So first of all, Kara, that was a, is she still here? That was an awesome talk. I loved listening to her. That was great. And so we've talked about the premise here is, OK, you've already consented your patients. You've talked to your patients. And it's not going to be the wonderful repair that Dr. Murphy was talking about. And we're going to go for a colpopexy. And in my world right now, these days, it's going to be robotic. I used to do laparoscopic sacral colpexies quite a bit. In fact, I learned it with Miles. I think he was at least mentoring me as much as I was mentoring him in Louisville when we were together learning laparoscopic sacral colpexies. And so I want to go through routine cases, so routine cases, how to establish some efficiency. These are my disclosures. A lot of what I'm going to talk about is something that I put together with my partner, Christina Saiz and Peter Rosenblatt in an article in the Green Journal, so some videos attached to this article. It's an open access article if you're interested. So the first step towards improved efficiency is to watch your own videos. And I did this by necessity because I'm getting pretty old now. And when I learned this stuff, I kind of learned it from myself because I didn't have a ton of people to learn it from. The robotics is what I mean by that. And so it's pretty painful to watch your own videos. It was for me, anyway. I thought I was pretty decent at the straight stick stuff. And then I'm watching these videos, and I thought it was terrible, but just being critical. And so I've convinced a lot of people over the years to do the same thing. And I'll go over the videos with them, too. But I think it's more beneficial if you create sort of a case report form for yourself and really watch the videos and just see where your slow points are. And so I'm going to hit some of these things. But those are kind of the sections that I think are important. All the getting started stuff, like with Kara. If you're going to do a hysterectomy, don't take forever on it. Being efficient with your dissections and your attachment. And then peritoneal closure and think about potential complications. So for the learning curve, I'm not saying you can't do these cases that are going to be tougher. But you probably want to at least recognize them. I love what Kara is about with the surgical coaching and thinking ahead. And so the kind of ones that gives me pause are very, very short stature or very narrow abdomen patients. I think that's harder to complete the copeplexy part. Not necessarily getting in, but to complete the copeplexy in those folks. Morbidly obese patients, of course. People with prior surgery, especially prior pelvic mass. Some of the toughest cases we do when you're going to go in and do a redo copeplexy. You've got no idea what's there until you go in and do it. Posterior prolapse that's bigger than anterior prolapse, especially if you're combining that with defecation dysfunction. Perineal descent and a very long cervix or other cervical abnormalities. This stuff I'm going to go over tomorrow. But I just wanted to kind of go through what some of these things are that are not going to be as efficient. So the rest of this talk is going to be about when the case is one of the more routine ones. I'm not going to say easy, but one of the easy ones. Oh, and if they're very elderly. The only reason that matters so much is that's when you really need to be efficient. You might not want to try to tackle the very elderly until you're good at it. You don't want to spend a long time on somebody who's 85 or 90 or something like that. So these being routine cases, these days, my cases typically involve a hysterectomy, the routine ones. And then the debate comes in. Supercervical hysterectomy versus total hysterectomy. And it's just a debate, right? So I like to do supercervical hysterectomies because I like the idea that my mesh exposure rate down the line is going to approach zero. And so the trade-off that I'm accepting is that's going to give me longer dissection planes that I have to deal with, right? Because you're going to have longer stretched out dissection planes, and you've got to deal with that epithelium and do something with it. Whereas if you do a total hysterectomy, you've got an easier time dealing with the anterior wall, shorter dissection planes, but you're going to have some low single digit percentage of mesh exposures to deal with. Now, I've got some of these summary slides in here. And I'm not going to go through all these points because I'm going to be talking about these points during the videos. So when I get to one of these slides, I'm just going to kind of skip through because hopefully I'm going to say all these things. So we'll just get right into it. So if you're going to do a supercervical hysterectomy and working with me, I'm going to be manipulating the uterus with the robotic tenaculum. And I'm not going to have spent any time putting anything in the vagina, attached to the cervix. I'm not going