I would like to introduce Dr. Karen King. She is the section head of the minimally invasive gynecologic surgery division or section, sorry, sorry, section at the Cleveland Clinic in Cleveland. And she's a MIGS person, not a urogyne person, so I think that's a great opportunity for us to learn something from our colleagues. Take it away, Dr. King. Thank you. All right, perfect. And the laser's dead. And the laser's dead, all right. First and foremost, thank you so much for inviting me to your people. You guys are intimidating. You guys do a lot of things that I don't do. I've learned a lot just from watching the lectures that I've seen. So thank you so much for having me. Like Dr. Murphy said, I'm a minimally invasive GYN surgeon, so my practice is primarily stage four endometriosis, bowel, bladder, thoracic diaphragm work, big fibroids, and laryngeal anomalies. So I'm gonna talk about difficult peritoneal access. Yeah, there's like nothing worse than starting your case off with a difficult entry. It really sets the mojo for your case. And so I'm gonna talk about different techniques that we can hopefully utilize to get in. I'm a consultant for Medtronic and the president of the Academy for Surgical Coaching, but it does not impact any of my slides today. So what I really wanna focus on is different ways to make abdominal entry easier in those challenging cases, understand successful steps for different ways that you guys may be approaching peritoneal access, so OVAIR, STRECT-Optical, OPEN-HASAN, and then talk about patients that have increased risk factors for injury upon entry. So patients I think about are patients with previous complex surgical histories with adhesive disease, obese patients, that subset of our patient population. So again, breaking down why access can be difficult, I try to create some buckets in my mind that give me a little bit more pause when I'm booking my patients. So prior abdominal pelvic surgeries is probably number one in my mind that can cause a lot of adhesive disease. Also the gravid uterus, so if you guys don't probably operate on pregnant patients, yeah, I would imagine, very often. You like operate after they've broken their things? Yeah, okay, got it. So my role, sometimes I have to go in after I've had an exomass or a cerclage or things like that, and so gravid uteri come into more play in my world. Body habitus, so increased BMI, can play a role in this. Hernias or abdominal mesh can make things a little bit more complex. Or just anatomic variation, so patients who have had abdominoplasty, right, and their umbilicus can be moved, like no longer is representing what you want it to represent, meaning where everything kind of merges up. And I don't know if this happens to you guys, but there's many times when my patients, I ask, have you had previous surgeries before? And they're like, oh no, no previous surgeries. And I go, great, fantastic. And then I go do their abdominal exam and there's like 19 incisions, like laparotomies. And you ask, oh yeah, I've had five sections, but that was just to get my baby out, right? Or I've just had a car crash and a splenectomy, but it's fine, it's not really surgery, right? And so you always have to be ready for these patients. And I feel like the virtual world has made this a little bit more complex. I see a lot of my patients virtually, and I have a partner who makes them stand up and lift up their shirt and turn to like really show what's going on under there. I'm not that intense right now. Non-patient factors, yeah, so surgeon factors, things like inexperience or lack of familiarity with alternate techniques. And so I think it's important to have a technique that you utilize a lot, that you're really comfortable with, but also having things in your back pocket if you can't use that approach or if you're having difficulty with that approach. So inconsistent technique, again, I think it's important to have a consistent way of getting in, but also having some more tricks in your back pocket. Then lack of preoperative planning. So I think the really building blocks of success for surgery happen before you even get into the operating room, right? So building the mojo is really understanding your patient's history, if they've had previous surgeries, maybe getting those operative reports, patients with previous bowel obstructions, right? They probably have increased adhesive disease, so thinking through that a little bit. There's also factors that we can't control sometimes. So equipment or environmental factors could include inadequate entry equipment. There's been so many difficulties at the Cleveland Clinic with getting our trocars that we oftentimes use. Things are on back order. And so sometimes we're utilizing equipment that I wouldn't ideally use. So longer trocars than I typically would or different equipment that I may not be as comfortable with, which does play a factor. Poor positioning. So I tuck all of my patient's