What I try to do in any case is assess, okay, is this more of a routine case or a tough case? And if so, try to figure out why. And then in the middle of the case, what I'm always kind of thinking about is how do I turn this harder case into an easier case, right? So these are just some of the examples that I'm going to get into today, and we'll talk about it. A number of videos of complications. I've gathered these things over the years from my colleagues. Whenever it's mine, I'll tell you it's mine. I don't like to stand up here and say, this isn't me, this isn't me, but the ones that are me, I'll tell you, and the rest of them are not. And I won't tell you where they came from because I don't think I'm supposed to. Here's a tough case. Whenever the patient is really small, I find that a lot harder than if the patient's obese. And I don't know if you're familiar with the pink pad, but if you imagine the width of a pink pad, she's so much smaller. I should have taken a picture like this, but my hand's fairly large, and I could practically reach it all the way across her just so she's a pretty small person. This image with the robot docked didn't do it justice, but it was tough to avoid the external clashing in this case, and just knowing that was helpful, and it just took extra time and just being more mindful and imagining where those instruments are the whole time. But I find the smaller patients to be more of a challenge than the bigger patients, actually. I mean, I loved Kara's talk yesterday, and once you gain access in a patient like this, then you're home free. With a couple of thoughts, I mean, you definitely want to kind of hang their bottom over the edge of the table because, don't forget, when they go into T-Burg, they've got a good amount of fat that's going to, they're going to slide, not slide up the table, but they're effectively going to move up the table because the amount of, I guess you'd say, fat around their back they have allows them to do that, so you've got to account for that when you put them in Trendelenburg, otherwise you'll find that their legs straighten out in the stirrups and you have to deal with that. But otherwise, I don't mind this case as much as the smaller patients. I think they're more challenging. I think we have to always look for and respect perineal descent. I thought Roger's talk this morning was wonderful. I've been doing a lot of combined sacrocolopexy and rectopexies down to the perineum as well, and so when you see this, and especially if they've got obstructive defecation, just doing a sacrocolopexy is not going to help this patient. You have to definitely get all the way down to the perineum and get some pretty robust attachments at the perineum to correct something like this, and a patient like this can have all, you know, her POPQ scores aren't going to be that impressive, right, because the numbers are going to be, you know, not reflective of what's actually happening. Another, here's an example of just almost a complete posterior prolapse. It's not as though you can think of the anterior segment as having good support, though. I think it's just the leading edge is sort of almost supporting the anterior, and it's hard to make the anterior go down, but if you stand a patient like this up, you can appreciate what's going on anteriorly as well. So in this case, if you're going to try to approach this one from above robotically, then you're going to need to placate not just the epithelium, but sometimes even a direct rectal placation and maybe even a rectopexy. And that's going to depend, you know, on the defecation symptoms. I think what Roger said is amazing and true, that you can have a patient like this who doesn't have any defecation dysfunction, and you sort of just really have to get into details with them and ask them. Cervical anomalies. Okay, I'm a big super cervical hysterectomy person. I like to leave the cervix in, but in this case, you really can't leave the cervix in, and it's kind of tricky because you don't have a good, like, co-ring or something to deal with the cervix like this. So what I've tended to do in these cases is just go really slowly, do the hysterectomy like I do, and then kind of feel my way with nothing in the vagina at all, and just wait until I'm, you can sort of just tell, after you've done proper dissections all the way down to the bladder neck, then you can tell when you've gotten past that point where the cervix is, and then just make your colpotomy. I'll put just a glove that has a sponge in it in the vagina to maintain the pneumoperitoneum, and then just do your colpotomy without using co-rings. You've got to be really careful, but it works. And if somebody else has another suggestion, I'd be interested because it's tough when they've got a big, bulky cervix. This one, I think, was almost completely replaced by Nabothean cysts. This talk kind of jumps around. I'm covering a lot of different points because I was trying to throw in a lot of things that I think are interesting or points that come up. Even when you've got a GH that's huge on a physical exam, so many times you can do a case like this and right afterwards in the OR take a picture or examine the patient two weeks later, and you've sort of corrected the problem. So I don't do very many peroneoraphies. I do it sort of, it's know it when you see it kind of thing. At the