All right, we are one minute past the hour. Thank you everyone for joining the first inaugural AUG's fellowship virtual training course. We're very excited about this and very excited about the faculty who have dedicated a lot amount of time in editing videos and putting content together for all of us during this kind of COVID time where in-person training earlier this year got delayed and we'll be pushing into next year. And so we really wanted to provide some value here. So a huge thank you to AUG's, huge thank you to the faculty, and huge thank you to all of you joining today. I'm going to do a brief introduction and hand it right over to Dr. Farnham and Dr. Myers to walk us through the presentation. If you have any questions throughout this broadcast, please utilize the Q&A and chat functions that you see at the bottom of your screen via Zoom. We'll monitor those and actively engage those questions throughout the presentation. So as far as introductions go, Dr. Richard Farnham is a clinical assistant professor at the Texas Tech University Health Sciences Center, Borough College of Medicine, and the HCA OBGYN residency program, Las Palmas Del Sol, El Paso, Texas. Dr. Farnham is a da Vinci Epicenter surgeon and Intuitive Sacral Copal Plexi course director who has trained hundreds of surgeons from primarily the U.S. as well as outside the U.S. He is market chairman, urogynecology tenant, West Texas region, and Co-McMaster Surgeon and Robotic Center of Excellence, and has performed 2,800 robotic surgeries to date. Dr. Erin Myers is an associate professor who specializes in female pelvic medicine and reconstructive surgery. She is a research director for the fellowship at Atrium Health Women's Care, Urogynecology and Pelvic Surgery Department of OBGYN. She is an experienced simulation director with recognition for excellence in teaching and coaching, winner of AAGL 2019 Game of Zones Surgical Competition while teaching BERT urethropexy, instructor at the Augs Fellows Robotic Course, and has a true passion for teaching and has taught robotics courses both nationally and internationally. So thank you so much, Dr. Farnham and Dr. Myers. I will hand it right over to you. Well, I certainly want to thank Augs for putting on this event. I want to thank Dr. Myers, certainly an honor to present this content. By way of overview, we're going to be talking about the robotic sacrocovalpexy procedure. We're going to deconstruct that and also talk about complications. We're going to talk about the BIRCWH robotic retropevic urethropexy, and then something that's very relevant for many of you, this transition into your new practice and what resources Intuitive and Augs has available for you going forward. Just by way of housekeeping, as Matt mentioned, if you have questions during the presentation, please utilize that chat function. We'll try to get to as many of those as we can during the lecture, and we'll have some time at the end. We'll also share our contact information. So afterwards, if you have any follow-up questions, we'll be able to get that as well. So again, I'm very honored to present with Dr. Myers today. Thank you, Dr. Farnham. I'm also very happy to be here today. Thank you to Augs. Thank you to Intuitive for having us, and thank you to all the fellows for joining us. Please ask lots of questions so we can be as interactive as possible in this course. We'll start just by listing our disclosures here, and the first thing we're going to talk about is robotic sacrocopalpexy. We're going to begin with a brief overview of patient selection and positioning, and then move straight into some tips and tricks while Dr. Farnham and I will compare and contrast different techniques, and then talk about some complications. Normally, a course like this is held over one to two days, so we've tried to pick the highlights for you and have shortened this into a two-hour session. So hold on. Here we go. First, we want to do no harm. For me, personally, I don't tend to place much in women who choose to smoke. We have native tissue options, and I recommend these for that patient population. Extensive surgical history. You may want to think about this and consider an extra-peritoneal approach for women with significant abdominal adhesions you're worried about pathology in the abdomen. A sacrospinous ligament fixation will avoid this space altogether and keep you out of trouble. Another population may be those with an elevated BMI. You may want to think about the extended operative time, increased blood loss, and overall challenge to the procedure. The patient may not be able to tolerate Trendelenburg position, and sometimes I'll even offer a referral to a weight loss clinic and perform the surgery once she is more healthy. I know that we all just love to operate, but remember, this is a quality of life surgery, not a life and death surgery, so it's okay to say no sometimes. Yeah, I agree, and in my practice, all of the fellows now are being trained in the wake of the 2008-2011 FDA safety communications regarding MeSH, and as we know, slings and sacrocolbexes were specifically exonerated, but there are patients that have real or imagined reasons to not want MeSH, and so this has a place, I think it has a large place, in our toolkit that we offer patients, but we do have to be aware of what the challenges are and do what is in the best interest of the patient. Absolutely, absolutely. So then, who might benefit from MeSH? Who are great candidates for this procedure? So an ideal candidate is one really who's maybe failed a native tissue repair, or maybe she has high primary stage prolapse. Maybe she has mild prolapse, like stage two or three, but significant risk factors for recurrence, like heavy lifting at her job, or chronic cough, or maybe a collagen tissue disorder. Our patient must also be willing to accept a MeSH product, just like Rick just said. This was more challenging about 10 years ago, when we started seeing those FDA warnings in 2008 and 2011. Many women during that time really couldn't even be talked into a copepex seed, no matter what. Some of the dust has settled from that, and I really don't find it challenging talking to my patients about MeSH anymore. Do you, Rick? I don't. Certainly, there's the actual clinical concern, and we'll get into MeSH erosion rates and these types of things that we have to be aware of, and then there's the medical legal concern, and I think that you have to have an informed