arms when I'm doing laparoscopy. I think that can be really beneficial at allowing you to be close to the patient and also minimizing risks of nerve injury. And so for all my laparoscopic patients, arms are tucked, but I think that can play a factor. Or poor lighting. Sometimes that can play a role as well. So again, I like to think things through before I even get in the operating room. And I do a lot of teaching with fellows and residents and medical students. We have pre-op conference where a major part of that is talking about history and our plan to get in. And for my pre-op visits with patients, I even put that in my assessment and plan of how I think I'm going to get in. Because sometimes on the day of surgery when I walk in and I have four cases, I want to make it easy in my mind where was I when I saw that patient of my plan. So pre-op assessment regarding history and physical, also including imaging. I'm going to talk about the visceral slide test. I don't know if any of you guys are utilizing that, but sometimes that can be helpful at looking at adhesive disease below the umbilicus. And then review of prior op notes. So I'm a big proponent of getting previous op notes, reading through that. How did they get in? Did they try four times at the umbilicus and then abort that? Did they have to convert? Things like that I think are really important. And then planning entry sites. So choosing umbilicus for an alternate site. So we're going to go through the umbilical entry, which is the most common. Left upper quadrant, I'd probably say is the second most common. And we'll go over some alternate areas that we can consider if we're having difficulty. And then patient positioning and prep. So again, just having the same thing every single time, same positioning every single time, getting into the flow state, decreasing bandwidth you get in to the operating room of how you like things, I think is important. So supine positioning. And I say that because sometimes when I'm up top getting things ready, my vaginal person is putting in the Rumi or whatever manipulator they're using, they can't really see. So they ask if they can raise a table, make some T-burg. They're making themselves maybe comfortable down below for that. But you want to make sure that when you're making your entry up top, you're not in that position of big T-burg. That's changing your trajectory of getting in. And so being very cognizant if the bed has moved, if things have changed, if the table is now high and you're all up in your armpits, you want to be comfortable getting in and the patient should be supine. The catheter, I think, could be important at making sure the bladder isn't distended. Orogastric tube, I think, is a little bit debatable. I place an OG tube in all of my patients when I get in. I had a partner get into the stomach with his umbilical entry, and that's like stuck in my brain. But I know that's an N of 1. And I know Magdi Malad at Northwestern is doing a study now looking at the risk of getting into the stomach on umbilical entry if we actually need orogastric tubes. And he told me a couple of weeks ago that I actually shouldn't be placing those. That study is not out yet. We'll see what he says about that. And so this is just a technique that some people are utilizing looking at adhesive disease underneath the umbilicus called the ultrasound visceral slide assessment. We're also doing this in endometriosis in the posterior cul-de-sac. So same idea, meaning is there anything stuck underneath the umbilicus? Do things move freely or do things not move freely? Is anybody utilizing this, the visceral slide test? I'm typically not. And just because it's a little bit longer in my clinic to make all this happen, but I'll have a video of it here in that what you're looking at, again, is just abdominal ultrasound. And you're right over the umbilicus here. And you're going to have them do a big deep breath in and big deep breath out. And you're just looking at a point on the bowel and seeing if it slides. So a normal test means that the bowel slides underneath by more than one centimeter. So that can sometimes give you some peace of mind that getting in at the umbilicus could be safe. An abnormal test would mean that the spot that you're looking at the bowel doesn't shift. And so that, again, would give you an idea that maybe you should try to avoid the umbilicus. When my learners ask me, what makes you not get in at the umbilicus? Like, when should I be doing? Yeah, that can happen. That's my world. It's really beautiful. I love my world. But the vagina terrifies me, just to be very clear. Like, whenever you were doing miles with a needle and that bulge and that thing, oh my god, that was terrifying. This, to me, is not terrifying. So just to be clear, I'm glad we all have our niches. But my residents will ask me, what makes you want to go in the left upper quadrant? And I honestly say, if it crosses my mind. And I