end of the case, everybody's consented for it, and if I think they're going to be disappointed with what they're left with in terms of their entroitis, then I would. But I would say it's probably in the neighborhood of, I don't know, 5% of the time that I do that. All right. So I'm going to try to cover some of the sacral pitfalls now. Here's a couple of slides I borrowed from my friend Peter Rosenblatt. This is the anatomy around the sacrum, and now it's labeled. And this would be, of course, an easy one. And these are all the things that we sort of have to survey. And that's the way I would approach any of these cases. Again, my approach to a tougher case is to, you know, initially assess, okay, what's tough about this? Okay, I can make this routine after I get all these adhesions down, or I can make this routine if I can just navigate the area around the sacrum, whatever it is. But I'm always trying to, in my mind, turn this into, okay, now we're in the routine phase, now we're in the routine mode. Now, you can have quite a bit of variation in the pre-sacral vessels. This is just the classic Netter picture, and then we've got these little images for different variations that can be seen with a separated artery and vein or very dilated middle sacral vein, just other combinations. And when you're in there and you see something big that you didn't expect, and then you really just have to back up and really know your anatomy, know where you are, and make sure you're at the promontory, and make sure you know where the ureters are and the bifurcation of the common iliac vein. Just a couple of things. And I'm going to show you some videos of some of these examples. Now, this is painful. This is 20 years ago. In 2005, I started doing robotics, and I'd already, with Myles, learned how to do laparoscopic copepexes, and this is me. I'm embarrassed of this, but, you know, I think this is my fifth or seventh case, something like that. And I was nervous about the fact that I hadn't really learned, hadn't developed the natural haptics that you get just from visualization. First generation of the robot. And here I'm thinking, okay, I was pretty oriented, believe it or not, to where the sacrum was, but I hadn't obviously cleared it away. I hadn't developed all those techniques that I have now. And so when I pull this needle through, I'll probably hear the sound I usually hear from the audience. Yep. That happened. And now I'm super nervous, of course, but I got a little bit lucky because when I pulled up on the two sutures, this is, I used to use Ethabond for this, and so when I pulled up on the zero Ethabond, I noticed that flow kind of stopped, so I felt a little bit about that. And so I decided, all right, I'm going to hold pressure, I'm going to pull up on this, get rid of some of that blood, see if it'll stop with pressure from creating tension, and then I'll just tie the stitch down and then hold some more pressure and pray. And hope is not a plan, right? So this was, again, something I'm kind of embarrassed of. This is the resolution of that. I sat there for a while with the Ray-Tech, and then I looked, and it was dry, and I thought, you know, maybe just one stitch is good for her. So and actually, it all turned out okay, but it didn't have to. I, you know, like I said, I'm kind of embarrassed about this. I should have taken a more methodical approach like I would now. Here's a little better technique, not quite as fatty at the sacrum, but this just shows my usual techniques. And that's a lot of what I was talking about before. First know where you are, know where the promontory is, know where the ureter is, know where the bifurcation is, and then just think in terms of steps. The first step, literally, is to get in to the peritoneum, and what I'm thinking is I don't care about anything except my one step right now. I'm just simple-minded. I'm going to go through the peritoneum safely in the right pericolic gutter all the way down, and that's all I'm doing right now. And then my next step is, okay, now that I've done that, I'm going to make sure it's open wide enough so that I can easily bury the mesh at the end and I don't have to struggle doing that. And it's not until I've done that part of the step where before I start thinking about, okay, now let me think about the sacrum, and the reason is because when you get to the sacrum after doing all this, it's easier. It's easier than it would have been if you just tried to get just the sacral dissection done before you opened up, and so then now I can redo my traction, counter traction, and here I'm like what I was talking about yesterday. I'm just looking for a little window of opportunity, doing little small movements and picking things up and seeing how they react, and then wait until I see a little window of opportunity usually off to the right side, and then once I see that, just exploit it gently. And then once you see your little gap, you're home free. There's the ligament, and now all I've got to do is make that open enough to put two stitches in. I use two stitches. There it is, and that's all. And I really wouldn't go further than that. So there it is. Now here's when I collected this. So a more poor technique. I think this is, I mean, basically it's going back in time to that one where I messed up. Just hope is not a plan kind of a thing. This one turned out fine, but