Dr. Arnold Advincula reviews his experience performing minimally invasive hysterectomy in a safe and efficient manner.
welcome and thank you for attending this event is brought to you by Cooper Surgical, a leading provider of medical devices for women's health care. For 30 years, Cooper Surgical has worked with health care providers to provide highly effective clinic and practice based contraceptive, surgical and obstetric solutions to complement our portfolio of trusted and reliable medical devices. We have also broadened our offerings, investing in the areas of reproductive genomics and in vitro fertilization. We are fully committed to helping improve the delivery of health care to women and their families. Cooper Surgical Manufacturers 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's 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 1400 orders per day, of which 99.7% are shipped the same day. Our customer service department handles over 2000 inquiries per day. We employ 1750 people worldwide. We are pleased to provide this educational opportunity on behalf of Cooper Surgical. Hello, everyone. My name is Kelly McCann and I am your meetings manager and will assist in running the virtual presentation this evening. I'd like to welcome you all and thank you very much for your participation. First, I'm going to go over a couple of notes on how this presentation will run. We have a 45 minute time limit with questions and answers to follow. Please keep in mind that all participants will be on mute for the duration of the meeting. However, you will have the ability to submit questions to the Q and A feature during the entire presentation, which you will see at the bottom right corner of your screen. There will also be a 15 minute Q and a session upon conclusion of the presentation, which Doctor Villa will take on immediately following. I will be letting Dr Vickie Lynn know when we have five minutes remaining, so the presentation can start to be wrapped up. I'd now like to introduce our speaker, Dr Arnold Advincula. Dr. Bikila is 11 family professor of women's health as well as the vice chair department of Obstetrics and Gynecology. Chief of gynecology at Sloane Hospital for Women Columbia University Medical Center, New York Presbyterian Hospital. I'll now turn the presentation over to Dr Picula. Dr. Michael, you now have presented privileges. And, uh, first of all, I'd like to, uh, thank Cooper Surgical for sponsoring this educational event and secondarily to thank all of you for joining in this webinar this evening. Um, first of all, I want to thank each and every one of you. You are all on the front lines of this pandemic that we've all been dealing with now for the the past few months, and it's great to actually be able to come together and sort of have a moment away from what we've all been dealing with on a daily basis. I know here in New York City, we've been struggling with the pandemic, and I, for one, along with the rest of my partners, haven't been doing any operations outside of emergency since March 16th. So it's really nice to be able to have an opportunity to, at least from a cognitive perspective, be able to talk a little bit about surgery, since I suspect many of you, um, have either decreased or have not been doing any elective surgeries during this time period. So even though from a hands on perspective, we can't do much, um, we've all taken on new roles. We can at least talk about surgery. So over the next half hour to 45 minutes, what I'd really like to do is, uh, talk about just some safe and effective, uh, tips and tricks concepts, sort of how I think about surgery. For those of you who've heard me speak before, a lot of this is probably going to sound redundant. But it's one of those things where I I really, honestly believe that a lot of these concepts are the things that are tried and true and have really kept me as well as my trainees safe while we practice surgery. So I'm going to talk about just set up. We'll talk about nuances around you, turn manipulation and the use of the laparotomy rain. We'll talk about the section techniques around large history as well as dealing with the uterus with obliterated spaces, particularly the anterior called a sack. And then we'll also then touch based on just optimal management of things like Pol Pot to me and the Vaginal Cup. And throughout this presentation, although all of you are muted, if you do have questions peaceful, free to type those into the Q and A box. And as I'm going along, if I see opportunities to address those questions during the course of the presentation, I'll definitely do that particularly where it makes sense. What I've highlighted here. And I think many of you heard me say this before, I'm really big into deconstructing procedures. You know, you hear people talk about deconstructing food and sort of reverse engineering how they present the different components to make it interesting. I honestly think that when you decompress are deconstruct that is surgery. It really lets you focus in on a variety of different steps and the things that you can optimize and you can potentially manipulate so that you can improve your outcomes and certainly in the red. What I've highlighted here are the things that I believe are impacted by concepts around uterine manipulation in how you handle that technology during the course of a surgery, and you can see that extends all the way up through even things like managing the cervix, the vaginal cup, um, and so during the course of the videos, I'm going to spend most of the time on videos. What I'd like to do is really focus on those highlighted red areas that you see here on the technical steps from either simple or complex hysterectomy cases. So the first thing I'm gonna touch based on it and then I'm going to sound like a broken record is patient positioning because I honestly believe that this is one area that I call low hanging fruit. It is where I honestly believe that many cases that are simple are actually made more difficult. And that's because the individual who's given the assignment of manipulating the uterus with any one of a multitude of devices is struggling. And that's because the hips may not be positioned properly. So as you can see in the schematic, this is the appropriate positioning for hip flexion for a patient in low lobotomy and most importantly, even even more so than deflection is just the ability to make sure that always, always, when you go to the operating room that you're looking at the ankle and the knee and the opposite shoulder so that they line up right, you want to make sure that that is Oh, that's lined up. But that's the way that you're going to get external rotation and hip abduction so that it opens up the legs and then you also, as you can see here, this is not drawn correctly. But you definitely want to have the perineum slightly off the edge of the table because you don't want that patient to either slip back further onto the operative table when they're in trendy Lindbergh. Because then you're really going to struggle with, you know, manipulation your assistant unless they recognize this is going to be fighting the cushion or the padding on the bed. So you want to make sure that you assess this so that you have adequate exposure. During the course of your distracting me, you can see here again. I have just a slight 170 degrees of flexion here, and I'm going to go ahead and get my drawing pointer here so I can see which one I have here. So you just want to have a little bit of that little bend right here and then if you notice here, this is what I really find to be the most helpful is that you can see that there is adequate external rotation and abduction of the hips that helps a lot. And you can