honestly believe that. Like, if I'm like, huh, should I go up there? Probably should, yeah? So if I'm considering it, then I probably should just do it. So the main ways to get in, yeah, are Hasan, Veris, DirectOptiView. How many of you guys are doing Hasan technique as your primary? Two, yeah. How about Veris? More, yeah. How about DirectOptiView? Yeah, split, yeah. So there's no right way, right? Like, the right way is the way that you usually do it. So that's very clear. And that's been shown in the Cochrane database that there isn't enough evidence to recommend one specific way of doing things. My go-to way is OpenHasan. That's the way I was trained in fellowship. That's the way I get into probably 80% of my cases. If I'm not getting in OpenHasan at the umbilicus, then I'm probably doing DirectOptiView at Palmer's Point, and we'll talk through that. So in short, there's no difference for vascular or visceral injury rates between the two. OpenHasan, you diagnose it quicker, yeah? So like, you know you're in someplace bad quicker with OpenHasan. And closed entry is associated with greater risk of failed entry. But in short, there's no one way that I'm gonna tell you today that you should be doing X way instead of Y. There's not enough evidence to tell us what we should be doing. So again, use the method that you're most comfortable performing. And we're gonna break down obesity in a little bit more detail because I'll show you the obesity map shortly. Like, most of us all live in really big obesity states, most likely. So I'll break that down. But sometimes when patients have those big pannuses, yeah? Like, the umbilicus is like, low. Like, real low. Maybe that's why you guys do vaginal. I don't know. But it can't be much easier vaginal when there's all that stuff, no? Anyway. So with that being said. Towel clamps. Yeah. Towel clamps. Towel clamps, Jesus, okay. So oftentimes for those big pannuses, I'll get in left upper quadrant because then I can insufflate and like, figure out where I wanna put my accessory ports. So I use my Palmer's point quite a bit. All right, so with VAERS entry, your degree, like your angle of entry should be different depending on your BMI. So if you think about how much sub-Q that some patients have, that should impact which direction that you're using your VAERS. So patients with a normal BMI, that aorta is actually quite close. Average probably seven to 11 centimeters. And I'll show you a study that was done right here in Nashville by our partners at Vanderbilt, Juncker's team actually doing distances between umbilicus and all the things, left upper quadrant and all the things. But it's a little humbling for those thin patients how close the aorta is, right? You can sometimes like see their stomach bouncing, yeah? So for my adolescent patients, for my really thin patients, VAERS makes me a little bit more nervous just because it's so close. But just make sure if you have a 45 degree angle, you should not hit it. And then for your really high BMI patients, so that 45 degree angle is gonna make it like 10 miles to get in. So for patients that are really obese, straight down is actually the recommendation, otherwise it's just a really far trajectory. I've heard of some people looking at MRIs beforehand and like measuring the distance between the skin and the peritoneum to give an idea of like, I should only go about this far, maybe. But like I said, in my mind, for those really big obese patients, I just do left upper quadrant. So open Hassan, reasons that we like it is because there's the umbilical ring, everything merges at the umbilicus if it's where it should be, meaning patients who have had abdominoplasties, right, they move it and so your anatomy is gonna be distorted. But if they have had their belly button where they were born with it and it's normal, then there should be a merging of all the things in that area. So I have a Vimeo page, all these videos are there. So if you just do Vimeo Dr. Cara King, you'll find me. This is an example of an open Hassan technique that my technique is still very similar to this, but I'm always making some adjustments and I'll talk you through those adjustments when I get to them. So in this picture, head is to the right, feet are to the left. I typically just use an 11 blade scalpel to make an incision on the skin. I do tent up with curved stats just because again, the aorta is oftentimes closer than you think. And then I extend my incision about a centimeter. So we're going towards the head, towards the feet, I call towards the head 12 o'clock, towards the feet six o'clock. And here I'm spreading way low at six o'clock, way high at 12 o'clock. What I see a lot of my learners do is just start gangbusters going right in the middle and spreading and that gives me palpitations because that's the part I'm trying to merge up into a beautiful little temple yeah and so I'm going way at 12 way at 6 spreading and I'm trying to make a nice