if you use this technique over and over, you're going to get into some big trouble. Also I am not a fan of having my bedside assistant actively involved in much of anything, but it's just my personality. Again, I think it's childhood trauma, something like that, but the more active they get, the more likely they are to harm you. They can get kind of rough with a sucker. They can get kind of rough with a kitten, or I would, gosh, I would never do that. But here they're just kind of saying, I think they know where the promontory is, and they're just kind of digging down. And if there was anything untowards in the way, then they would have hit it. Because imagine this technique for this case. This is a case that I did, and I was just using my little thoughts, you know, okay, let's just do safe little things. I'm not sure what's here. It's a lot of tissue there. I wonder what this is. But I'm just, you know, as long as I'm doing little safe movements, then everything's going to be safe. One little tiny movement at a time, this is what I'm telling myself. I'm oriented here. I know where the promontory is, but there's this big wad of tissue that I thought was mostly fat. And as I started looking, I was like, oh, no, that's a big vessel. So I'm thinking, okay, maybe it's that middle sacral vessel dilation that I showed in the cartoon form. And the more I did this, the more I realized, you know, that's pretty big. So again, I'm just showing the way that I would handle something like this, or how I do handle something like this, is just, you know, just little, little movements methodically. But if you think back to the technique I just showed you in the previous slide, that would have resulted in a ton of bleeding. And then you wouldn't know where you are. And then one thing leads to another. I think I always say that the little bleeding leads to the big bleeding, right? Because then once everything's stained red and you can't see the tissue react to what you're doing, then that's when you can really get into trouble. So the way to avoid the complication is just don't let the little bleeding happen even. So that thing's pretty big. But it's fine. We've got room there off to the side to put the stitches in. I think this video even shows that. That's unnecessary. I didn't have to do that. It's unnecessary. I don't know why I'm doing that. Yeah, so anyway, there's a couple of stitches that I put in there just to show. Now, yesterday we were talking about that case. And I was happy it came up at the end because you really do need to think about the disc and osteomyelitis happening. And be very afraid of that condition. And also the hypogastric plexus. Again, I think I alluded to this yesterday. But the hypogastric plexus, if you destroy that, you're going to create constipation in certain patients. And it's hard to take care of afterwards. And so I'm super careful anymore not to do that after having made that mistake before. If you notice the layout of the anatomy here, as long as you're heading sort of up the slope around S1, then the bone protects the disc. That's what I think. Here's that case that we were alluding to yesterday. Here's some pictures from our friend in California who had a terrible outcome where the patient had to have their sacrums essentially replaced. And here's the one I was talking about yesterday. This is the patient where the op note said the mesh was out, but the mesh really wasn't out. And this was just a soupy mess at the sacrum. And these folks generally have a whole lot of pain. And it's a totally avoidable complication, I would think. I mean, I'm not saying that with any authority. I guess it could happen. I don't want to set anybody up for problems. But I think if you just don't get into the disc, then you should be OK. So here's just what I mean by that. If you look at the slope, if you're going up the slope, I think the bone's protecting you from getting the disc. And that's probably something like 1 millimeter to 2 millimeters of thickness of a bite. And that's all you need. And you probably don't even need that much, because when we used to do the colpopexies down around S3, you could see the needle through the tissue every time. And it was still strong. So you do not need a bite that big, probably what I just showed you. All right, here's just another one. Again, I'll do this little practice swing, like a practice golf swing sometimes, just to make sure that what I have in my head is going to happen. All right. Now, anybody know what Moab stands for? I got that from Peter Rosenblatt also. I pulled this video off of YouTube. This was something somebody posted. I guess they were just showing their technique. Peter Rosenblatt coined this Moab, mother of all bites. Oh. And again, dating myself, showing my history, this is how people used to do this. And I don't think people were thinking about the disc. It became something people got aware of in the early 2000s that you can get an osteomyelitis. It's not going to happen 100% of the time. This can be your technique. And you probably aren't going to see an osteomyelitis more than 5% of the time. And I don't know why that's true. But I wouldn't recommend copying this technique. This is way in there. All right, so this is another video. I borrowed, of course. This is after a colopexy. Now a general surgeon's come in and wants to do a rectopexy with