see that I've also made sure that her name is adequately off the end of the bed so I can get adequate manipulation. They also want to make sure that whatever positioning that you create pre procedurally that the patient doesn't slip. So whatever method that you use choose a method that is consistent so that the patient doesn't slide on the bed. One way you minimize that. It's just not having too much trans Ellensburg. So I always quote these papers because it's really true. If you actually pay attention to the operative field as you're going into trance Schellenberg, you'll actually appreciate that most of the time you don't really need a full kilt. You can get a lot done with a moderate amount of Trans Schellenberg, and I think that's something extremely important to keep in mind perfectly with a heavier patient. Sometimes it's unavoidable. Certainly you'll need to go with a maximum amount of time Gatlinburg, but certainly always play around with that. And don't always assume you need a folk help in terms of you during manipulation. There's certainly a lot of options out there, and I think to me what's always been critically important is one having a lobotomy wing and I've always been a big fan of the Coke up since my days as a resident, but also having something that will allow for good torque on the uterus in terms of the ability to elevate it up and out of the pelvis, but also to move it from side to side and then further divine to find the four Knicks with the papa to me cup. To me, these these are critically important aspects of you know. Manipulations are a lot of different products that you can choose from to do that. And I think it's really surgeons choice, whether you want a traditional roomie or to use the arch with a coefficient or even a delineate er, and I'm going to share with you just some sort of nuanced things that I've learned along the way, particularly with regards to the delineate ER that I've been able to incorporate in my cases. So I don't normally utilize a ring sizer. But I put this on here as a reminder for me to say that it is extremely important to make sure that you choose the appropriate cup size. And I say that because there are some folks out there who just assume that they're going to use a one size fits all perspective, which you can certainly do. There's, but there's always a caveat. I always you've always got to pay the piper somewhere. And if you're going to use the one size fits all and let's say you have a very large laparotomy ring, but you may end up doing is putting the patient at a slightly increased risk because you are going to have a bigger company. You're going to be closer to the younger in that process, and I'm gonna show you a couple of quick clips. Eric, if you can flip over the video here and just give a second here for this load. But here is a video of, uh, this is in a cadaver lab. And I showed this video a lot when I talk about manipulation, but just to highlight a few things and I'm gonna freeze this for a second, I'm going to draw on this thing here. Now, this is you. See if I have worker here. This right here is the your order right here in the yellow. And this other item here that's coming above it is the uterine, right? So it's water under the bridge, right? And so what? What you want to do here is just appreciate that in this cadaver, when you take away the poster leaf of the broad ligament and you push the uterus up and you pretend that this is where you would normally dedicate your medicals, you're really far away from that your order when you do this right. And so let me let me let this video play so you can see that, right? So here's that. Here's your you're underneath the uterine uterus is pushed in. And when you normally cramp on the Copa Demi cup, there's a nice margin of safety. And that's really what you want to have when you do your case. Granted, we would normally have taken down both ante and post relief of the broad ligament. But it's really important to understand that when you take away the broad ligament, particularly the posterior leap, I cannot emphasize enough. Post your leaf. You will protect that. You're because it will, naturally lateral eyes. Sometimes you might have to do a little bit more in a more scarred Tell this, but in a more routine hysterectomy, bigger, small uterus. That's a very important step. Now we can go to the next video that shows a much larger Copa to me cup. Now that was a 3.5 centimeter cup in that first video. Now, this video here is going to be, um, a larger four centimeter cup, and I've just dissected the bladder down same cadaver. But just to show you that when you have a bigger cup, it's a bigger bulge, right, and it doesn't mean you couldn't use it. It just means that when you actually start to dedicate things and make a papa to me that distance between here, where you have that clamp on the vessel and the ureter and uterine crossover, it's just a lot closer, right, so The most important thing is, if you're comfortable lateral izing, your your order can sure use a big cup. But if you're not, then make sure that you size it appropriately. And the one thing that I will say is that if if you're gonna size up, you just have to again remember that that's going to be a bigger copado incision. It's going to be a proximal to the younger now. Are there circumstances that I use? Where I go up? What would you think would be a circumstance where I would go with a bigger cup? Well, in my o. R. A lot of times we will evaluate under examiner anesthesia the size of the uterus. And if we think that there's enough room in the vagina, that if we go with a four centimeter cup, even if we don't need a four centimeter cup, that we can deliver that uterus more easily vaginally, we will upside. And it's just something to think about. But I only recommend that if you're comfortable doing the proper deception on the inside, that you protect your critical structures like the younger. But that oftentimes will help because, as you know, trying to take even a 12 week uterus out. A three centimeter Copa Tommy incision is very different from a four centimeter compatible decision. So you can really make your life. These are just by thinking of those things when it comes to doing your lobotomy. So let me Can we switch out the video now to back to the slide? Now, the one thing that I want to point out here is to see if I can put to the next slide here, right here and we're gonna bring a video up shortly. Is the one other advantage of the proper Copa to me Cup size is that you really want that cup to fit up in the morning. Sometimes, if you make the mistake of having a smaller cup, you'll notice a blunting of the appearance on laparoscopy. And that really gets a little disconcerting when you're when you're using that as your GPS or your died. So you really want to make sure that that fits in the appropriate location, because if it doesn't fit in the appropriate location seated up high in the four x one, you won't see it well and number two, you're going to not appreciate the ability to preserve this uterus cycle. Ligament attachment. So proper placement of the Copa Demi Cup is going to allow you to be able to bring this incision and a location on the poster vagina where you can preserve detachment of the motorcycle ligament to the poster vagina. If you can jump to that next video real quick, Um, that cut out of this one. If you don't mind Eric and bring the If you have this as a freestanding video, can you do that? Great Play. Excellent. I'm going to fast forward this a little bit here just so I can get to the part that I want to demonstrate, which is right here. This looks like the cartoon, right? There's the uterus. Equal ligaments. There's the Copa to me cup on a conventional