to. And again, this gets back to the efficiencies that I've sort of developed in my world are all about autonomy, self-sufficiency. And I guess it's been by design, but then also by necessity because these days, I don't really know who's coming to the OR to join me. I mean, I'm basically, we have a fledgling residency where I am. I've got a PA, and she's good, but I've got the rest of the OR help I don't know about. So starting out here with the round ligaments and the bladder flap, I recommend getting close to the bladder with the initial aspect of the bladder flap on the peritoneum because that takes care of a lot of your dissection for you. You find that right plane easily that way. I recommend against getting into all the spaces and showing the, if you did have a resident, showing the residents how to work through all the spaces. I recommend just trying to complete the hysterectomy in the neighborhood of 15 minutes or so. It can be faster than that because the rest of the case is what takes so long. So trying to be fairly efficient and leave as much peritoneum as possible is what I'm after here because the peritoneum is useful at the end because I believe in covering the mesh with peritoneum. The nice thing here is I'm creating all the traction and counter traction myself. So the little things you got to be careful of, how long is the cervix? If they do have that very long cervix, you're going to want to still leave only about a centimeter and a half to two centimeters of cervix. So you got to keep going down with your hysterectomy bites on the vessels until you're only leaving the right amount of cervix. Also don't want to cut into the vagina here, of course. And when you're doing this move, you got to really know where that bowel is because you could cut right into there if you weren't super careful. There it is. There's the end of the hysterectomy. And I'll just lay the uterus in the upper abdomen for retrieval at the end of the case. And now we're going to get into sort of the routine dissections. So general points about sacroculpexy dissections that I want to go over, it's probably any dissections, but sacroculpexy is what we're here about. Constantly adjusting the traction and counter traction for optimization. And what I mean by that is in the videos, what you'll see me doing a lot of is picking up things and putting them down, and it's sort of getting to know what it is that I'm holding and where those planes might be by just over and over sort of picking things up and putting them down. Every time you make a move, especially with the scissors, you should have sort of a mental note almost of what's about to happen here. And when you're closing the scissors, if the tissue didn't respond the way that you anticipate, then you've got to redo your traction and counter traction. You can't just double down on wrong. And bleeding almost always comes from the vaginal side. That's a pretty good general rule. We tend to be afraid of the bladder and the rectum. So we're tendency is to go away from those areas into the vagina. And so when we get into bleeding, it's usually by digging into the vagina. My specific endpoints that I have for my dissections are always the same. Well, not always, but almost always. Bladder neck for the anterior dissection and perineum for the posterior dissection, unless there's some reason not to go down so far in the posterior dissection. There's a couple of little phrases here that ring out in my head a lot of times. Aim small, miss small. I think Vince Lucente taught me that when he was teaching me how to shoot a bow and arrow. And slow is smooth, smooth is fast. I think that's a Navy SEAL thing. It's also from Modern Family, I think. Anyway, I think these things are true. Here's the anterior dissection. So when I'm doing this part, again, there's not really much going on in the way of help from my bedside assistant, except for this move. Grabbing the peritoneum and pulling it in that direction. I'm always trying to find further efficiencies. So lately, and I don't always do this, but once they've grabbed the anterior peritoneum, they could just let go with their hand. And the instrument seems to do what I want it to do, actually. And then here, it's just finding the areolar stuff, pushing that down vertically, and then snipping the things that don't want to do that. And then always staying oriented with the anatomy, making sure that you're oriented 100% of the time. The tissue's reacting like you want each time you do something. And then just judicious use of cautery in the space. And just knowing when you're at the end of what you want to do. A couple of the other things that I try to keep in mind is it's easy to kind of narrow it down or cone it down towards the bladder neck. And you don't really want to do that, because a broader base down there is going to give you better support, because that's going to be the quickest place where you'd see something you might call a failure would be distal anterior. And so you want a nice broad area for