a stapler. And it brings up a point. There's a lot of points here. But first point is, whenever I'm working with colorectal, I like to be the one in charge of the sacrum, honestly, and plan it out and put the stitches in we're all going to use. Yeah, see? So this brings up a bunch of points. When you're dealing with areas where you could get some significant bleeding, you have to sort of have a plan in your head of what you're going to do if that bleeding is happening. And obviously, pressure should be first. In a case like this, eventually, I know the way this case went down, they eventually had to open this patient. And she did OK. But the suction's really not the best. Suction doesn't help anything in a case like this. You just need pressure and just probably just get in there. I'm just going to continue to play this, because the next move wasn't the right move either, if you think about it. Yeah, hope is not a plan. Yeah. All right. Yeah. Well, I mean, honestly, never, ever be there. Never, ever do that. I mean, that's like. That's plan A. I don't have a plan B. I guess I should have a plan B. You don't have a plan A. No, no. That's not true. Plan A of never being there, never happening, like that was And you saw that pilot checklist of the one in a gazillion happens. Sure, sure. Like something happens, and you find that you got bleeding from a space, and you don't know exactly which thing is bleeding, because you haven't cleared the anatomy away. And I don't know, something or some body did something that you didn't expect in your case. Pressure is number one, right? Absolutely. And then you have to, I would say that you need to think through, how bad is this? That was pretty significant bleeding. So I would be thinking immediately, I'm going to have to open this patient up in that situation. Immediately undocking. Absolutely. Yeah, the lovely thing is the robot can, you can just leave it still, right? And you can undock the rest of the instruments. So you could, so exactly probably what I would do is my fourth arm is the one that I would have in a good place for this. And I would try to stop the bleeding with the fourth arm. And then you can undock the rest of them. And then you could kind of get at it. And I would probably leave the pneumo so that it would be easy to make an incision. Yeah. All right, so moving on. Now, this is not a complication video. This is how I approach some of these patients with obstetric, excuse me, the defecation dysfunction. So this is, I've already done my usual sacral colpopexy. And the mesh is not attached to the sacrum right now. I'm using the mesh, holding the mesh up to get into this space. And I'm using a delayed absorbable braided suture here to just attach, very gently attach the rectum to the sacral colpopexy mesh. And this is a technique that I kind of developed along with a colorectal surgeon when I was at Cornell. And we did a number together. And it's nice. I mean, it's not for everybody. But when the patients have obstructed defecation and that intussusception, sort of internal rectal prolapse, and you're in that space already with your colpopexy, I think that you don't want to do nothing because that's not going to help them. I used to think, huh, if I just have the mesh there, maybe the rectum will attach to it. And that just doesn't happen. Their obstructed defecation is going to still be there. And you've created sort of a tough situation if somebody wanted to get back in there and help them. So I just started doing this. And it works pretty well. It's not just me. There's a lot of people doing this now. And again, I'm just working my way out. And I've just basically learned from the colorectal person I was working with what she was up to, what she was doing. These are very, very, very superficial bites. I'm just like Roger said, I have a lot of respect for what I'm doing here. Pat, did you say that you were already attached to the sacrum? No. Not attached to the sacrum. I'm actually using the mesh that's attached anteriorly and posteriorly to the vagina. And I'm holding the mesh up with the fourth arm to get in the space and work my way out. And you've taken the posterior limb all the way down to the perineum already? That's right. And so when you do that, do you ever cut and make straps that go lower on each side of the rectum? Or do you just take the whole thing down? Do you know what I'm trying to say? I take the whole thing down. You take the whole thing down all the way down the back wall of the vagina? And are you suturing corners to any part of the levator? Or is it just all on the back of the vagina? What I think I'm doing is just around the perineum, just attaching at the perineum. I'm trying to avoid the levators, because I believe the stitches in the levators can lead to pain. And so I'm just trying to stay in that four centimeter wide strip that is the width of this mesh. And so the next step after completing probably about six of these sutures, and then closing the peritoneum using the purse string. I'm just jumping around in these things, because I just came up with thoughts to share. This is a situation that I've dealt with a number of times now, where the mesh breaks. The classic person would be somebody who's obese, and she had a stage four prolapse. And then he comes back, and it just looks like the same prolapse that she had before. But the mesh