Post Program Survey
Sacrocolpopexy: Techniques for Challenging AnatomyOriginally Broadcast: April 7th at 7:00 PM EDT Objectives:
Learn efficient techniques for 90-minute outpatient Sacrocolpopexy
Troubleshoot complicated anatomy in Sacrocolpopexy
Avoid and manage common & severe Sacrocolpopexy complications
Presenter
Richard Farnam, MD
Welcome and thank you for attending. This event is brought to you by Cooper Surgical, a leading provider of medical devices for women's health care. For 31 years, Cooper surgical has worked with health care providers to provide highly effective clinic and practice-based contraceptive, surgical and obstetric solutions to complement our portfolio of trusted and reliable medical devices. We have also broadened our offerings, investing in the areas of reproductive genomics and in vitro fertilization. We are fully committed to helping improve the delivery of health care to women and their families. Cooper surgical manufacturers over 600 clinically relevant medical devices used by health care providers and offices, clinics, operating rooms, labor and delivery suites and reproductive IVF clinics worldwide. Clinicians overwhelmingly say they trust our products for their reliability, innovation and efficiency. Here are some other interesting facts you may not know about Cooper surgical. Since our inception in 1990, our focus has always been women's health care With more than 600 medical devices and over 3200 product numbers across a broad range of market segments. Physicians know and trust our products. We ship over 1450 orders per day, of which 99.7 are shipped the same day. Our customer service department handles over 2100 inquiries per day. We employ 1800 people worldwide. We are pleased to provide this educational opportunity on behalf of cooper surgical. Welcome and thank you for participating in tonight's event. My name is Alan Ships and I will be the mini manager for this evening's program. A couple of notes on how the presentation will run. We will have approximately 60 minutes for the presentation, followed by a question and answer session. To submit a question, please click the asking questions button located under the player window and fill out the form. Dr Farnham will participate in a 15 minute Q. And a session upon the conclusion of the presentation. If your question is not answered this evening, you will receive a response from cooper surgical after tonight's event. Tonight's presentation is entitled sacral Kolb opec see techniques for a challenging anatomy presented by Dr Richard Farnham. Dr Farnham is the market director. Euro Gynecology in robotics Tennant West campus governing board texas tech tenant, Trans Mountain Campus Assistant Clinical professor texas Tech in Borough College of Medicine. Euro gynecology residency director Hcea, el paso texas. And now let's turn it over to DR Farm. Well, thanks for bringing me in today. This is an honor and a privilege to present. Uh thank you for that wonderful introduction. Um by way of disclosure, I am on the Speaker's Bureau for cooper surgical, intuitive surgical and caldera medical. Today we're going to talk about Sagara complexity. We're going to talk about efficiencies and complications. So here we can see a example of a re operation for a disc Guidice. So in this particular case the mesh would have been attached to the L. five disc and an inflammatory process ensued. And this necessitates a re operation to actually go and completely remove the mesh. As we can see here as a camera kind of goes in and out. You can actually see the esteban fixation. Futures are still right there at that a pickle fixation point on the mesh and they have torn through their attachment point due to the degeneration of the disk space. So this is a rare but severe and important to understand complication that can occur from say cork apoplexy. And I think it belies the point that we you have to be very aware of identifying the disk and also um aware that this complication can arise. So if patients start to have this back pain complication were um have that in our differential and so we can evaluate that. And we'll circle back to this as we get more into the complications. But I just wanted to you know, jump out front here and show you what what we're in store for today. So uh full disclosure. My usual talk is about two days long. So I had to content a lot of material here to get through as much as we can to identify efficiencies and sick or cotopaxi Ideally this this surgery needs to be about 90 minutes if we've optimized our team and our own economy emotion without compromising efficacy. You know we we can get the surgery down to about 90 minutes. About that's about as fast as we can go at our epicenter training facility, we're gonna learn to identify what the complications are that can occur and also how to avoid them and when they do occur, how to manage them. I'm not gonna have time in this presentation to go through every single step and efficiencies. But I would certainly encourage you to use the resources through our eggs and A. G. L. Um other dinner events as we start to come back online and process all the vaccinations and and the country starts to open up more through cooper surgical. And we also have a full course with uh five hours of video review and then a hands on uh model where you actually get to do the surgery through intuitive based in Sunnyvale and um uh Atlanta. And then we have a course coming up in Vegas uh in May. So I'd encourage you to use this as a as a first step and then continue to expand your experience around the procedure. So, in as much as I don't have time to go through every single step, I think there are general principles that if we adopt to see agricole pixie or any surgery, we're going to fine tune, enhance and optimize the procedure. So we have to have a way of doing the surgery every single time in an airplane, they have a flight plan. It's basically, we're gonna go from here to there and we're gonna do it the same way every time, understanding that there's little course corrections that occur continuously. But we really need to almost habituate the procedure so that we sit down and it's almost automatic. There's no higher level thought processing that goes in. It needs to be very mechanical so that when challenging anatomy or complications or adhesions or some other pathology does arise, you know, we can use all of our, you know, trouble solving cortical processing to deal with those issues. And essentially the procedure itself is automatic in any surgery. We want to uh eliminate variability and we want a parallel task as much as we can. And two examples of that for a team example would be, You know, you can prep abdominal and vaginal at the same time rather than serially and you can save five minutes a case. There another example on the surgeon side after you doc the robot, rather than just sitting down at the console, you can go ahead and prep the mesh. And that way when the mesh, when you're at that point in the procedure where you're ready for the for the wire uh to be uh introduced, it's just ready and they just drop it in. You don't have to get back up and then prepare it and then surgical principles and these apply to whether you are in the pre sacral space. Space. Maurizius, uh erectile space, the principle of traction, counter traction. This kind of underlies an evolution of surgery that we've seen from open. We're using both hands to operate to collapse, risk opic and then robotic with laparoscopic. The truth is we trained an entire generation of one armed surgeons that hold a camera and have a fire stick and burn things. But with robotics you get both of your hands back and you need to utilize that. I. Proctor all over the country and I see people on the robotics still only using one arm. So we need to utilize all of the resources that we have available and continuously provide traction and counter traction. And in these spaces a lot of it is just sharp cutting mono polar cutting energy. When we have little vascular connective tissue brief versus coagulation energy. But it has to be him a static. The main advantage of being in these retro personal spaces is the anatomy is preserved so you can have a cold a sack of liberation but below the peritoneum the anatomy's preserves. So once we start getting bleeding in these spaces we lose that advantage. So I only see cut through what you can see through um and really identify all the critical structures that need to be identified and we'll kind of go through that as we go. Another general principle go from known to unknown. Um If you're making your you know if you have your post here and called uh an answer laparotomy incision. And then you're gonna get your lateral incisions go from where you already see the cup into where you don't see the cup. Um And that will always kind of guide you and keep you in the right direction. Next slide. Um, we have to build the team that also kind of champions. The idea of doing, um, whatever