this is not the perfect visualization of the model itself as a whole, but we want to show you how to place this. So this is a sagittal cut before going back to our looking at mris and stuff, but we've created a sagittal cut of the uterus but with the full service still in place, just you can see some pilot points that we think are really important sometimes get lost in translation. Yeah, so what I'm gonna do is I'm gonna show it to kind of from start to finish. So he's going to pretend to be the body of the uterus or the whole body basically remind everybody about what are the key, at least the bare minimum instruments you need on your bottom table there right here, avoid of the scalpel that's for a future demonstration, but I will say this, so you need a open sided bivalve speculum and that reason why is because when you place the speculum in, you want to be able to grab the cervix, whether you grab it horizontally vertically etcetera but you want to be able to go into the vagina and then pull the speculum out while leaving the team back in place so that these are the two most critical pieces then. Or even just to be able to pull all your instruments out. Um Once you place the device right, if you use a close sided speculum you're not being able to like extract your equipment because you're going to it's going to be around your manipulator. Then you need a uterine sound just so that you can actually measure to approximate whichever manipulator of any type of manipulator to use then dilator so that you're not forcing it through and then perforating in the wrong direction. Because uteruses with different pathologies can be sharply voted in any direction you need to dilate. So I see a lot of folks going to the O. R. And they're trying to place the manipulator, they don't dilate. It's a problem. You need to dilate. I often say I like to use prattville laters and I used to say at least 21 21 french with a prep will accommodate any roomy tip. It just makes it less of a complicated process if you do that and we have a couple on here whichever one Hager's prats whichever, so basically I will place a speculum into the vagina. And so what I'll do is here once I can see the cervix and view, I'm gonna open it up a lock it in place and I'll have already hold it for me just so I can demonstrate a little bit easier for you to see. So the speculum is in place, it's a little bit on the narrow side, that's okay. And so what I'm going to come in from just like I would from below and I'm looking through here, let's do a vertical grab, like grab one tacular um tooth in the cervix and went outside vertically. I just feel like I can pull a little harder and not like tangentially have a rent in the cervix but you'd like to grab. I'm a horizontal person but teach their own right? So basically then I'll take the uterine sound. And all I'm gonna do is I'm gonna obviously follow the internal loss but we open this here to kind of give you a demonstration with this uterus kind of cut in half. Is that basically right through here. We were setting this up before. Yeah, just the internal size so perfect. So we're now that we're inside the uterus, I'm gonna come up to the fund is and I like the subtle cut because you can kind of get a real time view. So now that I'm here, I'm going to feel for the length of my servant and my length of my uterus. I'm gonna put my finger on the speculum inside the speculum pull it out, get my measurement, okay, my uterus measures about 8.5. It's important to know that we are in between sizes here. Right? So then I would go and measure to about an 8, 8.5 on here. Now I'm going to dilate the cervix. So same setup as before, make sure this is pushed in. We've had our model stalling for a little while just to have it ready for today. Perfect. And again, like I said 21-23 French with a dilator. Um These are Hanks and the one downside, I don't like about having that little collar on there is um here just help you. There we go. Is that with the collar? Sometimes you can't get up into the cavity where you really need to be dilating, press the internal lost if you have a long cervix. So just be aware that sometimes you'll have a long service and you can't get in and it makes it difficult to get all the way past the entrance just for the sake of demonstrations, we've dilated this one up just to show. So now that I've dilated this out, what I'm going to do now is I'm gonna actually going to take the speculum out but the 10 actual um will stay so I'm just going to release my speculum before you do that. I will add that. I know you like to take everything out and then place because you're pulling on the serve because sometimes it's high up feel it in, its high up your place and you can place it with this first with the speculum in the same kind of con same concept and it's in thanks. So now we're going to hold this here, I'll release this. Obviously you have the body to help you hold things in place to side opening spec comes out, this is why you need to open sided by about speculum is you wanna be able to remove it and and and work with things without it being caught in your speculum, right? And then we would have already at this point inflated the balloon. So now that I have the industry, so important thing here is I wanted to demonstrate is if you say, you don't have it put to the as high up to the Fund us as you thought and say, I'm blowing up the balloon, what if I blew up the balloon here, you're gonna get a lot of resistance because you're gonna blow it up from this side here and you're never going to get the right torque on your uterus, right? So, if I actually inflated it here and I push this and I locked it up when I'm trying to anticipate their uterus, imagine the post of your aspect that fund is just dropping back and if you have a big post, your uterine, my oma or any my own was for that matter, you're never going to get the right to work on your uterus. So I mean the key thing here too is that before you take anything out like your speculum, the first thing I do is once I place this is I do inflate the balloon. Yeah, you'll inflate the, so I'm going to inflate and inflate it right now and you can see it opening up right here at, it's inflated and this automatically locks. You don't have to like clip anything this way, it's not going to fall out by accident while you're tooling around trying to get the speculum out and things like that. And I've used the tonight purely for the purposes of getting it through. Right. And