mesh attachment there. And so that's what I'm doing here, is trying to make it so that I've got that whole, I use a four centimeter wide piece of lightweight mesh. And I want the whole four centimeters basically to fit there for most of these patients. So that's my completion of my anterior dissection almost. Now I'm just kind of probably could quit, and I just didn't quit. But again, these planes should be pretty easy if it's a case where you're doing a hysterectomy at the same time. These for posterior dissection, when I learned how to do this stuff, the switching of cameras with the original version of the robot was a pain in the neck. So I just developed techniques of how to do it with a zero scope. But I think it is a good move to put a 30 degree upscope in. Here, I don't do it myself, because I'm used to this. But when you're learning, it can be a lot helpful. You notice what I did there. I skipped down from the cut edge of the cervix until I could tell I was where the peritoneum is sort of easy to pull away from the other tissue. You can see that. The bigger the prolapse, the longer the distance you have to skip down from the cervix. And you just want to find that nice areolar plane and stick with it. And you can sort of see the tissue planes react to when you pick them up and put them down. Here, I skimmed the vaginal epithelium a little bit. And that's what's bleeding there a little bit. And I'm just trying to stay in that plane where I'm hugging the vaginal tissue and not dig into the rectum. And you know you're at the end of this posterior dissection when you get to the perineum, which looks like the tissue doesn't want to open up anymore. And you sort of see a white end point. And when you're sort of learning this, it's not a bad idea to maybe stop and go do a rectal exam and see where you are. It's one way to learn. This technique can be used when a patient has a thickness rectal prolapse as well, but this just doesn't happen. It can be a little bit tricky right in the midline. Sometimes when they have a big prolapse posterior, the tissue there can be pretty thin. And you could potentially make even a defect in the rectum if you weren't careful. Now, if it's a post-hysterectomy case and it's still kind of routine, otherwise, this is just an example of that. I like to use the brisky retractor traditionally, long, wide brisky retractor, and leave as much tissue around the top three or four centimeters of the vagina as possible. So if there's a layer of peritoneum that's easy to leave there, I'll leave it there because I feel like it's insurance against mesh exposure. I'll tell you what I'm doing lately, though. Lately, I've been doing my sacral dissection on these cases first and taking the peritoneal dissection down and getting into the areolar plane posteriorly, but not doing that dissection. Instead, just then grabbing the vagina with the robotic instrument, the tip-up device, and not even using anything in the vagina for those cases. And that's kind of working out a lot of the time. So I'm not really needing the brisky as much lately. But this is just showing you that the dissection can look pretty similar. If you do have a post-hysterectomy case to do, the posterior dissection is usually the easier one. So I usually do that first and then sort out the planes of the anterior dissection after that. You can see how thin that's getting there at the very apex. So that extra layer of peritoneum is kind of key. One little trick, I think I learned this from Tony Visco maybe, that if you want to see the bladder easily, I'm not showing it in this video. I'm just going to tell you. You can have somebody raise the Foley bag higher than the patient so the patient's urine fills the bladder. It's just kind of an easy thing to do instead of trying to unhook and squirt water in there. And I think it was him that told me about that. So here, I'm just finding the right plane anteriorly. That can be the hardest thing to do in the more or less routine cases otherwise, is finding that good anterior plane that gets you to where you want to be. For sacral dissection, this is the part that initially gave me pause, gives everybody pause, because you do, as Kara put it, all the things there. So one thing I recommend is using your robotic right arm to sweep the colon off to the patient's left side. And then once you've done that pretty firmly, make a little dotted line that you're going to follow. I'll show you tomorrow an example of why this is a helpful move. But that dotted line should be about half the distance between the ureter and the colon. And when you open it up, what I'm trying to do here is, again, by way of efficiency, I don't want to have to go back and do anything else here. I want to open this up so that it's going to be easy to use it to cover the mesh. And also, doing a good job in this first step where it's just the peritoneum makes it easier when you're looking for the ligament. Because of the hypogastric plexus is there and the vessels and everything, I really don't