it is that you're doing, so robotics, you're going to college, the cigar cotopaxi and it helps to have team targets like what our goals a team because we have a process of learned helplessness is that, you know, well, you know, we're going to start on a 8 30 for a seven o'clock start time because that's just how they do it here. Well, it helps to set forth, um, at the beginning what your goals are. So if we have a seven o'clock start time, that means we're In the room at seven and it's not gonna be perfect. But as long as there are goals established, um, you know, you have something to move towards again when we discussed the importance of being consistent and this is a lifelong learning process. So go back and watch your old videos. Uh Sometimes still say man, I can't believe I was doing that. You know five years ago or five weeks ago. You can see your progress. There are lots of resources. Uh there are surgery, you is a good resource, the chairman of the probiotic special interest group at A. G. L. We have a facebook page with a lot of good video resources there to name a few and really there's no substitute for committing To doing the volume that's required. We know that a robotic hysterectomy. The learning curve is around 50 cases and the cigar is a harder procedure and you really have to kind of get through that in a year. So uh that's one a week which still is probably a pretty low bar, but that's the commitment it takes to get the reputation reputation, not just for yourself, but for your team because if they see it and they do it over and over and over again, they're all going to get better as well. All of the efficiency targets that I'm going to share with you, they're not going to work if we're doing well in case every month or two. So one of the other things is we need to utilize all the technology that we have available. So when it comes to the robot, we've got four arms that use all four arms when it comes to vaginal regulation. A lot of times this is overlooked, particularly in sacred texts. You know, we can use our fourth arm to manipulate the Cervix 12. You could, but you're really taking an arm away from the efficiency that could be utilized uh optimally if you had all four arms doing the surgery. And I mean, let's face it, the vaginal manipulation manipulators, a free port, right? You can put in um your coin, you can put in your delineate er and you can position the uterus or the vagina or the cervix depending on what we're manipulating. And with the help of the ally, you can have a static manipulation with no variability and really help yourself and optimize your ability to um position your target organ and use all three arms to do the surgery without an extra incision because it's, you know, natural orifice surgery. Basically one of the other things that I would say is we have to embrace and you realize all to continually changing technology. So the X. I. Robot was specifically designed to on a boom mounted system to avoid the collisions with forearm surgery. And so I would encourage you know, if you're gonna be doing these types of surgeries that you really need to be doing them on the X. I. I mean it's doable on the S. I. Uh when we look at our data I found that this is over a four year time period. One surgeon, one hospital hysterectomies, Agriculture a texas. I was 30 faster on the X. I. Than the S. I. And this was over, You know 1000 cases in. So this wasn't a learning curve difference. This is truly a technology difference. And as we can see one surgeon we have saved over almost half a million dollars just in O. R. Time by using this advanced technology. So that could be a selling point. If we're trying to bring this advanced technology into our O. R. S. I think it's important to talk about port placement with the excise system. We're going to kind of go straight across with our ports or we're going to do kind of a flattened Mcdonald's arch. That's going to appear keeping in mind that your assistant port can be anywhere in that vertical line kind of in that middle vehicular line. So in the O. R. This would kind of look like a rainbow or or that Mcdonald's arch. And once we're docked, you know this is going to kind of go straight across. I like to enter with my various needle in palmer's point. And so I don't put another incision. I just use that as my assistant port and exist example. It would be five court. I like to use an eight air seal for my cigar cold Pepsi. So I can just do needle exchanges through there. But that's essentially the optimal setup for your ex. I And I think it's also important to talk about where our 4th arm goes. And I would suggest if you are a right handed surgeon and you're better with using your right hand, your additional arm needs to go on your right side. And as we can see here, as we go through a series of animations, the traction and additional traction to your left, if you're if you've got your assistant arm on your left side is very different than on the right side of docking, you have true traction and counter traction and then you're operating down the middle. So it, intuitively, it makes a little bit more sense if you're right handed surgeon to keep your additional retraction on your right side. Um and everybody is going to come up with a technique that works for them. But I would suggest that it might make the most sense to use your fourth arm on your side, that you're you're better. And a lot of us are ambidextrous and could you either side. But I think, you know, it kind of makes sense to kind of think about it in this way that we're really getting true traction and counter traction. We have to have a plan to get from point A. To point B. So how do we go from, You know, if we're not doing sneakers or if we're doing them and it's consistently 3.5 hours, which is the average. I mean that's what it is. But how do we get from there to maybe getting more efficiency? And if we're starting out, I would suggest that you do easy cases first, quote unquote easy. Um You know, and I tell the residents and fellows, you know, the the easy cases are hard. The hard cases are impossible when you're starting out. And so an easy case would be, believe it or not sack ro hysterectomy because if you're doing a search on someone who already had a hysterectomy, by definition, they've already had surgery. Their rescue national plane has already been dissected in once before. And it's actually easier even though it's an additional surgery, the hysterectomy portion to do psychologists at first and then build your way up to um cases that eventually have more complicated anatomy and huge asians. Um, as we get more advanced in our, in our kind of habituation of the process and more uh, like a speedy as we go and we're ready to take on some of those more difficult cases. Maybe someone who's had an umbilical hernia repair with mesh. I think it's also important to have a dual consent. I'll give anybody a go. You know, if they've had five prior apparat Amis, I'll still take a look. We'll put in a camera in palmer's point and if, you know, they're 85 they don't have as much uh physiologic reserve and we can't do a three hour case. Um We have them duly consented for a retro peritoneal surgery, a vaginal procedure, like a sacred spinal fixation or a couple couple places depending on what their desires are. That way. Um You know, we have a backup plan. I think it's always important that for cases that you anticipate challenges, you know, to have had that conversation on the front end, we're still going to do a suspension, we're still going to give you the outcome that you want. But here's a here's a way and are kind of our algorithm that we're gonna go through. Um You know, many uh people might consider that too difficult and they would just go vaginal and that's fine. But I'm going to give them a chance. And if it seems reasonable once we have that first port in that we're gonna we're gonna do it, I like to have that flight plan do the same thing the same way every time. So we start with the preparatory, we start with that dissection because you know there are aberrations and anatomy, sometimes the left hand and iliac vein comes all the way down to the edge of L. Five. Maybe you can't put your suitors in on that one. You have to do your cycle suspension. You know, there could be other examples. Maybe they have a five centimeter thick fat pad above the crematory. And um you know, you're not at a point in your journey that you're ready to take on a case like that, that's fine. Uh So do that dissection first so that you are certain that you're going to be able to complete the surgery that you started. Um and we'll see in a video that we have coming up. How maybe if you do the steps out of order, you fixate the mesh first and then try to open the preparatory. You know, that could lead to some difficulties because maybe you don't even end up doing a Sagara cotopaxi in that case, follow the flow of the procedure. If you have enough traction counter