so I'm at the level of the fund us now, this is, it slips and slides. It's pretty, pretty straightforward. But if you look at this, we're just going to have this slide right up to the cervix and I know where I'm at because I measured the uterine fund is from here. So I said about 8.5 and right here I'm going to clip this in at the funders and it locks now you're already in. So there's a window lock here that correlates with the sound, right? So where she sounded uh, so that's proper placement, right? And then again, just take home point is, and we chose the right cup. This needed a four centimeter Kalpana me cup. Um, it sounded appropriately and the tip is right towards the fund issue, I want to be through the fund this, but you want to be at the funds so you can actually manipulate like, as, as chairman said, you don't want to have this thing being sitting down here low, um, down at the lower uterine segment. And then if you have a top heavy, large, bulky uterus, you're just going to lose your manipulation capability. Um, the other thing I want to make sure we bring up is, um, if you don't sound the roomy tip properly, particularly with, let's do the smaller ones. So let's take this one, for instance, say you measure this is six centimeters. Yeah. Let's say that it's a bigger, much bigger uterus. Yeah. Say you accent, you stop or there's an adhesion or you don't realize that you're not at the fungus and you're blowing this up. But the balloon is here on the side, right? Let's, let's take this out. Show to the balloon deflated and then it just backs up fully. Yeah. So imagine if you're putting this in from here, right? And this should be flushed up against the cervix. Now, if you notice, like I'm, I'm as high as I can possibly go. But I don't realize that because I don't have the perfect sagittal cut when we're doing our case, right? So what I'm gonna do this to a hand. Yeah. They handle just so that we can, but as you can see like what we're trying to demonstrate here is the balloon is buried in the cervix and at first you're like, okay, wait, maybe this is a good thing. What if it's like, I can't get inside the uterus. This may be a better way to facilitate, say like a difficult entry. There are challenges with that. There are two reasons why your balloon won't go up. It's going to be you're too short on the roomy tip and you're literally sitting in the cervix still the canal or you're in a false track. Right? And so a lot of people say we can't get the balloon to inflate and then they pop it trying so hard and I'm like, I can't, I can't fill this up. I'm hitting resistance and that's because this thing is not sounded appropriately. It's a short roommate chip. It needed to be, you said 88 to 9, right? Um, and this is only the six. So you're literally sitting in the cervical canal and I think that's an important take them, a lot of people will struggle and I can't get the tip to inflate and that's why you're either false track or you're sitting in the cervix, right? So that's the importance of making sure you sound, I think also really important point is don't take this spot this particular step for granted. If it's difficult entry, go in up top and then go back and do the manipulation under visualization because it really is a make or break point of the game, right. Questions came in just about seating the cup, right? One of them was, do you ever get a service that is flushed with the vagina? Right. And if so, how do you get the cup seated? And the second one is a surgeon said that uh sometimes he has to attach his cup with a stitch. Right. Do you have to do that with these products? If so, what do you do? Well, the stitches an easy one to answer with this device. You do not have to attach it with a future. It literally pretty with delineate or any of these products, if you do it properly, if you sound correctly, choose the correct cup, this is going to rock in the appropriate location. And it's gonna, it's gonna be correct. It's gonna be up against the hornets. And you actually, I don't like to put a stitch because then I can't I don't want to lose my ability to rotate the handle around, right. Uh And so it's not uncommon that you're pushing from an upside down handle to get a different antibiotic. Yeah, so I don't want to pin it down with a stitch. So I don't you don't need to stitch with the cocoa powder makeup before we jump to answering the question about no cervix or flush cervix. One of the things that we can show with that other model here. Um Sometimes we're gonna, you know, one of the big issues that you're into like their previously operated on cervix. That's like cyanotic, right? And one of things that you mentioned and there's this 11 blade, you know, sometimes you can see the dimple of the cervix. Sometimes you can sometimes you can't, but if you can at least see the dimple and you're having trouble trying to dilate. Like I hate lockable duck probes personally. I know you know, I hate those because I think they force you to make a false track because they're so fine That when you push hard enough you'll go anywhere. So I just like to take a 11 blade and I just create a little bit of a cruise ship incision. So I go, You know this way? And I just rotate it 90° and pushing again and and cut right at that dimple. And usually that's all you need to just break that scar tissue up the sick of tricks. There's a scar that's there at the cervical, opening the external loss or the new external loss based on the prior surgery. And then you can dilate, right? And I often try to start with a little bit of a fatter. Not not the, not the biggest dilator, but I take like the smallest sound. It's bigger than a sound, but not your massive because I just find this is going to allow you to find the right track as opposed to going with a really pointy narrow skinny dilator or you know, somebody can use us finder. Obviously that will work too. But um let's go to that question. That's a great question. The person who sent that question in because that is a common problem. It's common enough that we wanted to prepare for it. We actually have a model. We Afghanistan helped us develop a model here to kind of just demonstrate. So this is a uterus sand cervix basically. So uterus is here and what we did is we this is the this is like to work with us here. This is the vaginal vault here. Like ex vivo uh with this model that they built and the vaginal wall interior has been open. So you can see like inside, right, you