try to over-dissect. I don't do a lot of burning around the sacrum. And I'm just trying to see a little spot where I can put two stitches. That's it. And so I used to kind of clean it off a lot more. And I've regretted that a couple of times in patients who, I think, developed constipation maybe because of all that dissection. I start with the posterior mesh placement. I've always done that. I'll choose the lengths for my mesh based on the patient's exam. And then I'll cut the mesh to those lengths. Then I'll tie the anterior piece back. And then I'll just kind of stick with that. And it's a little bit of verification, validation that I'm doing what I'm trying to do. If the posterior arm mesh winds up right at where the cervix is, then it means my measurements were good. It's just kind of validation throughout the case. I do the first stitch in the midline down low by the perineum first. And then I'm just going to be kind of working my way out of that space. I'm going to talk at the end of this today about little tips on suturing. But practice is the biggest thing with suturing. Practicing well and getting good at the knot tying. I do think probably the fastest growing trend in robotic sacral culpapexi is to use barbed sutures. And I think that's totally appropriate in a lot of cases. I'm just more of a, I guess you'd say, prisoner of inertia on that. I'm just doing what I do. But I am very intrigued by that because it does seem like it would be a lot faster. I've got a video of that as well in today's talk. I'm trying to get the really good solid attachment down by the perineum and then just keep working my way out of the space. And I just skipped ahead a little bit there. And up top, I'm always going to try for the uterus sacral ligaments and then right at the crotch of the Y-mesh, attach it to the cervix itself. That's one of the nice things about leaving the cervix in. It's a really nice, robust set of anatomy with which to attach the mesh. I've always put the knots in between the mesh and the vagina, basically because this mesh is so wispy. It's hardly there anyway. And I can't imagine that the knots being on one side or the other matters. And it's never really mattered. I'm not a believer that Gore-Tex type, this is not Gore-Tex. This is what Miles was talking about, the generic PTFE. I'm not a believer that the Gore-Tex type suture, PTFE, is a generic PTFE. It is a problem. It's just not a problem. It could be, I guess, if you were going full thickness. But I don't think that it leads to erosions or itself suture exposures either. How many erosions is that? Oh, it's probably about five. Yeah, this is kind of edited. Anteriorly, I'm just going to flip the mesh down, attach it at the cervix really nicely. And then what you're going to see here is the reason why I don't use barbed suture. And that is I've figured out that this patient should wind up with anterior anatomy that's about, I think this is probably six centimeters of mesh. So some of that is attached to the cervix. So it's another four to five centimeters of mesh that I want the anterior wall winding up to be that length. And so when I flip this down, you're going to see it only covers about half the distance of that dissection plane. And so this is what I was talking about earlier. You have to do something with that. And so what I do is gather up that stretched out epithelium to the mesh by going through the mesh a little bit and then skipping way down and getting that vaginal bite. And row by row, I'm trying to gather that epithelium up so that when I'm finished, the end of the mesh piece that I've cut is at the bladder neck. And that's going to vary a little bit from person to person. It's usually somewhere between five to seven centimeters of anterior mesh length. And so I don't see how I would do that if I use the barbed sutures. Maybe somebody could tell me, but I haven't figured that out yet. So that's the reason that I don't use the barbed sutures. But if it was ever a case where, let's say, they have a leading edge as their cervix and you pull it up and their anatomy is good when you pull up the cervix and you could just lay the mesh down anteriorly and want it right there, in that situation, the barbed suture would be perfect for me. This is a little, this is just sometimes to break up the monotony, I'll do this. Like, throw three sutures in a row and then just turn that into three interrupted stitches. Just playing around. I think Miles's partner saw us playing around like this in the lab one time and made a video of it for Augs, actually. It's a nice, he did a nice job of that video. Akira. So, again, it's not trying to get, to make up all that difference in the discrepancy between the dissection plane and the mesh length in one row. It's like over and over doing that move where you're going, you know, some ratio, two to one is a common ratio for mesh length versus where the bite winds up. And I think I just skipped ahead to the end here because it does get pretty repetitive. And I definitely, I