traction, there's no guesswork. The planes will open up. You'll see little cracks in the fat pads that will allow you to dissect down to the anterior longitudinal segment every time, just listen to the patient. They'll tell you where to go. The bladder flap is actually the secretly the most difficult part of the procedure. And we'll kind of go over some of the reasons why that is. So I had the honor and privilege of giving the odds, fellows, robotics, cotopaxi course a couple of months ago with Dr Myers. And at that presentation she shared her group's publication on the breakdown of the sacred complex procedure, um how each individual step can be evaluated and, you know, there's over 50 different elements, which I think is a good comprehensive review and I think everybody should look at that for me. I like to have kind of easy breakdown. Uh something that's easily digestible. Sometimes complexity can be the enemy of execution. So as we can see here, we're going to start at the preparatory, we're going to work our way down the right public sidewall. Then we're gonna get into director vaginal space and then we'll get into the vesco vaginal space. We're going to introduce the wall imesh, we're already facing posterior. So we're going to fixate the anterior arm, then fixate the poster arm. I'd like to close as you go. So we'll close the peritoneum, then will fixate the a pickle arm, the international segment and then we'll close the peritoneum. So it's just this perfect little flow that minimizes unintended movements. So when we're doing this surgery, there are no unintended movements. Every single movement has a purpose. We're not jumping around from place to place, we're just following the flow of the procedure. And if we break down these steps, we have the crematory Rite public sidewall, recto, vaginal vesco, vaginal, secure and tear, secure, poster, repairing your lives anchor and then repairing your lives. So if we take each of these procedural steps And then we assign a target to each of them somewhere in the neighborhood of five minutes 10 minutes. We actually if we add those time points up, We can see that a 45 minute council time is very doable for a quality procedure without skipping any steps. What this would ultimately end up in is about a 90 minute skin to skin for secret cotopaxi and then a total O. R. Time of under two hours. So if they're giving you two rooms and you're flipping, then that basically means for a seven o'clock start, you're starting your second agricola plexi at nine a.m. And then if you have just one room, then maybe you're looking at a 930 turnover start on your second case. And that's kind of how you get 34 even 56 kopecks in one day. But you've got to do your part and you've got to get each of these individual time points into a reasonable range so that your team can feel like they're going to support you on the turnovers. If you're doing five our cases, They're not going to rally around to try to get you a 30 minute turnover between cases. So we have to work towards getting to that point. And again, we won't go through every single step. That's what are longer courses are for. But to keep in mind, these are our kind of our individual targets and our team targets. Now, it's important to utilize all of the technology that we have available And any additional thing. And this includes the robot has to save time, has to save money, safety and it has to apply itself to the 100 rule, meaning that in utilizing this technology, we get close to outcomes that are 100 as humanly possible and we'll kind of explain what that means. This is an example of some of the vaginal manipulation that can be used when it comes to technological innovations with hysterectomy. We've had a tremendous amount of engineering and innovation that's gone into designing manipulators like the delineate er to have this culpa to me ring, to have a balloon that um maintains number peritoneum. And it's, I just find it interesting when it comes to your an ecology, they're like, hey, what do you want to use for your manipulation? Um Oh, I don't know. Whatever is in the trade. Just hand me hand me a ribbon hemi a sizer. Well, I'm here to tell you there is a purpose built engineered device for say agricola vecsey. So this is the Advincula arch with the hoyt Sandra, cotopaxi tips. So this is design is based off of MRI Studies which gives you a optimally exposure for fixation of your mesh to the to the compass. So what we'll see here is a side by side comparison of what we're used to using on the right. Just a standard E. A. Sizer and the height manipulator on the left. So I think it's very interesting if we if we watch here because we see the same patient, okay two different manipulators, how the instrument arms are touching on the right and how much more space you have to lay your mesh flat on the left with the height manipulator. So you know it's one thing to talk about is another thing to actually see what that the differences in a individual patient. So the ally is kind of the perfect ally if you will for vaginal manipulation. So when you're using the delineate er or the hoyt we have the ability to take this robotic vaginal manipulator if you will to hold onto that manipulating device and position it So that there's no variability going back to 100 rule how many of you out there have ever had a case where you get down to the point and hysterectomy where you needed to do the copa to me and you say, hey, could you push in more? And they say I am pushing in and then you either reach down or you get somebody to push it in and you find out that they've got two more centimeters of cephalopod elevation involved. So this would be an example of that's all fun and games until somebody gets a ureter. Right? So you want to have that optimal static traction, particularly in a case like a psycho kopecks, where it can tend to be a little bit of a longer case and there is a human element of fatigue that sets in on management relation. So here we have a device that eliminates that variability and improve safety so you can grab onto the instrument. You can cause this elevation. Now I'll have some doctors say, wow, that's too much to mess with. You know, look at all, look at all this space it takes up. Well, I would say that if you're already using a robot, that argument doesn't hold much water so you can see that this ally manipulator allows you to get static retraction where the assistant can simply just press the pedal and it will lock the device into a certain position and again eliminate the variability, potentially save uh injuries because you have static, reliable, persistent retraction and you could potentially even take somebody out of the room and replace them with this device. But even if you're not doing that all of a sudden, you know, you're their best friend because you're the surgeon that gives the ability to uh position the manipulator and not have to hold it there and get tired for you know, an hour and a half or three hour duration of a case. So as we see in this video this would be a sacral uh hysterectomy. So we're hysterectomy first and then uh the complexity to follow. Uh But this kind of shows that manipulation in action, how the assistant can position the delineate er in this example let go and it just stays in that position. Um And frankly, you know, there really are only about four positions that they need to do during an entire case. And so your bedside assistant could potentially even reach down and do those positions uh and relieve you from needing to have somebody in between the legs for the case. Or if you already don't have somebody there, it makes your bedside manipulator their job a lot easier. And now we're going to switch gears a little bit and we're gonna talk about complications. So we're going to talk about things that may make a surgery even more difficult. We had mentioned earlier potentially hernia mash adhesions uh either from prior surgeries or endometriosis. There can be aberrant vascular anatomy. And then the the idea of duly consenting, if we think that there, if we anticipate challenges and we may have to do a vaginal approach um and you can always do a laparotomy. But our goal, I would rather um decide not to do this agricultural pixie and do a vaginal approach rather than opening a patient. And in my experience, opening really that it doesn't give you much of an advantage over what the exposure. In fact sometimes it's more difficult. Um And so everything that I can do open I could do robotically. So for me the dual consent would be you know potentially doing a different procedure vaginally. Sometimes we have fat pad that makes the dissection down to the internal lunch difficult, we can have redundant bowel issues. Um And some of these patients aren't in as robust of health as uh you know some of the perimenopausal patients that we have we are operating on octogenarians and they don't have as much physiologic reserve and maybe they don't tolerate as much to Nuremberg. So