can get a view that there's no cervix sitting inside this. So, this piece is just truly absent. This is absent. The cervix is gone. But the good news is that it doesn't take home point. It doesn't matter that you don't have a cervix in the physical vagina itself, right? The most important thing is getting in. Obviously there's a there's a whole new set of challenges, right? Like when you don't have a cervix and vagina, you know, your dilation part is going to be a little bit tricky getting you tip into the proper cavity, but there's no cervix here. And so it doesn't matter because as long as you can place the the uterus appropriately sounded. Get it into the cavity inflate their distal balloons locked in because the distal balloon is inflated and you bring the lobotomy cut down and you lock it in place whatever manipulator you use, this will work. And then when you look at it from above laparoscopically, you're going to see the copa to me cup right? Like you're going to see this delineated for you. Like any other case that you would do laparoscopically because you are as flush as you are. You're not going to be doing like an upper vaginal ectomy. You truly are just flush up against the lower uterine segment. So it doesn't change anything. The hardest part of those cases is actually getting into the comedy. But once you're in And I usually just for the most part because you can't size the Cervix you don't have unless the Vagina is really narrow. I typically will utilize like a 3.5 and this is pretty often default. Yeah, I mean, and that's probably the most common cup size most people will use as a 3.5, but I'll try to 3.5 really place that flush up against the four knicks, make sure you lock it down whatever you know, obviously sounding is key, but it will be in the right location and you shouldn't have any issues. I hope that answers the question for our viewer, the shortened cervix, that trickle ectomy all sorts that any, any sort of application. The other piece that we want to talk a little bit about is be a bladed. I feel like this one comes up a lot and you know, as a trainee, when I was starting, this was definitely a question of for me, you know, we use these devices a lot and a bladed. You do. I tend to be more of your smaller, you dry, you know, but it's just, it's one of those things you can get. Getting in can be a challenge, but it is totally feasible, right? This is what I always say. Um well, two things, right. We were talking about this earlier. Obviously, you know, it's always ideal that when you're perforating through a uterus and because we're gonna talk about perforating through a uterus that's been a bladed, you want to have a sampling. But obviously the problem is you can't get into the uterine cavity. So how do you sample? Um, I think that's a judgment call on the surgeon side, depending on your level of suspicion with with what you think maybe going on inside that uterus. Um, but you know, to me it's all about doing this under direct visualization. You'd never do it blind, You would want to have a laparoscope up above while somebody's down below getting your manipulators set up here. We have it cut out. I mean again the vagina has been incised and tears. You can see things. But you know, if you have a dilator in there, you could intentionally with some traction with a tin, accurate on the answer of the of the cervix and a dilator. You know, work your way through the fund this and intentionally perforate this thing through the very top of the uterus. Right? And so that's what I'm gonna do right now and you would do this under direct visualization. This model has been created to be like an a bladed uterus. So it was really glued it. So this is I mean, it took a little bit more effort for me to get this through the top the dilator. But you know, if you really truly have an abraded uterus that you cannot get into the cavity, we tend to like under direct visualization if we suspect it's benign pathology is just watch and perforate through the fund is right. Um and then when you dilate this up, you follow the same track, you follow the same track and then you can place your manipulator and in this case, for example, if I was using like ruby tips on one of the um would be to handle or on on an arch or even this. I would intentionally make sure because here's here again, here's the here's the cervix, here's the uterus, I'm gonna choose the biggest tip, right? Because it's okay that I I perforate through the top and I can then I can inflate the balloon beyond because I knew sandwiches in and you hold it just blocks everything locks into place with with whatever manipulator system that you use. But you need to do this under direct visualization, you to do it at the fund because if you go in the front or the back, you lose manipulation capability and you certainly don't want to perforate through the sides because that would be problematic. You get into bleeding at that point and if you truly can't get in or you're concerned about a malignancy, there is the option of a shorter test. Let's grab that. And so there's a really short tip. And the only obvious downside of this is that you don't get that much arc of the fund is right, but you will get the benefit of the cup for your culpa to me, which is a very crucial part of a hysterectomy. So again, we don't have coefficients hooked up here. Just for demonstration demonstrates, I'm just going to pull this off this handle and attach this. This is the shortest roomy tip. It's probably like, you know, usual services like 3 to 4 centimeters at most. And this will fit right in the difficult part. Was getting it to be blown up. Maybe a challenge because you might have some resistance as we measured before. It just really is going to sit in the cervix. So you can use this with the coefficients, right? These will work with coefficient and then your other instruments to help kind of lift the uterus and vehicle parts. And that's if you're concerned about putting anything in the uterus. Also, if you're worried, even if it's not a bladed, um, if you're going to use a delineate, er, then, you know, the piece here is that you just have to dial back, you're going to really pull the handle back pretty far so that you don't have much of it sticking out. You can still take advantage of the cup, but if you're not able to get in a lot of times, it's just, these tend to be smaller, you'd arrived, they've been a bladed, so you just want to be able to see the copa to me cup.