probably put in too many sutures. I mean, everybody tells me that, so it's got to be true. But I can't make myself stop, but I'll admit to it. All right, so anterior mesh is finished. Now, the next thing I'm going to talk about is probably the thing that the most people have come to me and said, hey, that really helped me out. And that's this, oops, not this one. I'll hold that thought. This is a video that somebody gave me, and I would say who it was if I could remember, but I can't remember. So if you know, tell me. Somebody gave me this video, and it's their way of using a quill barbed suture, you know, the double-armed barbed suture to lay the mesh down. And I really like this video, and I wish I could give them credit because, as you can see, there's a little cartoon of the plan, and what they're doing looks just like the plan. And there have been randomized trials comparing individual suture placement to, or interrupted, I should say, to barbed sutures. And, of course, it's faster to do this. I don't know even what the point of those studies was because nothing against the people that did those randomized trials. It's hard to do a randomized trial, but I think everybody knew how that was going to turn out. So I think this is a pretty effective technique, and I like watching this whole thing because there are various ways. Another way that I've heard people talk about doing this is putting in four interrupteds or two interrupteds just to tack the mesh down and then run it back and forth. If they're using the non-double-armed barbed sutures. This is, yeah, I think so. I don't think anybody would use a permanent barbed. I've never heard of that. But, and I fully believe the research and everybody who tells me that you don't need permanent sutures to attach the mesh. I'm not going to argue with that, but I still have kept doing what works for me. But I think it's definitely true that using a delayed absorbable suture is just as good. All right, now getting to the thing that I was going to say. Doing the peritoneal closure, if you're going to cover the mesh, which most of us do, then I like to do the first step as a purse string before attaching the sacral part. And so if you haven't done a crazy amount of dissections during your hysterectomy, then it usually looks like this. And you can just start at about the 5 o'clock position. This is a zero monocryl. And it's on a SH needle. And the reason I use a zero monocryl is because I'll take these really small bites of the peritoneum, but with that kind of thick zero smooth suture, it doesn't tear into the suture or tear through the peritoneum. And I'm just going to go really close together and really close to the edge all the way around. And I have my own little in of one thing. I had one poor lady where I must have left too big of a gap when I was doing this area. And she developed a hernia into this thing, an iatrogenic hernia. I still feel bad about the poor lady. So I'm super careful. I mean, she was fine, but she didn't enjoy that. So I'm just going close together, close to the edge all the way around, making sure there's no little places where a bowel could get in there. This is the dicey area, when you're getting close to where, not just the ureter is off to the side pretty far, but I'm going to get right to where I came through the blood supply here in a minute. I feel like I can see where the vessels are. And so when I'm going through that area, I will just try to just not hit them. And it doesn't have to be much. It just has to be a little bite there. And then again, just kind of tediously close together, close to the edge. I think that, for me anyway, the efficiencies with all the cases, but especially the routine ones, is more and more autonomy. I just think that it makes me faster. I don't know. And these aren't super fast either. These cases will take a couple of hours, two hours. So three routine cases in a day would be a reasonable day. And a lot of times, I only do two. I think you can do it. You can probably do these things a lot faster. But I'm not trying to be much faster than that. I think people do fine when you do that. So that was the edge of the paracolic gutter. And now I'm over to the other side of that. And I tied a little loop on the end of this. I have all these video segments available as well. That Green Journal article shows most of it. And then there's a YouTube channel as well that you could find. And this I'm just pulling. This is where it pays off to have the zero monocryl stitch, because it just pulls through the tissue. And then I'll tie this little kind of nonsense knot just to keep it together. You probably don't have to do this, but I just do. Just tying it off to itself for a second so it doesn't just unwind. And the reason I do this is because I think when I'm setting the tension of the mesh, I think it's maybe a little more realistic to what the case is going to wind up being like if I have that closed off as a purse string. So then, again, this is just another one of those summary