using the technology of the X. I. With the trump bed you can actually put a patient into and out of trump Schellenberg during the case without having to undock. And here we would see an example. Um I kinda have a love hate with this technique where we future pixie the replica of the large bowel to the left public sidewall to kind of get more static retraction. Um Here's an example where you know, my left upper quadrant assistant. It's not enough. Just just pulling the colon over is not enough, it's still falling in the way of the promontory. So we actually have to suit your fixate the public and left public sidewall. Um You know, and it's good it gives you that retraction. Um But the type of retraction that you need for the preparatory is not the type of traction that you need uh for the recto vaginal deck section. Still a lot of times you then have to take that bow down uh to do the rectal vaginal destruction and then put it back up. But as you see here, even with that vexation, we still need to clear out that redundant sigmoid uh to have a shot at getting to this preparatory. So the sacred complex is the gold standard um you know, has really the highest success rate aside from coca cola assist. So why don't we do it on every case? Well, there do have to be considerations regarding uh the utilization of a mesh, even though we spend a lot of time every day talking to patients about the differences between vaginal mesh and abdominal mesh. Um It's are, you know, it's our best procedure and in some uh consideration it's our it's our last stand. So we you know, I like to uh reserve this uh for recurrences. In many cases my primary repair is going to actually be a robotic future. Sick of all suspension. But if we look at the anatomy, um you know, this is why it's challenging, but this is also why if we're gonna do a sacred couple pixie and we're going to incorporate this, that there has to be a currency element. We really have to be doing this procedure all the time, at least on a weekly basis to familiarize. And really, as I mentioned earlier, kind of habituate our dissection into this anatomy. There's a lot of time that we spend worrying about middle sacral vessels aorta. The reality is that europe is nowhere near Where were operating. So you know, if we're up by L4, you know, we really need to kind of familiarize yourself with this anatomy because that should never be part of this dissection. Um The left common iliac vein, that's our that's our nemesis. I mean that that's the great vessel that is going to give us challenges the middle sacral. I mean it does come off of the aorta, but as long as you're getting traction counter traction, you're never going to be able to pull those up off of the anterior longitudinal ligament. You're always going to be able to they set down onto them, identify them, keep them out of the way or if you need to domesticate them so that you can place your futures without being concerned um about transacting them. Now the idea is fixed station point is going to be right at the top of that S one. You're going to avoid the disk, you can avoid the left coming in vain. You can identify your mental cycles. Um You know, the inferior military artery um is usually not identified are involved in this dissection, but it can be closer on that left patients left side uh then then you suspect. So that's something we have to keep in mind of the right ureter. And so these are all things that we that we need to be mindful of as we're doing this dissection next line. And sometimes there are an atomic variations. So we see here the left coming like vein kind of being lower than we're used to seeing it. We have a very small window to suit your fixate into the interior longitudinal segment at L. Five. Uh In this case we see kind of a bulging disc. We don't want to shoot you there. So we have to either try to you know macgyver our future into that little space that we have between the middle sake role in the left coming vein. Or more appropriately probably go down to the top of S. One there below the disc, below that bulging disc. And make that our fixation point on central uh anti longitudinal ligament. So sometimes it's just there's too much redundant bowel, it just ends up being too much of a challenge. Uh And we need to move it out of the way. We've tried in putting the patients and steeped in Ellensburg. Maybe the patient doesn't tolerate it. And we showed you one of the tricks that's available for manipulating the large bowel and getting that out of the way. But what about the Sikh of the appendix? The small bowel. Sometimes this starts to fall into our operative field um particularly that high up on the preparatory and that's a you know, sphincter tonic enough dissection as it is. We don't need to worry about small bowel falling into our operative field as we're doing that. And typically what happens is you take your manipulator and you scoop the small bowel. Then what happens? Well two more loops, appearance place so that you scoop that up, then what happens? And then the second falls in and you move that and then more small bowel. So really the only way to crack this nut is to have the ray tech and circulate or circumscribe all the bow and then move all of it and mass with one manipulator. And again, this only works if you have half the rate check underneath the about half of it on top of the bowel and you move it all as one block. And then you can see here how we've really given ourselves uh all the room that we need to accomplish this uh dissection onto the um preparatory here. Uh They did a systematic review um dr Hudson at all. That looked at complications that are involved with agricultural sexy. Now, the interesting thing is that the major complication rate was not rare. This was headlined by cyst, autumn ease and erosions, but any number of other complications as we see involving the small bowel, the ureter vascular injuries. And then of course, postoperative complications other than erosions. You know, nerve pains, alias uh blood transfusions. What have you uh the storm embolism. So um you know, it's been said that the only doctors that don't have complications are doctors that don't operate enough and liars. Right? So this is something that I think it's fine and good to show optimal surgery. But I think we get the most out of it when we actually take these types of things head on. Talk about the complications, when they happen, how they happen, how to avoid them. If we break it down by region on the promontory, again, the middle cycles, you know, you can get into those that usually just a little bit of bipolar energy to take care of that. The one thing that really gets us into trouble is that left comedy leg veins. So that's something that we have to identify, be aware of anatomically and keep it out of our way. The disc injuries that we talked about you right public sidewall dissection most of the time it's a chip shot. You identify the motorcycle ligament, you stay right on top of that on the right public sidewall. That'll keep you three senators medial from your inner. It'll keep you away from the sigmoid and you ride that right down in the pelvis. But um sometimes it can be closer than we think and I think our margin of safety comes in with our dissection technique. We really need to be very meticulous about going one cell layer at a time identifying the organs and staying right in the middle, in our best vaginal plane we get cyst, autumn ease that can occur vaginal preparations and of course our regular vaginal anatomy. So this is how we see it in meters. And if we kind of just flip the slide, this is how we're used to observing it. So here we're going to see an example of some aberrant anatomy. So this is also happens to be a thick um preparatory where we've got at least 3-4 cm of pre cycle fat on top of the preparatory. If I if I go with my an atomic queues, I'm going to go from the bifurcation of the external and internal iliac kind of where the ureter crosses over go 300 medial. I should be smack dab right on top of the L. Five. And what I find is nothing but blue right? An ocean of left counter iliac vein. Um And so what do we do? Uh You know, you can continue to dissect down and and and you know get yourself down on the S. One S. Two or you're gonna have a backup plan where you decide to do a you know, sick revolt suspension. But these are the an atomic variations that you know may make it challenging. Now, had we not gone cell layer by cell layer on this dissection, you could see that you can end up bisecting right into that vessel. And that's a bad day for everybody. And he would be an example of this is kind of an older internet video. But uh this pre sacral director me actually, but it's the same anatomy and what it shows is you kind of have to recognize where you are. They think this is the superior uh hyper gastric plexus that they're expecting. It's actually the left common iliac vein. And if you make a hole in the left common iliac