is all attached at the vagina, but the mesh arm broke. And so what I typically do in this situation is what you just saw. I dissect the mesh free from surrounding tissues carefully. And I used to think, maybe I should just leave that sacral attachment and then connect to that. But most of the time, I don't do that. I just take this whole sacral arm out, even at the sacral level, and then just do it over. And on the vaginal side, I don't go down. I'll dissect all the way down to my usual, and then I'll see if the mesh is going down as far as I would like. And if it is, then I just lay a new piece of mesh, probably five centimeters or four centimeters on either side, make it nicely attached. And when you think about it, the lightweight meshes that we're using, being like 18 grams per meter squared, something like that, even if you've got two of those, that's still not as much mesh load as we had when we used the first generation of the type one mesh. So that's what I would do there. Yesterday, we were talking about, should we cover the mesh? And my opinion, we should. And here's just a, this is not too long ago. I was in on a, I did this surgery. This is a patient where I had done a colpopexy 10 years ago. And she had a distal anterior failure. This was not a case with a uterus. This was a post hysterectomy colpopexy. And she developed a symptomatic anterior wall defect. And I just like how the mesh was covered. And I think covering the mesh is nice, because look, there's hardly any adhesions here. What I did in this case is just dissect open the spaces. And I saw that the prolapse just happened beyond the edge of the mesh. And I just put a new mesh in to connect to the old. Did you reattach the safer or just connect it to the old mesh? On this one, I connected to the old mesh. And because there was nothing wrong with this mesh. Nothing had broken. All right, now transitioning into some dissection and suturing pitfalls and thoughts. General points, I went over this yesterday. I think it's important to obviously know where you are at all times. And then constantly adjust and optimize your traction and counter traction, as opposed to what I call doubling down on wrong. Like, this doesn't look good. Here, let me spread my scissors in there again. You know, and I'm not making fun of anybody. But you get lost in these thoughts sometimes. And you think, I thought that was right. So I'm going to do it some more. And instead of saying, oh, that's not what I expected. And then just change it up. Or, my favorite thing to do, if something's hard, skip it. Do something easy. Because by the time you come back to the hard thing, it's usually easier. Every time you make a move, know what to expect. Bleeding is almost always from the vaginal side when we're talking about dissections. And then the specific endpoints and the other thoughts that I've given you. Here's one. A colleague shared this video with me. Not exactly a good video. Not exactly a complication. It's just a good illustration of recognizing when they started out in the wrong plane. So this turned out to be a nice dissection. It just, right here, if it's, so I always say, when I'm in this, if I'm teaching somebody, what I'm saying at this point is, make it look like it always looks. Make it look like it always looks. That's not how it always looks. Make it look like it always looks. And this little point right there by the scissors, that's an areolar spot. And if you had opened that up, then you could redirect and be in the right place. This is a split thickness vaginal dissection. And I'm surprised it hasn't started bleeding yet, but they'll always bleed if you keep going. And they can fool you sometimes because it looks like it's getting smooth, but that's still a split thickness vaginal dissection. And you can probably see the plane now as a little triangle heading towards the robotic grasper. And this is doubling down on that wrongness when what you're really looking for is the areolar plane that's pretty much always there. So when you see that little bleeding like that, it should be a clue. You stop and say, wait a minute, maybe I'm doing this wrong. And then just check it out. And if it was me, I'd probably move that fourth arm in and out a little bit and see how the tissue reacts. But there's the plane over there. And I like this video. I think it's really well edited. And so you can just sort of see. If you come across, you figure out where the rectum is and just stay above that. And then you can just correct and move on. And if there's any bleeding, take care of it. And if you think it's really a thin area, then you could kind of be careful about your sacral colpexy stitches there and try to avoid the actual split thickness dissection with your stitches to avoid that mesh exposure. And there's the correction. And the correction went all the way down to the perineum. I don't think we need to keep playing it, but that's what that is. This is what I mean by suturing to the levators. This is a mesh product that was wider than the mesh we have now. I think this one was five centimeters in width. And there's still a group of people out there that believe in suturing the mesh to the levators. I think that would, I forget who was a proponent of that, but I do think that'll cause pain in a number of people. And I'd recommend against it. Yeah, microphone. You know, when