laparoscopy case and notice the ability to preserve the euro cycle ligament attachment to the poster vagina. To me, this is critically important When when we're doing cases, there's no reason to damage that natural ligament. This attachment if you can preserve it at the time of your company, let's go back to the slides, please. And again, if anybody has any questions, uh, peaceful. Free to type those in. And I will keep looking at the Q and a board in case somebody wants something addressed while I'm going through the presentation again. You can see here. If you look at this Copa to me ring, you can see how that situated appropriately and when you do this properly, you won't have. I can fast forward here. You shouldn't have much vaginal epithelium around the lobotomy site. It should just be the Porsche of the cervix, as you can see here. And you can see this is a case where I actually upside to a four centimeter cup. And in doing so was able to make a strategic incision on the lateral aspect of this uterus where there was a large fibroid and I was actually able, and you can see that here. See, it forms a little clamshell. I was able to pull this out sort of like a mini excite technique through the four centimeter Papa to me and avoid having to take it out. Trans envelope, please. So again, just think about that. But again, you always have to pay the piper somewhere. So you want to make sure your dissection properly again. It's support when you're using roomy tips, in particular, choose to proper size. That really does impact your ability to torque on the bundle aspect of the uterus during manipulation. A couple of things I want to touch based on quickly before I jump into the videos, Um, I often get asked, What do I do in the post endometrial ablation uterus? And if I can't get into I mean for me, I'll scope the patient from above, watch under direct laproscopic visualization, my dilation of the cervix. And even if I have to create a false track, what I will do is create that false track right through the center of the uterus, as if I'm intentionally skewing it basically. And often what I might do, and I'm going to jump ahead here is if you look at this dramatic cartoon here, I may take and drive a dilator all the way through the fund this and pick the largest roomie or a just like a delineate er so that the balloon tip in place outside the abundance of the uterus because usually we have a bladed smaller. You'd arrived, so you really can't get away with this on a huge uterus. But if you've got a small uterus where you're not concerned that there may be any kind of malignant process, there really is no harm incorporating through. You want to make sure you do through the fund this and not through the lateral aspects or the anterior or posterior, just because it either gets you in the bleeding or makes it difficult to manipulate, You've really got to go through the top. Um, well, that's what I do for post endometrial ablation. If you've got to leave for a cold knife cone and you don't have much cervix in the vagina, Obviously the most important thing is being able to find the office and getting into the cavity. Often I'll use an 11 blade and create a cruciate incision over the dimple where I anticipate the office is located. And then if I can place the roomie or the manipulator in in the proper location, it doesn't matter that there's not that much service in the vagina. Or if it's an absence of service, because when you look laparoscopically, you will see a normal looking Copa Tommy Cup position as if it had a cervix in there, and you can still do the th without any issues. Similarly, if you've done a L S H lobotomy cups, work great for facilitating the trade collectively, and a lot of times I will use the smallest, roomy tip and again under direct visualization from above. Watch myself dilate through the top of a stump, making sure that there's no bladder or rectum in there. And as soon as you can get that smallest roomy tip, you can situate the lobotomy cup, and you can do a trade collectively pretty easily Again. Foreshortened flush cervix is no different than having a post sleep or cold knife cone case. It just means getting the cup up there to delineate the Hornets. It doesn't matter that there's not any service in the vagina. And, of course, with a narrow vaginal enteritis. You can either use a soft cup or you can certainly make a small. He's the epitome incision to try to facilitate placement of the cup, which will then repair at the end. And sometimes I'll let patients know I'm going to do that in order to be able to place the lobotomy and again sometimes if you're dealing with a cold night cone or possibly, just use a smaller, roomy tip so that just at least sits in the cervix and helps you delineate the for next with the Capitol Cup again, Tension can't emphasize that enough. And then, with the new McClure, the last thing I'll say is that I don't I don't inflate the new McClure balloon before I do Michael Potter Me. I don't like to blunt the ability to really see the Cup during the course of my deception. Once I have that deception complete, and I'm ready to do the Copa to me, that is when I'm going to inflate the new motor balloon because that is really designed to just maintain, you know, when you make your incision. It doesn't serve any other purpose during the course of your deception. So you don't want to blunt the ability to see this happen to me right during those cases, particularly doing them robotically. Occasionally, there are folks who utilize, for example, the ups, and I certainly I'm a big advocate of the uterus positioning system. I know for some people it looks intimidating because it's another piece of equipment, but I want to share with you how easy it is to incorporate this. Not just in the hysterectomy cases, if you want to use it for that, but also occasions where you just need static placement of your uterus. Right now, this is just an example of a photo in my O. R. Where I have it mounted to the bedside. I've already pulled out. This is at the end of a case. So I took a picture after I pulled out the arch with a roomy tip on a reproductive surgical case. But I'm going to show you here how I easily place that. And so the most important thing is that you are going to mount this behind your cramp that holds your stirrup, right. And you want to make sure that your stirrup is placed at the end of the bed rail not beyond it, but at the end of the bed. Rail, right. The stirrup component, not the bracket. But the bracket allows you to mount behind. I'm gonna play this here to show you. I know there's some sound on this, so ignore that. All right. Chronic by the blue. So what? I'm showing you here is that it's important to to balance the weight of this device. You want to grab blue, there's blue handles, and that's where you want to hold it. And I'm going to show you here what it looks like when we, um when When you mount it. So here again, see the bracket for the stirrup and notice the stirrup is not beyond the rail at the edge of the rail that stretch your distancing appropriately. And then this positioning system will mount behind your stirrup bracket, as you see here. Now, I'm going to show you a video of this play here. You'll see that he's going to show you in real time. In about a minute, you can actually mount this thing would be ready to rock and roll. I'm gonna make sure that that thing is not dick. I picked it up right at the Blue Handle. I bring the cart right next to the bed so I don't have to carry it very far. Arms are touched at this point. Makes it very easy to drop. Drop this opinion once you've had it and touch the arms at the patient's side, plug it in and turn it on. It activates traveling. You step on the foot pedal