vein, don't put a section irrigator and expand that whole. You have to have a strategy and a plan that you can troubleshoot. I'm not going to show the whole video here. Um But I just want to uh demonstrate uh an example of how during a single kopeck, see this anatomy could be in play. Um And maybe you know, I've already got three futures fixating. Um My typical arm of the mash, I really probably didn't need 1/4 1 but I got greedy. Got it anyway. Now in this particular case I had dedicated the middle sacral. Uh so this isn't that this is left common iliac vein, I'm just catching that lower edge. And right now in this moment I have a millimeter defect in the left common iliac vein just that the width of a needle. Um What you don't want to do is you don't want to panic. You don't want to rip it out. You know you want to have a plan in place. So um knowing that we have a major vessel uh defect here we're going to activate our massive transfusion protocol in case we need that. We're going to ask for vascular surgery or the next best thing right? If that's not available trauma surgery general surgery um we're going to get five okra lean ready and available to structure this and we're gonna hold pressure. That's the beauty of the robot. Right? We can statically hold pressure and frankly we can go and do other things. I mean all bleeding stops eventually right with pressure and time. Um And so we can introduce some various human static agents. I remember seeing in a video about 10 years ago and oncology video, they got into the I. V. C. And they just put um a floatable thrum and product and they came back five minutes later and this little defect was closed. It was bone dry. So uh in this case figured hey why not do that hold pressure? Um But you know vascular injuries, Great vessel injuries are one of the scariest things that can happen. Um And so we need to keep level heads. We need to have a plan activate the plan but turning it from uh high stress scary thing into a controlled thing simply by holding pressure controlling the defect. So here we're going to that global forum and product. Unfortunately in this case we got away with that we're working. Uh But as I said had we not we had the plan rarity to to be able to uh future it as needed. This is going to refer to kind of as we continue our dissections to go from the preparatory, what's the next area that we can have? That would be a challenge. Is this right? Public sidewall dissection? Now, I didn't um show all the videos of each step in the procedure. And again, I would encourage you to come to one of our full day courses for that. But we talked about the principles. One of the principles is operate with two hands traction, counter traction and paint brush with your mono polar cutting energy. One of the techniques that I always see people getting in trouble with is kind of this stabbing technique where the scissors are pushed into the tissue and you know, you're not going one seller by a time. One of the other challenges to the eagle eyed viewer here is um you see that the procedure is done out of order in this example. So they've already fixated them, uh developed the planes and fixated the mesh, and now they're going back to doing the preparatory and right public sidewalk section. As you can see here. You know, we got into mr stinky. Um and that's a particularly difficult challenge because now the entire surgical field is contaminated. And you really if we follow best surgical practices, you you can't put a foreign body into that operative field. So then, you know, now we would have to do another surgery. Um So on the right pelvic sidewall, the key is to stay on the inner circle segment traction, counter traction, you know, one cell at a time and you'll stay out of harm's way Again. With 100 rule close to 100%. Now, as we continue through our dissection recto, vaginal is pretty straight forward. Uh that plane is usually pristine. You get into the plane you dissect down. Um so I'm not going to specifically talk about that. Uh deceptively one of the I guess traps that we can see with uh agricola pixie is the best vaginal plate. So, in this animation, we'll see how a normal bladder flap is developed. We just come down our scissors, we get traction. Counter traction, will open the space, and the bladder will pop up uh as we would expect it to be nice and easy. And that gives us a nice plane to the sect on. But what happens is sometimes after hysterectomy, the bladder will not heal nicely on that anterior surface of the vagina. It will actually adhere to the top of the vagina. Or what if it heals all the way on the backside of the vagina? Now, if we aren't aware that this risk can occur, then sometimes we're gonna end up dissecting and we haven't identified that the bladder is all the way adherent to the backside will go right into the tissue, thinking it's our plane and we'll get right into the bladder. So this is another example of why we do the steps in the order that we do them. We do a rectal vaginal dissection first, because that plane is easier, frankly, because virtually no patient has had a prior dissection in the rectal vaginal space, virtually all patients have had a dissection in the best vaginal space. So that rectal vaginal that post here dissection informs us of where the bladder is. So, when we come over the top we can see is this the nice bladder that is adherent where it's supposed to be is on the top? Is it all the way around the back? So in this video we're going to kind of see an example of how, you know, this dissection normally takes place. So we have already done our Parliamentary Republic sidewall. We've done a rectal vaginal list section. Now we're coming into this interior dissection. So one principle I think is extremely important is the ability to backfill the bladder. So we can delineate that anatomy. Um We can distended bladder and that will kind of help us, you know, in this plane to see where, you know that bladder starts to end and where the vagina begins. Um Sometimes the planes can be deceptive. Here we see that kind of that white glistening vaginal cirrhosis that we want to see that really guides our dissection. Um Some of the tissue might start to appear Detroit serie, okay, so that that muscular band that we want to keep up and we want to go into that plane. Um You know, you you can dissect into the right plane, you can dissect into the bladder and you can dissect into the vagina. I would submit that the vagina is probably an easier entity to to fill to correct if we get into that plane, ideally, we don't want to get into either one. Um But we really want to just use that power of attraction counter traction to create that ariel or tissue. And we can see that um that tissue plane went down very well. I think one of the things we have to be always on the back of our minds is laterally where the tissue bunches up, and you can't always necessarily get that perfect layering out of tissue as we get in the midline here. As we're doing this dissection, we need to take a little bit of care because as we see, we've gotten into the bladder uh in this case, so uh super thin. Now again, this isn't the end of the world. Um No one would fault you with this astronomy to abandon ship and do another procedure. I think the location of this astronomy is relevant to whether you continue or not, since our mesh is gonna fix it to the uh front and back of the vagina and then be deviated to the right side. Um Inasmuch as this is a left sided injury. I think I feel comfortable with this repair that we're going to close this and then um uh you know, be able to do our surgery as planned. Um So there's a couple of things that we need to do. So identification is the key. Um Also I think we need to tag the defect uh immediately so that if, you know, we need to complete some other portion of the dissection, we know exactly where it is. We also need to kind of free it up because we need to be able to kind of overlap those edges back together prior to doing any of this. We want to do an immediate cyst Oscar p to make sure that our defect is far enough away from the your orders that we don't have to stent them. And if it's within a centimeter, we definitely need a stent the orders to kind of keep that visualization in place so that we don't turn assist autonomy into a, you know, an additional injury. Um In this case it's a small enough defect that centimeters away from uh you know, the plane that we need to do dissecting in. And we can go ahead and just do our planned closure. The closure does have to be watertight. Um There's a lot of ways to skin a cat. The classical would be to take a polly glycolic acid or a michael future and do a running closure here and then do a second chamber cleaning layer. And then you can even do a third Saros a layer if you felt that was necessary. But here we're going to kind of indicate that over at the end of that section, we're gonna repeat artist Oscar to make sure that the closure looks good and fill