peak of my fascia so try to avoid pushing that away you want to be bringing that to you from there I'm taking my 11 blade going down to the tips of my Kelly or my curve stat and then again I'm spreading way down at 6 o'clock and way up at 12 o'clock I'm trying to make again it's like white slide of fascia and when you do it right the fascia is just glistening and you know exactly where you are and also with the stock you oftentimes will see a little blip of like fat and people sometimes will think that's momentum it's not so everything merges and it means that you actually are midline so I clear that off again I'm bringing the thinnest part up towards me and then I then I get in sharply once I think I'm in I take my curve stat I'm aiming towards the feet I'm not going straight down towards a order I'm going and about a 45 degree angle and then I drop my s retractor in and I just drop it very gently and to make sure I have no resistance I don't helicopter it so like my entire life is built off of stuff that went wrong and so I had a resident put it in and helicopter around and snagged the infarepigastric and slut like cut it in half what the hell I haven't seen that before yeah so since that moment I don't helicopter anymore and so and then I tag my fascia I've actually started doing umbilical for these so I've been trying to make my belly buttons look better at their post op and so I now I'm taking my stock and actually tagging it to the fascia on the left and the right and at the very end if you tag the stock to the fascia right away and tie those two together the belly button looks perfect at the end the other thing that I've started doing for these is before I yank on the fascia and then push my Hassan in now I actually tuck those flaps of the umbilicus in and then push my Hassan through it may see count seem counterintuitive a lot of people are like let's yank up on that you wrote everything and then shove it in but then things can get swollen yeah and like it doesn't come back together as pretty as I want I have to admit my I do a lot of stage four endos my cases are not quick it's so sometimes my patients are under for six hours so I'm doing a big bowel resection bladder resection utero re-implantation so the longer those the umbos kind of eroded like that the more swollen it can get so now I invert it in like push everything back in and then put my Hassan in and the belly button is now living the way that it wants to live for the entire case my belly buttons look remarkably better now so just a tip that I've I've started integrating within the past year we are big country there's like bad stuff going on is anyone from Colorado here yeah I wish right yeah so or do you see so like every year that I present this map it looks worse like literally every single year so most of us live in pretty highly obese places and so for these morbidly obese patients do not base your life off of skin or subcutaneous fat need to base your life off of their bony landmarks okay so ischial spines xiphoid process cost of vertebral edges so with these patients right I'm going all the way down palpating bony landmarks that I can trust and so the xiphoid process again the the cost of vertebral angle from my left upper quadrant Palmer's point and my ASIS is like our iliac spines those are gonna tell me where I need to go in regard to my entry now some of these patients again can have these really big panaceas that go down and so there's different ways that you can manage this so on average like in a normal human being there should be about a hand width between that it's like that iliac spine and the umbo yeah so if you like touch yourself and you feel here to your belly button it should be about hand width so about eight centimeters between ASIS and the umbo and there's studies saying that if it's not like that when you go to prep your patient you should return it to that area and so again so you see where their ASIS is and if their umbo isn't at least a hand width above they actually recommend returning it up to that point that's like a lot of weight and I've seen a lot of people do a lot of things with this I've seen like towel clip things I've seen taping of things I've seen like it brings me back to my OB days with c-sections you guys remember that yeah it was like a lot of things were going on and that's what they recommend I will say one of my good friends and an incredible surgeon Megan Wasson at Mayo Arizona I heard her speak a couple of months ago and she was like I don't care the umbo is I just go straight through it but to me that I don't do that so but she does and she's incredible so it's not saying you can't but I'm saying I don't and so when I have patients I have those big pandas hanging down I just ignore all of that and just getting up top so from Palmer's point right the definition is gonna be three centimeters below your left costal margin mid clavicular plane I always drop an og2 for my patients to