and then you can lock this thing in place. When you step on the pedal, it's loose. And then when you let go a lot So now I'm basically ready to prep and drape my patient, including draping this particular device. And as you can see, that took about a minute of video play to be able to demonstrate that. And you can see how you know, again, extremely important. We got also what instrument you mount on the end of this. Now it's got different adapters, depending if you're gonna use a roomy and arch or delineate er but you can see how critically important it is to make sure that your patient buttocks are positioned appropriately on the table and that they don't slip when this thing is attached. And you can see that here at the end notice I have good external rotation and abduction. Ankle knee opposite shoulder, a little bit of deflection. This device is mounted tons of room to manipulate. I go on the T bird, I'm gonna be in great shape, so I'm gonna jump into some videos and I'm gonna try to highlight here over the next 25 minutes, Uh, from different concepts on large uterus. So I'm gonna show you kind of what I believe are the important dissection techniques that I believe have been tried and true, Uh, for doing t o h. I'm gonna show you first of all, a video on just a a standard large uterus with a subsequent Copa to me. And I'm not going to show the whole history because we don't have hours here. But I'm gonna go to highlight on the unedited videos going to follow this first video, then with a staged open to me showing you how I managed entering to the vagina on a really large uterus where it's difficult to get an affliction. And then the next thing I'm going to do after that is talk a little bit about how I use the Copa to me cup. To help with the anterior cul de sac gets obliterated. As you can see in this picture here, how do you get that hysterectomy done so we can jump to the first video? That would be great. All right. So just to frame this this uterus is it's not too big. This uterus is probably about, I don't know, 16 weeks. Uh, you know, my philosophy is everything always looks a little bit small when you're viewing things from a little higher up in the belly. But this is umbilical port placement. It's probably like probably 14, 15 weeks size globular uterus. Uh, most important thing I can see the cup. That should be your first sort of safety check. If you don't see at least some component of that cup during your surgery double, check that the placement was correct, particularly if you weren't the one doing it right. I just like to make sure that that thing is sitting up there nice and up in the four next. So I can really see it as my guide because you don't want to be dissecting towards the wrong thing Now. When it comes to the tube, you can either, you know, take the tube out now, leave it attached to the uterus, or leave it attached to the to the next and come back Word at the end of case. The most important thing you need to think about with double management when you're doing a benign hysterectomy is that you want to make sure you don't need it in your way. That's the most important thing. So let me, uh, let me demonstrate something here. All right? Just passport. Just a little bit here. So you can see I've made a little window here. I'm gonna just jump ahead periodically. Reason I did this is that I was using this video is a teaching cases. I was talking This case through my to my trainees is that I'm highlighting that it's important that instead of grabbing all these tentacles all at once, it's nice to be able to take a tube separate from the uterus Ovarian separate from the round. That's how you're going to get much better. He must assist during the course of an operation, right? As opposed to trying to grab all these particles all at once. These devices weren't designed to dedicate that much tissue at one time. And as you can see, my biases that I do my hysterectomies all robotically exclusively just because I like the ability to replicate open surgical technique with robotic surgery and you can see here just again highlighting and again normally, I would take this to burst, and then I would take the, you know, very. And then I would take around that. And you can see that there's moments where I'm causing because I'm just teaching my team what I'm doing here. You can see we've taken the tube taking the part of the, you know very in. And one thing I want to highlight to you hear that I call a finesse move which mimics a badge test is when you take your ad next to off the uterus. Try not, and I'm going to draw it out here. Mhm. Try not to violate this area. I called the triangle the Golden Triangle, right. Try to leave this intact, right. Try to leave your ad next to attached to the round. Don't undermine underneath the round ligament here, you're an extra off of it. Otherwise, what you end up having is this ovary on this very attenuated, often attenuated medical. And I worry I've won that it's going to dangle close to the cup. It could potentially even maybe to horse. But if you leave this attached like you saw me do here, what ends up happening is your redneck. So will naturally retract laterally because the round ligament is gonna start to shrink away. Right? Notice how that round attached to the ordinary when I pushed the uterus in and over totally opens up the space. And again, this is what I call your standard large uterus hysterectomy. The beauty of it is most uterus are are They may be large, but the lower uterine segment is narrow. Right? Look how narrow this is. I love it. This to me. Slam dunk! This case is going to get done. There's no reason why we're not going to complete this case because I can see the ring if, as long as I can see the ring I know in my hands I can get that surgery done. So you can see here. This is the Copa to me ring right here. And one of the things that I'm going to emphasize here in this case is that when you do each side again Vinick maintaining this this anatomy push the uterus in all the way. Seth Elad. And what you want to do is make sure that when you make your bladder flap, always make it lateral to medial. I never quite understand why people start making bladder flaps in the middle of the bladder. You want to start lateral to medial because you've got the leaflets separated and you want to make it over the fat part of the cup. So when you do this, make sure you do it over the fattest part of the cup that you see me doing here. And when you push that cup all the way in and you make it over the fattest part of the cup, that is the natural plain. Now, again, we're not talking obliterated spaces here. We're talking routine that's directed me big or small. That's where you want to make it right and you can see here. I want to see white. I want to see Cuba cervical fascia. And when you pick up the edge of the bladder popped and I don't I'm not afraid to hold it like this and you push in and you score here again. I'm going to draw on that area. If you score in this area here, right there, that is where you want to be, right? That's where you want to be for making that that incision right there. You want to score along that and that bladder is going to come down. You're going to see that I can almost see the beveled edge of the cup here. That's that's the Cuba cervical Pasha. Bladder is done. I've gotta pushed in. Right? So you want to make sure that you do that and I want to show you something that's and cheerlead for the broad ligament and bladder flower. But you can see here. I still have a little bit of posterior leaf right here. I'm going to stretch that and you're gonna wanna inside that. And you want to relax that and develop that where you intend to cramp the uterus So you can see here that I'm able