you say you suture down to the perineum, I'm still having confusion if it's just that you're suturing along the whole back wall of the vagina all the way down, or if you're literally putting something down on the floor somewhere. I'm putting big bites into the perineum, usually three. But if it's somebody with perineum, I'm putting three big bites into the perineum. And I'm not putting a lot of pain into the perineum. I'm putting a lot of pain into the perineum. Three, but if it's somebody with perineal descent, it'll be maybe five. And then all the way up the posterior wall of the vagina as well. Remember, I overdo it. I put too many sutures in. That's what I do. So like five stitches across that bottom left part. That's right. So here we have examples of the stuff I was saying to not do. This is, that doesn't look good. That doesn't look like a plane you want to dive into. And so now is a good time to stop and use your other thoughts, one of which is maybe get into the posterior area first. And then you know exactly where the vagina is, at least posteriorly, because that's usually easier. And then you can work your way around and sort of triangulate to the right plane. This is doubling down and tripling down on the wrong thoughts right now. And it's almost better to make a cystotomy than to do this. Because if you didn't recognize what you had done, then you've got a less than paper thin area left intact in the bladder. And that could wind up with a fistula or worse. Notice also, the camera angle is off. When you're having trouble, it's a good thing to just take a breath and make sure your horizontal is correct, because a little bit of a lean on that camera can really throw you off, especially when you're in ureter territory. Do you ever think about the spider webs? Like on that other video, when you're in the detrusor muscle, it kind of looks like spider webs. Yeah. Yeah, yeah. If you find yourself saying, huh, this vagina has crisscross fibers, then you're like, oh, no, it doesn't. You know, you said bleeding almost always means you're in the vagina. Would you agree that maybe the one time that's not the case is post-hysterectomy anterior dissection? Yeah, you could be anywhere. You could be in the bladder, too. That's true. That's accurate. This is just another one. This is one where they got into the bladder. And so it's looking fine. I mean, you can dissect the peritoneum off of just about anything like that. So it's not like that should be reassuring, but I think it was. And of course, if you're operating through fat to get down, then you very well could be operating through the viscera. And so this is exactly why. That's obviously the first move they made in the case. And that's exactly why I always do, in a post-hysterectomy case, the posterior dissection part first. Because it's almost always easier. Because for reasons that Kara maybe can study, I think, I really believe endometriosis and prolapse are practically mutually exclusive, don't you? I mean, how often do we see bad endo in our cases? Almost never. So that's obviously a hole in something. And if you look around, there's the detrusor fibers. So it's obviously a hole in the bladder. But just to double check, I'm going to make sure you see the foley. Now, a little tip on a cystotomy. We've all made them. We're all going to make them. It happens. But you don't need to make it bigger. And if you got one, the impulse is, oh, let me sew that. But what my recommendation would be is complete your dissections and at least use it to your advantage. Because now you know exactly where the bladder is. And finish your dissections. And then close it. And I think most of us would close it in two layers with Bicryl. I know there's folks out there who would use a barbed suture. And I don't have a problem with that. It's just not what I do. I would do a running layer and then an imbricating layer. Here's another one. OK, you've got to know where you are. You've got to have your traction and counter traction proper. And then when you're getting into what you think is the right pericolic gutter dissection, if it's not opening up with a reel or tissue, you just stop immediately and figure out, OK, what's going on? Where am I? Again, any time something is not what you expect, it's a better idea to stop and figure out why. So you can start to see what's happening here, right? At the top of the screen is the cul-de-sac off the picture. And there's the rectum. There's the colon. Right. So the question usually comes up on the previous video, what would you do? Would you still do the colpopexy? And absolutely. With a cystotomy, you close it nicely. I think you can do the colpopexy. But if you get a rectal or a colon defect, I personally wouldn't go on with the colpopexy. So that's a pretty good-sized defect there. Now, here's one that I found interesting, imagining how this would happen. Again, you've got an overactive assistant. And if you look at this, I hope I made this play over again. If not, I'm going to ask you all to play it again. After talking it over with the surgeon involved, I think what was happening is you've got your overactive bedside assistant doing stuff. And for just a split second, your mind tricks you into thinking that's you. And off screen, you've got your scissors. And you're moving them. And then, wait a minute, they're not responding like that