make sure stomach contents are empty and you have to think about previous surgical history so relative contraindications or me gastric bypass one ectomy or spinal megaly or hepatomegaly but for me from my Palmer's point I actually go right underneath the rib so I don't do this whole three three centimeters down with my hands I put my finger like in the xiphoid process I follow the ribs around and whatever this is what is that an eminence of some sort whatever that is that's where I go and and that typically is like always been a clavicular line but it's like never served me wrong I hate saying those things like you just said you haven't had a year or kink and I was like stressful it up for you but it's never led me astray so yeah I just put my finger as I could process follow the ribs around and that first digit that's where I always go make my incision right underneath the rib and again this is one of my patients that I've had last year I just ignored all of that I was like no we're not gonna do that there's her ASIS I I'm just gonna go right up here right and everything went fine so you can do any way you want at Palmer's point so you can do Hassan anywhere you want on the body or various or direct like you can just pick wherever you want Hassan isn't mean it has to be at the umbo so for a closed bears I've seen some people just go straight down but I've also seen again one of my colleagues at Columbia I remember Arnie Arvinkula lecturing about this and that what he's actually recommends is putting the bears right underneath the rib and then rotating cephalads you're almost like snagging underneath yeah I know that's my face too I don't do that some people do there's no definite right or wrong I practiced that on a cadaver and I did not get into the hearts that I think it's probably possible but but for me I choose not to so I do direct optical so I'm very simple human in that I'm just looking at colors so like when I get in direct up to view I just want to look at colors so I see subcutaneous fat it's yellow so I see yellow right off the bat and then I see into your rectus sheath right it's gonna be red and then rectus muscle post your rectus sheath is usually white pre peritoneal fat and the moral of the story is as soon as I see my second yellow I'm in so I'm gonna see some peritoneum and then momentum so the bright yellow subcutaneous fat and it goes like red white red there's like some colors there second bright yellow every time is momentum so just look for the second bright yellow so this is an example oh another thing I want to say that I see a lot I see a lot of people and again there's no right or wrong but I see a lot of people like grab the area and then tent up with towel clips and kind of like fight going in and again no right or wrong but in my mind the trocar is literally made to enter the abdomen by like split spreading the tissue and so for me I just place I need to do an outside the body video of this I just place the trocar on put my camera on and then you just twist gently I just twist it's gonna go and just twist gently like don't sweat don't have people lifting don't like do all these things like literally put your camera on and this is me just like twisting my trocar in because I think when you start tenting everything up all you're doing is spreading the distance is making the distance bigger so this is again just gentle twisting of your trocar like use it what it's made for here we see bright yellow okay great and then you're gonna go through some whites and reds right so you're gonna see rectus sheath you're gonna see a pair the peritoneum you're gonna see white there some fascia and then the second bright yellow every time second bright yellow you're fine just it's all you have to remember come out put your guy in and this patient had umbilical mesh so I was expecting all of that it's my happy place yeah this is a study that Yonker et al did right here in Nashville at Vandy and she measured via imaging distances from the umbilicus so in that top picture a is the umbo bottom picture is a left upper quadrant and they measured that incision to like all the things that you don't want to hit and what they saw was at the umbo you're usually about 7 to 11 centimeters from the aorta farther from everything else and then the left upper quadrant you're much obviously farther from obviously all the big vessels but you're only about 4 centimeters from the stomach and so I know it's a small print but I'm hoping that you guys will have my slides or the paper to look at it it's a little bit humbling knowing how close you are to the things but just keeping that in mind and understanding the distance of the instrument you're using the size of the patient so aorta to the umbo in all comers is about nine centimeters umbilicus to the spleen as far as 20 stomachs about 13 from the umbo if you're getting in down here but left upper quadrant right you're only about four centimeters from the