slides. Then when it's time to do the mesh tensioning, I always do the same sort of thing. I'll estimate where that mesh would lay against the sacrum and be good. And then I either have somebody that I trust at the bedside who can say, yeah, that feels just right, or I'll just walk over to the patient, put on a glove, and feel it myself. And then I'll know exactly where I want to go on the mesh. And here I'm going up the slope so that I'm avoiding that disk space. And I like to go up the slope kind of at an angle. It's not exactly vertical, but it's definitely not horizontal. And I'll just tie a square knot there and then do another one so I can always see exactly where I am on the slope there. And once I've got these two things together, I can make a choice. I've got either I'll have my bedside assistant push the large blunt leucite retractor into the vagina to create slack so I can tie these down. Or more often, actually probably I only do that anymore about 5% of the time, what I'm usually doing these days is I'll scooch my third arm to hold the colon while I grab the mesh and create the slack for myself. And that's just because I don't think that my assistant likes to put the probe in the vagina. So I just tried to figure out a way where I can just do that myself most of the time. But anyway, that's the completed thing except for the step two of the peritoneal closure. And step two of the peritoneal closure is really easy, super easy. It's just going edge to edge. My other robotic instrument there is just keeping that ovary from flopping in my way. So once I don't need it anymore, I'll move that. And I don't mean to suggest that you've got to do the surgery this way. A lot of the efficiencies come from, as Kara was saying, know the anatomy, and then just proper technique with your dissection so you don't have a ton of bleeding to deal with, and then just staying and avoiding the ureter. As you're doing this move here, you could be close to the ureter if you're not right at the edge of the peritoneum. So staying right at that edge keeps you from kinking the ureter. I used to hear more comments that this mesh looks too tight. And of course, there's a pneumo right now, so that makes it look a little tighter. And it doesn't matter to me what it looks like here, because what matters to me is how it feels vaginally. And if it feels anatomically correct vaginally, then it doesn't really matter. As long as it's covered, in my opinion, how tight that mesh looks doesn't really matter. So I'm just finishing this up. In this case, it was routine. The anatomy around the sacrum is easy to sort out. I've got some videos tomorrow that'll be more interesting than this. So there's the finished product. All right. Now I'm going to get into a little bit about the anatomy of the peritoneum. And I'm going to talk a little bit about the anatomy of the peritoneum. Now I'm going to get into a little bit about some suturing and knot-tying tips. There was a pig lab where I took some time at the end, and I did some do's and don'ts about suturing techniques. And yeah, so it's live tissue, but I'm not practicing bad techniques on a person. A few thoughts that I recommend about this. By handcuffs, what I mean is you mess up, in my opinion, when you're learning robotic suturing, and your hands separate. So if your hands generally move more together, like you're wearing these handcuffs, you'll do better. And each time you're about to start tying a knot, there's going to be this way that the suture is trying to ask you to do it. And if your mindset is rigid, where you always wrap the same way, you'll get slow that way. And so you just look at it and start just trying to do it the way that it makes the most sense in the moment to do it. Rigid step-wise approaches are bad when it comes to suturing. Practice is everything, though. So here, I'll show you some of this stuff. So this is a really common mistake. I was trying to show this. So doing the wrap, and then thinking of it not in fluid motion, but in sort of segments. OK, first I wrap it, and then I go find the tail, that'll get you into trouble because by the time you've wrapped it, you've pulled your suture out. This happens a lot when people are just getting started. And the way to avoid that is to hover your, for me it's my right hand, hover my right hand over the tail, and so I'm wrapping right over the tail, so all I gotta do is reach down to grab each time, which I'll show you in a minute. Another one is the loop is way too long, so it gets stuck in the gears of the robot, and then you can break the suture or it gets frustrating, and in tight spaces it gets really frustrating if you do that. Another one is if it's too short, and you can pull your stitch right through when it's too short also. Here's a little trick for tying things under tension. Monofilament sutures, especially a PDS, is bad to break sometimes when you try to tie under tension, and so rather than do a surgeon's knot which I think can break a PDS, I'll just do this little trick where