the bladder. Make sure it's a watertight closure. Now, for the sake of time, I'm not going to complete that. But suffice it to say that uh, you know, identification is the key. Then we need to make sure that our anatomy is in a way that repair can be done in the fashion that we wanted to and then make a decision as to you know, proceed with the surgery or not. So here's an example of a case where we have a patient that um you know, 70s, late 70s has not seen estrogen for you know, three decades. And uh the tissue becomes very a trophic. Um You know, we're going to carry out a section as we normally would as we saw in the last video this traction counter traction. We're gonna retro fill the bladder. So we know exactly where the bladder is. You know, kind of taking one seller down at the time. We've already completed our poster in a section that informs our anti intersection. And unfortunately, um you know, our assistant is a little too strong on this one. And you know, we're doing a a manipulator uh abdominal manipulation here apparently. So, um I'm sure all of us have had this happen. Uh and in this case we just need to uh close the vaginal cuff as as we would if we had done uh total laparoscopic hysterectomy with our sacred texts, go back to the drawing board and you are complete our vesco, vaginal plaintiff section. So um it's a rare type of thing, but I think with patients that don't have as good quality of tissue that it bears mentioning to the person that's doing manipulation, that this this type of thing can happen. So here we find ourselves back on the right public sidewall plane and we're just going to kind of talk about every possible complication that can arise. Wait a minute. You guys showing the wrong video here, we've gotta why are we cutting the Ureter guys? I'm just kidding. So this is actually a porcine lab where we were doing some other dissections and testing other technology. So we fully utilized our opportunity here just to illustrate the point that, you know, um this is a type of injury that can occur. So um this type of repair isn't exactly how we would do the repair. Uh were it to be um in a in an actual case, The main thing I want to illustrate is in a Eureka Eureka Rostami, we want to future at that 6:00 position first for our repair. And the reason we do that is, you know, if you start at 12:00, it's gonna end up being very difficult to put in that posterior repair um that very posterior future. So we're gonna start At the six o'clock position, tie that one down and then work our way around. You would also do this repair over a stent. But again, this is just kind of another example of a type of injury that that could occur either by thermal injury or dissecting into it. Um And then just having a plan in place in the event that something like that were to happen. Um And some of us would repair this, some of us would repair it with the help of urology. Some of us would just recall urology um And again, for a thermal injury, you'd likely actually being uh doing a urine or neurosis. Tosta me because you have to respect that margins around the thermal injury. I just kind of circle back to what we started the case with. You can see a normal L. five disc on the left and on the right. We have an inflammatory process on this MRI scan that is an example of disk itis. She also incidentally happens to have a uh L. Four bulging disc. So she has pre existing back pain. But again, it's something that we have to be aware of. This patient was complaining of pain. Got an MRI and identified this and we were able to manage that complication. So there you have it. Those are the efficiency models and all the complications that can arise. So how do we position ourselves best to a rise to those challenges and be able to avoid or manage them when they do come up. So, I really think it's important to habituate the surgical process itself. Get at least 50 cases under your belt so that you're not using any of your energy. Doing the procedure itself, you can manage the challenges that arise. So mastering those surgical mechanics, do the easy thing first. And then the hard thing will become easy. Give what the, take what the patient gives you in the dissection, observe meticulous human stasis. We have to preserve all of our planes. Once we start bleeding the retro criminal space, it just makes everything more difficult. Always have a backup plan, spending three extra hours doing the surgery isn't going to benefit anybody. Have a backup plan in place and then just have a clock in your head. You know, if you're not basically getting to your the end of your fixation by three hours, you really need to rethink, you know what, how much additional time is going to complete this procedure. And should we be looking at another option? Um and whatever option is safest in your hands, whether that's opening, having a vaginal procedure, uh motorcycle suspension or or something else, we need to take advantage of all that technology has to offer. There are certainly surgeons that don't use any cop optimizing device at all. They just use like a some kind of a manipulator or an actual um on the cervix. Whereas that is very functional. It also is undeniably limiting because you're using one of your arms for something that could be used manipulated vaginally. So we could use our delineate our manipulator or are or hoyt manipulator. Uh And I think the ally is kind of the ideal running mate if you were in this process because you get that static retraction as we saw the advantage of and some of our earlier slides. So there are several design advantages that the delineate er has over uh you know, other Kalpana miser devices on the market. Um You know, they have the balloon anchor uh in the fund this of the uterus says as most devices do. I think one of the greatest advantages is this vaginal include er balloon um you know, with with a posterior culpa to me cup that some of the devices have, that really gives you uh inconsistent maintenance of numa peritoneum. Whereas this balloon will accommodate to any caliber genital hiatus and and it will give you again that 100% rule where you're always going to get excellent maintenance of newer party um throughout your surgery, the last thing you need is during your surgery, if you're getting your cul pa to me to lose your normal peritoneum, small bowel jumps up onto your mono polar active electrode and all of a sudden you get a complication. That could have been avoided. Had you just had a balloon include er in place and I showed the video just to kind of highlight some of these design advantages. Obviously this is a hysterectomy, not a Sacred cotopaxi device, but if we're doing a sack ro hist, um you know, this is I think best in class for uh for your uterine manipulation. So uh the the delineate er is kind of like the best in class. The v care. You're kind of like this guy, you've had like, you know, you were ahead of your time at the time, but you've gone through a 20 year innovation hiatus. Um You know, you don't have a balloon excluder. Um, you've got that, you know, post your cup that doesn't work as well. The actual shaft, the instruments very very flimsy. Um uh and you don't have this wide of a range of cup sizes for to accommodate different anatomy. So if you're going to use a cop optimizer, which I suggest you should, I feel that the delineated gives you the best options around that. The other possibility or option if I can suggest for manipulation once you've done your super cervical hysterectomy. Uh In this case is to just go ahead and pull the shaft back on the manipulator and just use that. Not only does that save a significant amount of time because you don't have to stop and switch manipulators, um It also is really the perfect cervical manipulator because that cup fits exactly around the cervix and um you know, so it'll save time. You do at times get that little nub that pokes out. It doesn't really compromise your fixation. Um I found that if if it bothers you you can cut one window and pop it through. Um And that doesn't compromise the integrity either. But this really is the ideal device to use um For sacred hysterectomy, I think the hoyt is the best for hysterectomy. And then of course, with either device to use the the ally to kind of maintain your static manipulation. Um and then once we've kind of got all their fixation points, we're going to show how the political arm of the mesh can go through your parent rail tunnel and then you can bring that up and fixate that to your answer longitudinal ligament. So we're gonna kind of wind this down. I definitely want to thank everybody for joining us tonight. Um You know, I think as with completing your residency or your or your fellowship, uh you know, that's the first step, right? This is a lifelong commitment to education. Uh this might be one of the first steps and improving cyclical apoplexy outcomes. There are many more resources available. Um And I would encourage all of you to contact your