to visualize This patient is fairly thin. You can see that This is where I'm pointing out. The ureter is I'm actually gripping it right there. That's the order, right? That And you don't want to be down here. This is what we're going to be. But notice the distance. The distance. I'm going to freeze this for a second. The distance between here, I'm gonna put the pointer here. Distance between here and the younger right here is pretty large again. Cup should be pushed in all the way. I've lateral is all the posts Relief with the broad ligament. You want to have a naked cup at this point, right? That's what you want to be able to look at naked cup. So I'm going to release all this post here broad ligament because I just want to be able to clamp without any peritoneum. So your orders here, where the green arrow is cups pushed all the way in. Look at where I'm going to clamp. Absolutely impossible at this point to damage your your order because you've got you've done this, right, cases where I've reviewed for medical legal issues, your internal injuries and video has been provided. One of the biggest lesions is this this The steps were done, and I can literally see your orders being dedicated because they're pulled into the peritoneum as this gets clamped here. So the Copa to me cup is great. You see the nice bulge and now I'm just going to go ahead and we can clamp this right slide off the cup. Pinch it close. I see white and I see white here. That's just vessel burning here you're here where the green arrow is We are far away. And that's really what you want to be able to see right now. I'm not going to cut this until we do the other side. But this is side one. Done. No bleeding a vascular dissection planes, big uterus, but skinny bottom. That's exactly what you want. I'm going to jump ahead here, and I'm not going to show you the other side because the other side is gonna look the same, right? You can see I've jumped ahead. When you go to the other side, you're going to finish. You're going to finish here on the other side. You're bladder flat, so the bladder flap has to be further developed. And then you're gonna create the skeleton ization on this side, and I'm gonna jump ahead again here to show you a couple of things. I'm gonna skip through this right here. Too much. Yeah. I'm gonna freeze this for one second here. Sorry, I jumped back here. Um, sorry about that, guys. All right. Oh, good. This is where I want to be. All right. Let me let this thing play off here because I want to show you something that once you've done both sides before you do your called to tell me what you want to make sure things look like here. And I just want to I'm just gonna jump back a little bit here because I think I missed the part. Here we go. Let me freeze this. So let me fast forward here. So we've done both sides of your hysterectomy and right before you, dear cope, I mean, I can tell. I feel both veterans because the uterus is purple and I've already relaxed and transected the one on the right. But I want to show you a trick for the for the other side here. You always want to make sure that you lateral eyes the your order before you make your Copa to me. And that's what I'm going to show you right here. So I'm rededicating this and I want to show you a very important step. This has saved my my rear end on multiple occasions just being able to lateral eyes that your order that uterine excuse me ensures that my yarder in turn, is also lateral ized. And you can see here I've cut the uterine, and I'm going to cut all the way until I hit the Cuba cervical fascia. Right? And watch what happens when I released that uterine. It's gonna lateral eyes, right? So I'm just I'm pushing in. Let go. After I dedicate a little bit further. See how that uterus is lateral ized. You got it right here. That's my uterine right there. The cup is totally naked. That's my if the uterine bleeding, I can grab it. I've got I've got the papa to meet up here. So when I do Michael Potter me, it's going to be so much easier at this point because I've let that your order, I mean that uterine lateral eyes, which in turn keeps the ureter collateralized like as long as I stay medial to this structure, No way I'm going to get a your order, right? And if this thing starts to bleed a little bit, I can elevate it, and I can dedicate it. If you do this step, you will minimize just by releasing that uterine laterally, making sure you hit the Puma cervical fascist so it slides off. If you do this regularly, it will make your Copa to me incision around this Copa to meet up so much easier You won't run into any bleeding in the corners because you've completely controlled your uterus Medical. I'm going to show you what that looks like. Now when we start the company incision, right? Oh, too far, too fast. Too fast. Just pack it up here. Okay? All right. Can get distinct position. So when I make the papa to me incision, what I normally do is, um, it's basically start either anterior or posterior. Um, and you can see here we're struggling a little bit just to get the uterus position the way I want it. Because I don't like to start this part of the surgery until I have things the way that I want them. But let me just jump ahead here to the part where we are January to make the laparotomy apologize for my jumping around. I want to make sure that and if you notice I'm using a 30 degree scope here, 30 degree scope helps you when you're doing your papa to me. Now I know I've jumped ahead a little bit too far, but if you're using an X I robot, let me tell you I used a 30 degree scope for all my procedures because look at what happened here when I went to 30 up on the scope. I can see totally well behind the uterus, right and notice my uterus cycle ligaments are preserved to the poster vagina, and I can be use a lot of pressure with an open scissor blade. I use co rag, but I move quick and notice that I don't I I cut on the beveled edge and I don't bury my tips into the Copa to me cup. That way you avoid charring and you avoid gouging out the lobotomy ring and you can see there's my vessel, like on this side. I didn't spend time because it would be behind on time, but, um, this yard is a little bit more prominent on this because I had to dissect it out a little bit more on on the right. But you can see here I'm coming around, and the distance between your order and the Pottery Cup is pretty dramatic. There's just it's just not near each other, but I think those are things that are important to keep in mind when you're doing your Copa to me either start in the back of the front, depending on what's easier I started on the back, which makes it a lot easier to then do the front if you've got a top heavy uterus, right, if you can see. But that's 30. Up and down on the DaVinci is fantastic. This whole case has been done with a 30 degree scope, and you probably don't know whether you're appreciated that in the beginning. But that's the scope that I've been using. So let me jump both quick now to the second video because I know I'm starting to run out on time, and I want to highlight some important things before we run out of time this evening. Power seems to go super quick. This is another really huge uterus. Uh, in this case here, um, I'm trying to visualize this large uterus case. You can see it's very bulky. Uh, this is a three armed robot case with a 30 degree scope. Uh, similarly, I'm making sure I can see the ring. Everything's positioned. I've got a third arm in there that I usually use just to deflect the uterus the way that I wanted tilted. But you can see I'm already mostly down to the to the lower uterine segment on the left here. And the uterus is skinny in the bottom. Anytime it's a skinny uterus in the bottom, and I