you can do this, and then if you crisscross your hands, it'll stay down. Here I'm trying to show it's still coming open, and so do that, and then crisscross my hands, and then it'll stay down for long enough to finish the knot. That works most of the time. And so you can see I'm hovering my right hand by the tail so that it's easy to just grab, and I'm more of a fluid motion. One of the places I worked, they had this mantra that if you're not switching hands, then you're not tying a square knot, so I just made this to show you. You can sure do a square knot, you just have to crisscross your hands as you do it. But these are definitely square knots. And finally, no, I have one more thing. One of my many reasons that I love the GORE-TEX suture is this. One of the tips I have for efficiency is to just cut the long one when you're suturing interrupted. Don't cut both, that means you have to leave the tail the right length. And GORE-TEX is the one reliable suture, it's not GORE-TEX, it's PTFE, it's the one reliable suture where if you just make any old throw, a couple of throws, you can just pull it and keep pulling, and the tail will pull right to the length that you want it. Unless you haven't gone through very much tissue, then it could pull out of the tissue, but you probably wanna know that anyway. But if you keep pulling, you make the tail whatever length, most suture materials you can't do this, but GORE-TEX you can. And that's probably why we throw so many throws, five or six throws in this stuff, because it is slick like that. But that little move is not just for the perineum like this, that little move you can use to speed yourself up when you're suturing because your second throw, every time you put down a stitch, can be the tail adjustment throw. And then you're always just dealing with the tails that are the right length, and I think that does add to efficiency. And then there's this, I don't know, I guess my partner would always say to me, why would you ever wanna try to do that? But that's, again, breaking up the monotony. Little trick for tying the super short ones is to just hand it to yourself. So you lay your right hand in the loop and let gravity hold things still, or left hand, whichever it is. And then just hand yourself the tail. And the minimum number of throws I'll deal with, again, I realize I put too many in anyway, so if this isn't the greatest one, it's probably not the end of the world. But three throws is the definite minimum. And I believe that is our last slide, so I can, saved a little time for questions, I think. Thank you. Hi, thank you for that presentation. These are just weird, nuanced questions for you. So do you always fold the mesh when you secure it at the sacrum? It looked like you did in that video. Is that? Oh yeah, I meant to talk about that. The reason I fold the mesh like that is because it's so light, and because I've seen videos, and I've actually had my own patient where the narrowest version of that mesh is called the contour. And I've had those break before, like 18 months out from the surgery. And so I like the one that's wider, and I fold it and have to get a double ply there. And I do that every time because I think it's stronger. And I also, just questioning, when you put that Y, that V part of the Y over the cervix, are you aiming for that to be posterior or anterior? And do you want it, like that crotch of it, tied down, or do you want to leave a little bit of relaxation for kind of mobility? I feel like the way that that, in a typical prolapse where the anterior wall is the one with all the laxity, I think there's enough laxity left just by doing it the way that I just showed, because there's all that epithelium that I gathered up. And so I don't have an issue, I don't think, with that part getting too tight. And what I'm trying to do is to have the post, I guess it would be the posterior edge of the cervix attached right at the crotch, and then I'm just laying the cervix to the next place where it goes as I lay it flat down. Does that make sense? Yeah, thank you. Okay. Do you have any tricks for the excess pericardial fat around the nasopharynx? Yeah, oh yeah. I'm gonna show some of that tomorrow. But the biggest trick I have with that is just going off to the side. I think just digging in right there at the promontory where everything is, is how you get into bleeding or issues. But even if it's a really big mound of fat, I find that if you pick that up and put it down a few times, you can find a little realer window of opportunity just off to the side, like almost to the edge of where the sacrum is, and then you can sort of work your way more medial. So it's, I call it the fatty fingers like this. It's not just a sheet. It's like these fingers of fat, and you can find a space between the fingers and then you're home free. We have a question online. Which port do you use for the robotic tenaculum? Oh, I have a, on the patient's left side lateral. Okay. I, you know, you've mentioned my partner Akira. He trained with