cooper, rep, your intuitive rep, whoever is in your local environment or your society odds, Nagel to seek out other resources that you have available. And again, it was it was a pleasure for me to participate in closing. I would just say um you know, a sacred cotopaxi is uh not the same for everybody. I would suggest if uh you know this is your idea of a sacred couple pixie. We call it the the to stitch. And uh tactics. See um you know, we need to up our sacred cotopaxi game. We need to get to the point where we're doing um anterior dissection, you know, down to that Trigon post your dissection, down to the perennial body and getting us, you know, personally, I put eight searchers interior 89 9 to 12 posterior and three on the on the preparatory. And we are doing that in the context of our 45 minute council time. Because this is our gold standard. This is the best procedure we have. We want to give our patients the best shot at long term success. So we'll be happy to stick around for some questions. And um again, I want to thank everybody for coming. It's it's been an honor to present today. Thank you Dr Farnham. Just a reminder. You can ask a question by clicking the ask a question button below the Webcast screen. If you're in full screen, you will need to leave full screen to see that button. I'm not going to turn the Q. And a portion of the program over to Doug K from cooper surgical. All right, thank you Alan and and first of all, Dr Farnham, thank you very much. This was a really interesting and compelling presentation. We enjoyed this a lot. So uh we appreciate you providing this information for us. So we have a bunch of questions that came in so why don't we get started? The first one I see that came in is can you briefly talk about your utero sacral application? Uh suspension technique? Yeah, well thank you. Douglas has been a great opportunity, I'm glad that we had such a great attendance and there's so much interest in these topics for the uterus cycle suspension, you know, that's kind of separate from what we talked about tonight, but again, another robotic prolapse repair. Um I do want to try to focus on the Segre complexity for the Q. And A. But I will say that just briefly we'll do the hysterectomy and then we will suspend each side and essentially duplicate the proximal and distal motorcycle segments first with a delayed absorbable barbs, future like a B lock 1 80 then uh permanently and run that through the cop and then permanently black age approximately motorcycle segments with esteban. And then we do that on both sides. There actually is a video that I have online with that. It's also in surgery, you through A. G. L. Um and we'll actually be updating that that video here uh, in the next coming months. So that's essentially what we do for uh that prolapse repair. Right? And if they want to find your videos online, how would they find that? Is that through your youtube site? Yeah. So the youtube is just um spelled out Dr Rich Youtube. And also you just go to my website for an MD dot com and you can go to the link directly from there. So the next question that came in is uh, if you do the hysterectomy first, how far down do you dissect the bladder prior to removing the uterus boy? That's a that's a great question. Um I like to set the table first so I will do all of the dissection um prior to doing the hysterectomy. So um if it's a sacral hissed, I'll do the preparatory right public sidewall recto vaginal space as we saw in the presentation. And then um I will go interior and I'll accept that down to the Trigon right then and there. Uh and then we'll proceed with doing hysterectomy. So all of the dissection work is done. So as soon as we amputate the uterus at the level of service, we just drop in the UAE mesh and starts to train. There's no more dissection at that point. The um bladder. Uh What I've seen other people do is they'll use the energy device to kind of uh do the hysterectomy. And they actually infusing the planes together to just have to go back later and then open them up again. So I think it's just better to set the table, do the next section on the front end and then you're ready to go as soon as you've completed the hysterectomy. Mhm. We had a product question come in, someone said they haven't used the Ally before and they wanted to know can you use the Ally only with specific manipulators or with all of the cooper manipulators or And also a second question came in on Ally, are there any uh tips and tricks that you have for setting it up with the Advincula arch in the sacred tips? I'll group those two together. Yeah that's kind of a lot of things to talk about their um so you can use the best manipulators with the ally. Um I say jokingly tongue in cheek, but the reality is that um I do I do feel and I do use the products that I think give my patients the best chance at a great outcome. Um So the al I will work with the delineate er for hysterectomy, the roomy for hysterectomy the hoyt on the Advincula arch. So those are the and there's a blue and white one depending on which one you're using. The white connector will go on the Advincula arch. And the question I guess the second part of that question is any tips and tricks for that because it's not super intuitive, it doesn't just fit in. So what I do is there's a handle and then I place it into the cradle about a centimeter back and I just slowly slide it in and you'll actually feel a very subtle click as it falls into place and then you close the attachment over it. Um If I understand the question correctly, another question came in on on what technique you use for robotic high utero sacral ligament suspension in a post hysterectomy patient. Yeah, that that's uh that's a good question too because um if they have already undergone a hysterectomy, um I think I mentioned earlier that you know, the sinker is actually not my primary choice for repair in most cases. Um I'll usually do distract me with the motorcycle suspension, uh you know, barring advanced prolapsed. Um But if it's a patient is not interested in mesh or maybe, you know, it's a stage to prolapse and they're amenable to a uterus sacral. Um The future choices are a little bit different. I'll still kind of develop the bladder flap as you would when you do a hysterectomy. Um And I'll typically actually still just use the 180. I'll grab the approximate leader sacral segment. Dist leader cycle segment, then through the vagina in a posterior, enter direction, then back through the vagina, then back through the ligament and then back through the cuff again and tie that down so that really bunches everything together. And the delayed absorbable. The six month delayed absorbable future is going through the cuffs. So there is a search for what you're going through the cuff, but that will eventually reabsorbed what holds this all together. Long term is the esteban that you're going to place through approximate list of your cycle arguments um that keep that ligament itself replicated. Um And then, you know, you just, the goal is that Once the 180 absorbs that there's enough healing and scarification that it holds it into the, into the ligament. And it's about 85 87 successful uh in in my practice. And I think that reflects pretty closely to the literature for five years success. Yeah. There were there were some questions that came in just in terms of some of your results from from going to robotic surgery and a group. These together a little bit. One of them was that you mentioned, the complication rate uh with robotic procedures is 19 and they want to know what the if you knew the complication rate for open cases. And then the second one was also just about suffering time uh with suturing time included in your timeline. Uh And and then you know, if not how do you allocate uh to suit you the mesh both anterior early and posted early. Yeah. Again, both great questions. And I I would have to look at back at the at the study. Um Unless I misunderstood the study I thought that was all agricultural taxi for that complication outcome. Because it wasn't that analysis. Um So there is not a statistically significant difference or I've not seen that in the literature difference between open laparoscopic and robotic. So complications are similar across to whatever modality that you choose to do but whatever you do all the time, that's what you're good at. And you individually will be better. We have our what we call quantify the impact data where we monitor our outcomes and then we compare that to national benchmarks. The data on that is more robust and hysterectomy because that's where you know a lot of the uh Baseline source data that we get for comparison. We don't have as much data for first agricultural sexy. And I didn't present any of my personal data. My complication rates are, um, somewhere in the neighborhood of 5-10%, including all major minor complications for sacred text. The second part of the question, um, you have to repeat that. It was about