can see the the cop means it's going to be a slam dunk. But what I want to show you here is what I do when I have to stage of called Petya. Me. Right. But I have to stage of called pas to me. I'm gonna jump ahead here. They go back here. Sorry, guys. Here we go. Uh, yeah. Okay. Great. Let me please. This one pocket I used to torture myself with trying to do the Copa to me with this darn huge uterus attached to the service. And a few years ago, I realized, My God, why am I torturing myself? There's no rule that says I can't separate the corpus from the cervix. I should just pretend I'm doing an l S h and stage it. So basically what you see me here that I'm going to do here, basically is I have a uterine corpus that this is about a 20 plus week size uterus. Very top heavy and bulky, but again skinny, Lower uterine segment. Once you've done the dissection properly, you've got a naked ring. I know I'm not going to be able to lift this uterus up easily, even with a third arm to try to get the poster Copa to be done. And instead of torturing myself, I'm going to stage this and I'm going to amputate through the neck of the cervix. This is the neck right here where I'm gonna put the arrow. This is the neck I'm gonna drive right here. And this is where the delineate er really helps me a lot. So with the delineate, er, what I What I do is because the delineate, er you can actually, which is different than the coefficients on the roomy. And the arch is with the delineate er I can actually physically hold the Copa to me component in the vagina, unlocked the handle peace and slide the shaft of that manipulator in and out of the uterus without distorting the location of the company ring. And so what I'm essentially going to do here, I'm going to play this video is I am going to slide out. Um, as we do the proposed to me here, we're gonna start, and I'm gonna cut until I hit the manipulator. Right. And someone's gonna I'm headed here a little bit, just so we can Oops. What happened here? Uh, back to five. Okay. Okay. So see how I started the Copa to me Once I start the Copa to me and ethical pa to me the l S h component the stage Copa to me. Once I start that and I cut down, I'm gonna have my assistant hold the manipulator out of the uterus and pop it back into the abdomen. Right. And again, I want to I want to pass. I want to back this up a little bit so you can see that, right? Here we go. Sorry about that guy. Um, here's the ring. There's my uterus. Collateralized. This is the neck of the cervix. Right here for the green is you're gonna see me. I'm gonna hit pretty soon the shaft of that of that manipulator. And in this case, it's going to be right, because it's the delineate. Er, if you're using roomy tips, then you'll you'll look for the colored tip that you use. So if you got an orange tip and they're gonna look at the orange now, what's nice is I can tell my bedside assistant Unlock the clip on the delineate er, keep pushing the cup in, but slide the shaft out and push it back in. The reason why you want to do that is that and then I'm going to re lock it when I push the tip back in through that defect so we can answer, flex and basically fractured the neck of the cervix and complete the amputation safety. So I don't hit the bow post nearly right. That's essentially what we're doing here, right? So finding it back out just to show you that you can see him watching, watching, watching and then we're gonna pop that you don't really need the balloon inflated to. Usually we deflate the balloon will inflate the balloon when we pull the cervix out so it doesn't fall in the abdomen. But at this point we can deflate the balloon, and then essentially, once this is deflated, I'm going to tell my bedside assistant I want you to an effects that manipulator as much as you can buy an affectionate lifts up that lower uterine segment. I can completely amputate now, and I don't have to worry about hitting the battle. So that's something that you want to consider when you do this and let me tell you, it's been a lifesaver. Instead of watching my like fellows or residents struggle with a lobotomy or even myself struggling, I just do this. It takes an extra five minutes out of my day, but it's so much more controlled. And at this point, you know, once you do this, my gosh, it's a chip shot to do the Copa to me. Actually, for our trainees, I usually have, uh, even an intern sit down because it's easier for them to do a laparotomy when all they're looking at is the company ring, right? And again notice that the ring is pushed in all the way. But I can control the slide of the shaft of the manipulator right, and I can finish this off. And then once this finishes off, um, it's easy to do. The lobotomy won't have to struggle to do that, and then then we just close the cup at that point, and if you're doing an L S h. So this is what an L. S h would look like if I was doing an L S H. This is what you want to see in a super cervical. If you're keeping the cervix behind, you literally want to know that that service that you've left behind and not lower uterine segment and one of the things that you want to keep in mind when you're doing this amputation is as you get to this component right here, this last little bit right here, make sure that you control the peritoneum back here because you don't want that weight of the uterus to tear this peritoneum back here. You don't want to tear that perineum in the back right here and have that building to post your cold attack. You want that parent name to stay attached? So what I normally do is I'll dedicate this to seal that and then we'll cut right along this line right here, right where the green arrow is. I'm gonna cut right here. That's what you want to do. That way you don't That doesn't care backwards. Just a little finesse things that for me, part of surgery to is aesthetics drives me nuts. When you when you you know you violate tissue that doesn't need to be violated. And you can see here that this was a super cervical. There's my cervix. This is the vaginal foreign exposing out Here's my uterine. And then when we do the Pol Pot and then fast forward just a wee bit here again notice I'm developing my particles so that my uterine is really lateral eyes nicely. So when we make that happen to me decision it's going to be easy and again a bit more. We don't and again notice that when we do the Copa to me, you want to make sure that you're not bearing your tips are you typically use the beveled edge. Um, you know, I can tell that this is like one of my residents sitting here doing it because they're taking their time. And there was a pause between switching out to get somebody else to do this part. But it's a lot easier to do, particularly when the uterine has been lateral ized. You know, this is usually where people get a lot of bleeding, is in the three and nine o'clock position. But if you prep the field, you don't get that bleeding at three and nine o'clock, right? You don't have to worry about chasing that. A lot of your general injury occurs when you get bleeding in this corner. And once the cervix in the cup are gone, if you go after it, don't forget that your order is not going to be a lot closer to all these structures. Right? So you want to keep that in mind, And then once this is all out, uh, jump ahead here for closing that support closure here, it's okay that the that the vagina is a little bit bloody. I looked for that, actually, because I know that it wasn't an over desiccated closure, right? I don't want that cup that that that cup to be over desiccated, where it's all charred, right? And so I'm going to bring in the bar future. Here I use a cobra grasshopper and a mega needle driver non cutting because I hate it when a trainee cuts