people that do not reparent and analyze the mesh. I would like to, oh, he trained with people who don't reparent and analyze the mesh. Who here does robotic sacral colpexy? Raise your hand. Okay. No, keep it up. If you reparent and analyze the mesh, take your hands down. Okay, so you do not reparent and analyze the mesh. So neither does my partner, and I'm so jealous, because I'd love to just not do that, but I can't bring myself to do it. How about? He's the one that told us to not bother to do it. Your partner. Yeah, okay. Yeah. And that was your reparent. So far, we've not had any problems with bowel obstructions or, I mean, really any problems without it, and it just speeds it up, like the efficiency. And I think there's two large series, one in the UK and one in the US, where they show low rates of complications with that, right? Would you like to speak to how necessary that is? I still do it. Yeah, I mean, the trials are retrospective and they're flawed, and especially, I mean, I'm good friends with everybody that published that trial from Chicago about that, but my take on that is Chicago's a big city with a lot of hospitals, and there's no reason why they should assume that every patient with a complication went back to their hospital, which would be the assumption you'd have to make to believe that study. I think it's irreversible in Chicago. Yeah. Okay. It's true. Yeah. Well, and we can deal with herniate under the mesh, so if we have it tighter. I mean, the, oh, go ahead, but the, I mean, if. Sometimes you can still herniate underneath the mesh on the cases where you have to make them tighter with the bowel, so in those cases, it certainly would make sense to re-peritonealize. I completely agree with that because I've had to go back on other people's cases where they didn't cover that, and it's just a mess. I mean, the bowel can even go all the way around it, and that's a big mess, so, yeah. I actually have a question. Pat, why do you suture directly on the vaginal wall and then into the mesh versus, like, I'll just lay my mesh down and suture right in through it? Is there any reason you do that? I just find that to be sort of efficient. Right, so that's the situation where, if the mesh is the right length for the space anteriorly, and I want it to be right there, and I don't care about gathering anything up, then, yeah, I'll go right through the mesh, but if I think I gotta make that room up, otherwise, the only way to make the anterior wall look good is to just pull harder on the sacral side, which is not the way I do it. I have a question. You know, every video I've seen you present usually has a full coverage anterior and posterior, and in the theme of it's all about the apex, I'm wondering, you know, if you think of Peter Rosenblatt's sort of most recent iteration of just making a bit of a mesh ring to pull everything up, do you ever have cases where you just say this is gonna be a cervical lift or a cervical anterior lift and leave the posterior alone? Any variation? I have, I'm tempted to do that sometimes, and Peter Rosenblatt's series is pretty selective patients. Like, he's talking about when he's got the cervix as the leading edge, and he's gonna put that cerclage thing, and he replaces the cervix into a normal position, and that corrects everything, so that's a logical group of patients, and I've been tempted to do that, because I think it's a really cool thing that Peter's doing, but by the time, you know, you're in there, and you've got the robot, and you're doing the copepaxi, and you make your dissection, and you're in the spaces, it's like a few more breast strokes to get where you wanna be, and I just do it the same way. And you love it. Yeah, no, I, yeah, my therapist says it's from childhood trauma. Do you, if a patient does not want a hysterectomy, are you willing to do that, you know, as a hystereopaxi? How do you counsel them? You know, just, to be honest, after we have our long counseling session, they usually don't wind up caring, because they maybe thought that the uterus makes hormones, or something like that. You know, when you really get into the why, I find that they usually don't have that strong of feelings about the uterus itself. Would I do a hystereopaxi? Of course, I would do that, I wouldn't not do it. And I've done it for patients that are looking for future fertility as well. And so, yeah. While we're doing questions, if the rest of the faculty can come up. Well, when you've done a hystereopaxi with mesh, do you make windows in the broad, like describe how you've decided to attach the mesh around the uterus? Right, I haven't done that. I've just done posterior and to the cervix. And then, because in the situations where I've done it the most, it's been where somebody has the opportunity, maybe they're gonna get pregnant, and I wouldn't want that mesh in the anterior space.

robotic sacral colpopexy

surgical efficiency

patient consent

video analysis

anatomical challenges

surgical techniques

robotic autonomy

pelvic repair