stomach about six centimeters from the liver so it's keeping that in mind and fellowship we got right into the pancreas you've seen that before that's a bummer yeah when you put in there's like green comes out I was like then got him a fellow teach me everything we just put a drain in yeah all right excess report location I know this isn't exactly my talk but just so you guys know anatomy a lot people are saying like transilluminate everyone has their triggers like to me transillumination is my trigger I don't hate that like just know your anatomy don't transilluminate I don't believe in that these vessels run underneath the muscle so oftentimes you can't even see it so the main thing that you're looking for obviously the infrared progesterone vessel comes off the external iliac it's gonna come off right in the triangle between the oblique medial umbilical ligament and the round I'll show you that better in a second but even in your most obese patients it's always gonna be in that location so I want to get you guys away and maybe you guys aren't even doing this but of transillumination just know your anatomy so you've got your round ligament insertion right and then you have your blurry medial umbilical ligament going up you have that V that like beautiful V every single time that infrared gastrics and be coming out in the middle of the V every single time so just know your mad anatomy find your vessel and don't hit it all right all right we're getting close to the end so for alternate peritoneal sites so again umbo is usually my number one that makes me nervous then or if I can if I consider not going there that I'm gonna go palmers point left upper quadrant you can go any way you want Hassan Varus or direct optive you my choice is direct optive you but it does not matter how you get in there alternate points are gonna be Jane's point so Jane's point is going to be two and a half centimeters lateral to your umbilicus or it's about in between honestly your vertical the vertical line between your ASIS and your umbo but it's about two and a half centimeters either medial to your ASIS or lateral to your umbo and at that point there should not be the infrared gastric artery and everything else should be pretty far right you're away from midline from the aorta your stomach should be high and so again if I'm using any of these other points I'm usually doing direct optive you it's just my it's my comfort zone I'm out of the umbo so again just make your five millimeter incision place your choker there put your camera in I don't do insufflation some people turn low-grade like a little bit of insufflation on when they get and I just don't do that either I just do the nice twists and it's usually good and then Lee Hwang's point again another area that has shown to have very low risk of adhesive disease depending on previous surgeries and so that is gonna be about ten centimeters above your umbilicus so you want to make sure you don't get into the liver obviously you can do that like tap thing that we do in medical school to like here for dullness sometimes and know where you're at but that's usually a really safe spot usually not on the false of form usually liver is okay so just things to think about all right and then you still can't get in there are some papers looking at actually transuterine abdominal entry with a varus and so you place your patient in Teberg you can grab your I just grab the anterior leaf of the anterior lip of the cervix and I sound my uterus to know how big it is and then you just aim right through the fundus with a varus have any of you guys done this me neither only in cadaver labs I'm gonna be very honest because I've never not gonna leave them the other ways but cadaver labs I've practiced it now that I'm in a room full of urogynes can use you just do post-uriculpotomy I guess if you wanted to right like that's what you guys are comfortable with so I should add that slide I'm not usually lecturing to urogynes yeah or post your cul-de-sac yeah so but you could probably just do that with your usual technique maybe not necessarily with a varus I live in the world of stage four endo like I would never do this and like it probably any of my patients because there's gonna be rectum adhere there 99% of my patients but again you can place your patient in Teber you guys know how to do this one you guys are you guys live in that area but I want to make sure that you obviously don't go in too far to hit the sacrum and the vessels all up there all right so in summary thoughtful abdominal entry is really important that starts before you can get to the operating room and ultrasound is really the only imaging that has shown to help you know if there's adhesions below that umbilicus thank you so much guys I appreciate your attention

minimally invasive gynecologic surgery

peritoneal access techniques

preoperative planning

abdominal entry methods

anatomical variations

alternative entry points