the future by accident and we're gonna close this and I'm just gonna say a couple of words about the closure. One is that When you close, please make sure that you truly get the corner. You want to make sure that you've got the corners of each side, so that when you take your bite, you are basically going in what I call a left stand sign. Right? This is the less than sign you're gonna go from from out to end, in the out, but in an angled fashion so that when you tighten this up, that suit is gonna lay in the corner. You want to make sure that you've got that compressed so you don't have bleeding post operatively, right? So notice I'm going to take the bite. It's going to come out Pasha, vaginal epithelium. And then I'm gonna go back the other way, and I'm gonna again notice that a little angle, right, I'm gonna grab get vaginal epithelium. The Cuba cervical fascia come out in the corner right where the uterus cycle is. And once I lock this down, that is gonna cinch that corner down Really well, right. That's what you want to do. You don't want to travel too much with your first bite and start to far medial, because although it looks like things are going to be approximated. That area is not going to be tight. And that's where you can get some delayed bleeding, right? You always want to be careful that you've done that in a way, Uh, that you're you're securing the corner really well, right? And again, once you've threaded through your eyelid, you always want to make sure that you pull that. I'll it down, right like we're doing here. So you bury the islet and then go ahead and take your next fight. There's no reason to keep pulling Sutra through because this will never anchor until you take that next bite. Right? So again, when you make a nice bladder flap, it's so easy to take a healthy bite. Basha, Epithelium, Epithelium fashion, Right, Just to show you there. And this is a real time just what that looks like. And you want to get a little bit of that perineum, right? I like to marry that back to the vagina. And again, I'm going to show you here. What happens when we pull that type Watch where that angled pitch lays to me, that is extremely important right there in the corner. Boom. You too, Ryan quarter of the vagina that technically, is the equivalent of where your cardinal uterus sacra ligament complex used to be. But that's where you wanted to sit. You never want that future to lay lateral to the uterine. Because if it does, what are you gonna get? You're gonna You're gonna be close to the younger right. So you never want some people will say, Oh, I want to make sure I like it that uterine better. Sure you can do that. But remember, you always got to pay the piper somewhere. And if you're you're eager isn't adequately lateral eyes. You might think it again. Bladder. You completely like, take a tick bite. There's no way this stuff isn't going to heal Well, right. And I want to marry epithelium epithelium because with barbs future If you do that, then you're not gonna get graduation tissue in the vagina because you're going to have no raw surfaces exposed to the vaginal, uh, milieu. So you want to make sure that that that really marries nicely. So I, um I'm noticing that I'm 7 51. Let me just fast forward here to show you what that looks like. in terms of finished product. Um, same thing here. You want to make sure that you have gotten your corners as well on the opposite side as you did on the primary side. So whatever side you did first, the opposite side needs to be equally as secured. So you want to make sure that you've got that you know, whether it's the greater than left hand side, that regulation that you do on both corners so you don't have any bleeding. And again, the only thing that should look charred in your pelvis should be your medicals, right? And in this case, I didn't show that in the video, But you're wondering why there's no end next. So we had to take the left at next to But notice that the right index is nicely elevated because I didn't violate that round ligament attachment to the end next to So can we flip? Eric, can you flip out of this? I'm not going to show the third video. In fact, I'll say that's a teaser. And maybe what we can do is if Cooper Surgical is willing in the future. What I can do is we can dedicate an entire program just to management of obliterated. And you're called a sack and obliterated poster called a sack. I think I was being a little bit ambitious, thinking I could cover all of this in under an hour. Um, but essentially, and we could even, you know, skip through all the other things that I talked about earlier if we want to invite this very same group to a program in the future, and that's on tonight and we will just cover this because I know this is a royal pain in the rear end for a lot of us when we're in the operating room. But I have a lot of neat tricks for how to manage that obliterated anterior cold. Is that, um, And so maybe we can address that on another gate as its own isolated topic, because I love to cover that. There's a lot of really neat ways you can use manipulation and the Copa makeup to make that actually quite easy again. Just the last couple of things here on the vaginal cuff closure again, you can see here that angle, that's what you want to get that corner and whatever shooter you use they all work. Well, um, you know, surgeons choice, but I love Barb future for this closure, because it really makes it nice. Insecure. I'm gonna skip this video because we talked a lot about cuff closure already gonna end here by saying that. You know, when you guys see your hissed, your laproscopic, whether it's conventional or robot assisted laparoscopy, think about strategy from the beginning to the end. I'm a big strategist. A lot of what I do is often very redundant, very repetitive. But I find that it's easy for me to approach cases with a certain level of structure course. Every case is different, but there's always a key backbone to your cases. And I think what I hopefully what I talked about tonight kind of outlined some of the things I believe are the core backbone features of a successful, minimally invasive hysterectomy. Um, if you understand the anatomical relationships and how they change with manipulation and the lobotomy cups that's going to serve you well, choose your instruments wisely. Uh, and again, like I said, the dissection technique really combined with the instrumentation is the key to success. And if you end up with that naked cup at the end. Um, that means that you've done the dissection correctly. So with that, I'm going to try to jump to questions. People have been pretty quiet. I haven't seen a lot of Q and A questions coming up on the on the Q A board. Yeah, sure they are. Now, um, let me see here. Um, well, let's see. Um, there's been questions. Let me see if I can adjust this so I can see more of the questions here. Um, well, it sounds like a lot of people here. Oh, gosh. Somebody changed my view that I cannot see my questions now. Here we go. All right. So somebody asked me to comment on differences between the V care and the co manipulator. Um, you know, the bottom line is, you know, both are comparable in the fact that they both give you a handle to manipulate, and you've got a laparotomy cup at the end. But there actually are some subtle differences that I've learned through the years, and I've used both of them perfectly earlier in my career. The one thing that I think is the difference is really in the cup. design. Although some people like a groove in a cup, I'll tell you that. I honestly think that that predisposes individuals to more charming, because when you use electro surgery, which I think the majority of people incorporate into their surgical cases, you you