instrument. Oh, that's not me. And then, your scissors are back there mucking and things. Can you all play that video again? And so my way of dealing with this is I don't really want them to do anything proactive. It's really boring to be my assistant. So lucky for this surgeon that they saw that and could deal with it, because that's the kind of thing that could lead to a patient getting super sick a few days later, right? All right, here's another one. I like that tenaculum. But you cannot open the tenaculum off screen. You just cannot do it. If you think you've opened your tenaculum off screen, stop immediately, because that could happen. And again, they're lucky that they saw that. Because if they didn't see that, then that could lead to a patient getting really sick. For mechanical bowel injuries, I'm sure we all do this. We know our favorite general surgeons that aren't going to just do a colostomy, that they're going to be willing to close an injury if it was there. And that's pretty key. I think it's, I mean, I don't know about you, but I'm not throwing into my pre-op counseling that you might wind up with a colostomy, right? That's not something I say, because I've never had it happen. But anyway, it's a good idea to have some good colleagues that are general surgeons that could come help you. And even if you recognize a thermal injury, that they would be willing to resect that area and potentially do a direct closure. All right, that aim small, miss small thing comes in here. So that needle is a weapon if you're holding it, right? And so their eyes were on what they were about to tie, and the needle went off screen and hit that. But they're used to using clips, so clipped it and moved on, and that turned out OK, apparently. Again, knowing where you are at all times. This one plays for a while, but I want you to pay attention. Right now, the tip of that instrument, the tip of the fourth arm is at the promontory, right? Wait, let me see. They're going to do the thing again. So at the tip of that instrument is where the promontory lives. And they're just way off on what they're thinking, I guess. So there. So the tip of that instrument is where the promontory is. So the stitches that you'd want to do should be way below that instrument. That instrument is three centimeters long, and they obviously don't know where they are right now. Now, that instrument hasn't moved. The one that where it's now, it's just a little. So the tip of that instrument is where the promontory is. So that's where they're at right now. So the tip of that double fenestrated grasper there is not quite to the promontory. But they think they're over the promontory right now. And you can sort of tell just the way they're operating. They don't know exactly where they are. And so it's just a good time to stop and regroup and figure it out. Don't be reassured by white things. I'm waiting for that audience reaction again, it's coming. So it's all about knowing where you are when you start, because right there, you can be convinced that that's a flat top of the sacrum, right? But it's not. Yeah, oh this is almost over this is the last this is the last video It's almost finished just you got to see this And just to be sure, yeah, so that's, you know, the left common iliac vein and the promontory is way down below that. And my buddy who gave me this video came in and saved the day. That's his closure of that vascular defect and then they went ahead and did the case. And the patient was actually fine but, you know, I thought that was instructive of not doing the stuff that we talked about. And that is what I have for you. So we're trying to connect with the surgeon in Africa who's gonna hopefully be able to take questions about the next video. While we're doing that, any quick questions for Dr. Culligan? But then we're gonna, as soon as we get ready, we're just gonna cut straight to that. Yeah, my question is to you and everyone on the floor. While I can't comment on mesh and grafts in New Zealand, we no longer have them, and robotic surgery, but anyone performing V-notes and appreciating the beauty of views and retroperitoneal dissections, especially when it pertains to precise applications on the sacral spinous and dissecting the sacrum, maybe the future for V-notes robotic surgery? Yeah, that makes sense. I'm not sure I've completely understood the whole question. Maybe the question is the direction of vaginal robotic approaches to all these surgeries that we're talking about, sacral spinous fixations, sacral copepixes. Oh, sure. So I don't think this is, I don't think copepixes are superior to what Roger is doing. It's just, I think that we both are correcting the anatomic defects, and I think it's just sort of what you're comfortable with and correcting the defects whichever way you feel comfortable. Thank you. We do have a quick question regarding that abnormal cervix, vaginal hysterectomy, then sacral copepixy for abnormal cervix. I know I do a fair amount of that. Oh, I think that's a great, especially for resident teaching, doing a vaginal hysterectomy first and then doing copepixy is, that's a pretty widely used technique, and it's great for resident training. All right, thank you.

surgical strategies

robotic surgeries

traction techniques

sacral colpopexy

anatomy knowledge

preoperative planning

complication management

surgical outcomes