structuring time was when you gave your total time with suturing time included in that and if not how to allocate, uh, that time to suit you the mesh interior early and posted early. Sure. So when I was showing that timeline, we're giving 5 to 10 minutes per each of the eight elements of the surgery. And on that timeline, we saw 5 to 15 minutes for the fixation of the mesh to the vagina. And depending on the number of futures you're going to do if you do the math. I mean it's got to be about 30 seconds per future. Um, and if you're doing these features all the time, that's that's a reasonable goal that you're going to get your timeline down to where you're five minutes on the front. Um Maybe a couple minutes a pickle, five minutes on the back and then your repaired realizing. Um There are and I don't want to call it shortcut because I think it's probably in the right hands for people that are doing high volume. Um they've gone to using barbed future, so instead of stuttering at all, they kind of do a box barb future all the way around and then kind of curl it up in the middle. I've not personally found that to be as satisfactory um visually as it is putting individual futures and I think I've got my rate for the futures down fast enough that it also doesn't save a lot of time. Um But every once in a while I will do it just to kind of stay in the habit of doing the barbs future and see how that goes. Um But I have seen, you know dr Myers data looks really good with using a barbed future. Um So I honestly think whatever you're comfortable with as long as you are doing it well and making sure the meshes and bunching up, you can do integrate a barbed future, You should definitely make sure the mesh is laying flat. So whatever that takes for you, for me it takes nine on the front, 9-12 on the back. But somebody could do that in four futures, I'm sure and do a good job of it as well. What we don't want to see is we don't want to see you know, 23 stitches and then and then moving on to the next step for the sake of saving time, because then you're compromising the ultimate outcome. And this really is our, you know, gold standard procedure. So you know, if we're going to do it, we want to make sure we're giving them the best shot. That long term success makes sense. So a few questions and I know we're running tight on time, so I'll get these in. There's a few questions on dissection, right? And and one so I'll lead with this one. It was when dissecting? How do you know you're at the tri gun? Great, great question. So um luck. No, I'm kidding. Um So there's a there's there's you eventually form a kind of a gestalt to uh where you're starting to see a change in the tissue as you're dissecting down. Now, you can also help yourself by um at the very beginning of the case, when you put the foley in actually feel with your vaginal palpitating finger, pull down on the foley and check the length of the urethra. And you just have let's see your TVs 12, your uterus four, You've got eight cm and you just kind of use your needle driver as a measuring stick and that that kind of gives you a gauge. Okay so that'll get you in the ballpark um You know if you're down 3-4 cm and it looks like you know uh you're getting the bleeding you might get into the bladder if you keep expecting getting an injury to get an extra centimeter is not benefiting anybody. So it's it's kind of a process. The more you do, the more comfortable you'll you'll be getting further and further down. Um Understanding that you know our ultimate goal is to avoid a complication now other than having those general parameters to work within a couple tricks that you can use. Um And you know, some of these, I've just come up with your practice, some of my learning fellowship, some of them are just great ideas I've gotten from other people. So I think I mentioned Dr Myers and I did a presentation in december and so she said just put the foley in. Just shove the rest of the fully back in and it will outline the bladder for you. The I guess the base of that fully will outline the water for you and that that will show you um Sometimes just moving the bladder, the fully up and down can give you a good clue. Um You could put a cyst the scope in and trans illuminate right where the Trigon is and can see exactly where that edges. So those are some other tricks that you can do. I would say that I use those infrequently at this point just because we kind of set ourselves up with a basic kind of a ballpark understanding from the beginning and just kind of have a good understanding as we're dissecting down where the limit of that tissue is. Um You don't have to be at the try going to the millimeter. I mean understand that much. I mean but you just you want to get down you know, to repair this anti r defect as low as you can go without getting into trouble. But I guess that's the take home message. Mhm. All right, we have time for one more question. Okay these are great questions by the way. Well there's a few questions that just come in uh specifically about the delineate er and I'll again I'll kind of group them together a little bit. Uh There was one asking about are there any tips when you're switching from V care to the delineate? Er And then the second one was uh if you're using uh the delineate er for A. T. L. H. Do you have any advice for a retro voted uterus? Okay. Um So I I feel that uh 90 I mean they're more similar than they are different. So 90 of the v. Care and the delineate er are basically the same instrument. So there's not whole lot of adaptation. I would say. The two biggest concerns that I get what I'm doctoring are. Um Some people rely on the little groove on the V. Care and they find the group they stay in it. Um A lot of times they'll say just kind of for the residents that gives them the guide. But I would say if you start with your early cos you get an earlier and early answering poster culpa to me you're going to find the the bevel on the delineate er and just stay on the top of the bevel. I mean really that's no different than being in the group. Just stay on the top of the bevel all the way around. So I would say that that's probably one um you know easy tip to transition. Um The new inclusion is obviously better because the balloon completely occupies any size that the vaginal space will need filled. And that posterior clutter cup in the daycare doesn't always do a great job of that. So automatically that's going to be a good uh advantage in the transition to take care of or take advantage of rather. And then of course the compatibility with the allies, another uh big thing that I think it's advantageous. Um I guess extending from that question to the to the other question um You know I've got time but if if we got to wrap this up, let's give you the last question um With the delineate er or with a clear view or with um Rumi's umi humi uh the care whatever you want to use if you've got a retro voted uterus um You feel that an exam when you go to dilate uh Sometimes it helps to grab the postal service and pull down and it'll kind of straighten the cervix out and then um your sound in your dilator, we'll go right in. Now I always like to dilate and some people don't dilate but for me it just feels like the manipulator goes in so much smoother When you serially dilate from 48 mm on the on the hanger dilator. Um And then the other trick would be, you know, um the all these manipulators are kind of like a U. Shape. So instead of doing it in the in in that direction with the you going upwards, you just turn it the other way and then you take the tip of the instrument and you follow retro overdid into the uterus, inflate your balloon and then just flip it back up and that will just pop the uterus from retro averted up too introverted. So there's a couple of simple things you can do um and that could be with any manipulators not specific to delineate. Er Yeah, great, great, that's perfect. Well good. Well we're hitting up against the time here, so I I appreciate it. These questions were, the questions were great, your answers were great, we appreciate everything tonight, and uh and thank you, and if there's any questions we didn't get to, uh we'll make sure and get a follow up, you'll be hearing from us with a follow up to any open questions that weren't answered yet. So again, Dr Farnham, thank you very much, and uh let me turn it over to Alan at broadcast Met. All right, thank you both very much. We do appreciate your participation. This is gonna conclude this evening's event, uh just as a reminder, um you know, as Doug said, you know, we will be following up any questions that were not answered, um but if you can please take a few minutes to complete a brief survey about tonight's program, you can click the post program survey button at the bottom of your screen, um and that'll take you right to the form, You can fill it out for us, we would appreciate that. Thank you very much and have a great evening. Thank you
Richard Farnam, MD