really want to allow that electro surgery, the mono polar scissored to have a current art to the tissue. And the only way that you can accomplish that well is by pushing in on the Copa Tommy Cup and letting your instrument almost just tickle or dance on top of the Copa to me ring. By doing so, your tissue will separate like butter, and you can use cut or co ag, and it will work really well and you can move quick. But if you close your tips of your scissors and you stick them inside of that groove and drag it, it's going to be a little slower in terms of the speed of Copa to me at times. But you'll probably end up with a little more dedication effect. So one of the things I think is the difference is you have to be an individual that either appreciates a group or a lack of a group, and I like the lack of a group. I like a beveled edge. The other thing is often that a lot of cops on the market are tapered. And the one nice thing about the Coke topic again pay attention. And look at these things is the CO Cup is uniformly the same shape the whole way down to what I call the well, and the well is deep and the deeper and more uniform the well, the easier it is to to slide and fit that cup up high up in the vagina into the Hornets. I'm sure you've seen cases where you've got a bulky terrorist cervix that that doesn't allow the cup to sit easily. If you've got a tapered Copa Demi cup or you go to small, it's not going to sit high enough, and it's going to alter your dissection view from above. So to me, those are the biggest things that I've seen. Um, where where they're slight variances between the V Care and Coke up. Um, somebody asked me also like, Why do I wait to transect the uterine vessels on the first side until I do the other side. The reason I do that is it avoids back leading. You know, if you translate your vessels on the left side, which is the side, I typically start with first. Then you've got it. Unless you steal thoroughly your back bleeding. Then you have blood pouring into the field and you always have to rely on somebody to suction that out. I hate blood in the operative field, so I typically will complete one side, steal it, but not transected do the opposite side when the opposite sides done. Then I transact that right hand side first. Then go back, transact the left hand side uteruses purple, beautiful pa to me and and for me, that has really been a way to minimize people sticking to such an irrigator in there. Uh, and getting in the way of being able to to see what it is that you're doing, what you're doing when you have a large uterus and you have a lot of back bleeding, it really becomes aggravating when you're dealing with that. So I just It's a way to keep the operative field queen when you're doing something like that. Um, let's see here when you amputate the uterus. There's another question when you amputate the and by the way, I I've seen a lot of names come up here people that I've worked with in the past, and it's so exciting to hear and see all of you. Uh, that's fantastic. So to all of you and I won't name names out there, there's a whole slew of you, but thank you for tuning in, and it's it's great to see all of you. Um, one question is, when you amputate the uterus protocol economy, what do you do with the uterus? What I typically do, um, is I let the uterus slide up either into the left or right para colic gutter or just sit. Just stuff a lad out of my view, because usually the uterus on average, the uterine weight that we treat in our division is about half a kilo. That we do, you know, robotically on average. So we usually have large motorized, and they usually will just sit just supple that to our field of view. I don't normally tag it with a stitch or anything like that to hang on to it, because usually we're able to readily see it now. If it's fibroids, for example, from a myomectomy, I will tag all of those. But from a from a hysterectomy perspective, I usually just park it in one gutter or the other and usually haven't had any real difficulties. If it is a small uterus, um, that might be another story, but usually with a small uterus were able to immediately deliver it trans vaginally. And there's another question on this topic. Apologies for the interruption. We have time for one more question. Okay, well, I'm going to end with the question on testosterone P. Uh, somebody will ask about my position on that. And I'm a universal Festus copy person. Um, even though, and there's a lot of great studies out there, a lot of pro con argument papers that are out there, and I think they all have their merit on both sides. I can tell you that I subscribe for one reason. Both clinical and spoke medical legal. I think it's for me. It's an easy thing to do in R O. R s. We have an easy to stop to be set up. Uh, there are a lot of societies that have put forth communications, encouraging the use of universal photography at the time of benign hysterectomy. I know a G l is one of them, Um, and certainly for me. I like to know that when I left the operating room, even though I know I've got the order is protected and their lateral eyes, I'm confident I haven't done anything to injure them. Being able to say that I have confirm hate and C and E flux on both sides, part of even the O. R. I feel that that's good from a medical legal standpoint and also just peace of mind. Um, it doesn't. It tells me, at least at that point in time, I haven't transected or litigated the order. It certainly doesn't tell me that I'm free and clear of a delayed thermal injury because you can certainly have the flux of a your your little, uh, see the real or e flux at the time of a hysterectomy where you accidentally thermally injured something, you can certainly see any flux, but not no doubt that you've injured it until, you know, maybe 5 to 7 days later, when your patient bounces back to the e. D with some plant pain and fevers. That's when you'll pick it up then. But at least you know that you've ruled out things like thinking like transaction ligation that'll be ruled out by the cyst. Oscar P. But again, remember, just because things look good at the time of surgery does not mean that if you're patient bounces back after th that your federal injury should still be in your differential diagnosis. I cannot tell you guys enough the number of cases that I end up reviewing where, for whatever reason, nobody is thinking urethral injury. When somebody bounces back 5 to 7 days later, think about think your order. Think pelvic abscess. Nobody likes to think that they hurt their patient. And, of course, none of us go into surgery thinking we did or are going to do that. But if you keep those things on the top of your differential, it will serve you well. We all have complications. I've had my fair share in my 20 year career thus far, but I always keep those things until ruled out it's on the top of my list, Um, and with that last tip it I think we will think call it, uh, an evening again to all of you out there on the front lines. Good luck. Uh, stay safe. Stay healthy. I look forward to the day when we can go back to seeing each other at live events because I I really, truly enjoy that more than not being able to see people in the audience while while I'm speaking. And when we do get to operate Good luck, everybody on your cases. And, um you know, I'm always happy to answer questions that people might have after the fact. And certainly if you, like, just reach out to your Cooper Surgical rep. I'm happy to share my Columbia email with you. Um, just provide a cell phone. And I'm always happy to call people back more than I am typing long emails. If you have clinical questions, I usually get back to folks. And again thanks everybody for tuning in and have a great night