consent that clearly describes what the risks of MeSH are, what the risks of vaginal MeSH, compared to slings and sacrocopalpexy, and as long as that conversation's been had, yeah, I haven't had problems. I haven't found myself in a position where you need to talk someone into it. Absolutely. I think it's really, the landscape has really changed over the last few years. When we do think about MeSH options, though, we must definitely consider the alternative. Historically, a vaginal native tissue repair was always performed primarily because the alternative was an open sacrocopalpexy. Now, though, with minimally invasive techniques, we can offer an abdominal procedure primarily. We do have to think about this, though, in context with the history of MeSH, and like we said, that 2008, 2011, about 10 years ago, with that safety notification, many women were coming into the practices asking for native tissue repairs. So timely enough, in 2014, the optimal two-year outcomes trial were published. This was a randomized trial of women undergoing either sacrospinous ligament fixation or uterus sacral ligament suspension for prolapse with or without behavioral therapy. There was a very strict definition for success. It was defined as no apical descent greater than one-third the vagina, no anterior or posterior prolapse past the hymen, no bothersome bulge symptoms, and no retreatment. And at two years, it seemed pretty good, success of 64% with minimal symptoms afterwards. Then, however, in 2018, we could see that that success rate did deteriorate over time to only 35% with hovering in the 50% range of anatomic or symptomatic failure. Fortunately, many of these women did not seek retreatment, so it's hard to say if they were bothered by these recurrences, but nonetheless, they were noted. When we compare this to a more recent study performed by Dr. Culligan and his team, this was published with their five-year outcomes. Now, this was a case series and not a randomized trial, but it did include a similar number of patients and also had a strict definition for success. Success was defined as no anterior or posterior prolapse beyond the hymen, no apical descent greater than one-third the vagina, no bothersome bulge symptoms, and no retreatment. Guess what? They found no mesh exposures at five years. One of the things we've worried about with this would be the mesh exposures, but we have reassuring data coming up. There are many factors one must consider when deciding between a native tissue or mesh repair. You have to think about your training, your comfort level, patient factors, your experience, your team. I find this study very helpful when I'm on the fence and I could go either way with recommending a surgery to a patient. In this study, 125 women had preoperative POPQ and then underwent a native tissue uterosacral ligament suspension. One year later, they measured the postoperative C. What they found was that a more negative preoperative D correlated to improved postoperative support. To me, this means that women with less preoperative prolapse or less disease to start with had better outcomes. For every one centimeter in descent in preoperative D, the postoperative C was lower. A cutoff value for about minus four was really the sweet spot. When I'm on the fence and a woman has a preoperative D worse than minus four, I'll usually recommend a cobalt PECC-C. Dr. Farnum, before we go into setup, do you have any other thoughts on who should or shouldn't have a cobalt PECC-C? In my practice, it's actually not my primary repair, but I do about 250 robotic cases a year and about 80 to 100 sacral cobalt PECCs. I have a pretty low threshold for going either way. It really depends on what the patient's goals are. There are patients that have stage four prolapse and they would be happy just to have something inside the hymenal ring. There are patients that have a leading edge at negative one at a starting point. It really depends on what their goal is, what the long-term outcome is. There's a lot of factors. I think it's great to have this data to work off of, but really as a primary repair, if it's inside the hymenal ring, I'll usually do a robotic hysterectomy with a uterine sacral cobalt suspension. Then we'll have a conversation if it's outside about the sacral cobalt PECC-C. Like we said, comfort level, experience, all of that plays in patient factors and goals. It's a complex decision to make for sure. So we'll move on to docking. I have just one more disclosure that wasn't on the disclosure slide, and that's that I still operate on the SI. I might be the only one on the call that does, but hopefully one day I'll get to play with some new toys. For me here from left to right, you can see I'll have two arms on the patient's left. I do dock on the left. I'll use a fenestrated grasper in the most lateral arm, then the PK in this next arm. Of course, the camera at the umbilicus. In my right hand, I'm right-handed. I'll use the monopolar scissor and switch that out only for the mega suture cut needle driver. Then my assistant port is all the way there on the right. So for the excise setup, which I believe most of the fellows have been trained on as they come out into practice, most of you are going to be having fourth-gen technology, and Aaron will tell you there's not a lot of range of error on an SI. If you're off by two or three centimeters, you're going to have collisions, and that's usually between the one and three arm. With the excise system, it's a boom-mounted, multi-quadrant technology. The best design, really, it's designed to function with kind of a straight-across approach. What I prefer is kind of like this flattened McDonald's arch. In our practice, for right-handed surgeons, you'll use the third and the fourth arm on the right side. That's your dominant hand. Our assistant port, we actually have on the patient's left. Now, that port, you can kind of cheat up and down in this line because that doesn't have any effect on collisions. This is kind of how the setup looks on an un-insufflated abdomen. Of course, that's going to distend once they're insufflated, but again, kind of a straight-across approach or just this flattened arch. Once we put our ports in here, you can see this kind of lines up straight across and then docked, very similar format. One of the things that we're going to talk about and the beauty of being able to present with Aaron is we have different techniques and we have a lifelong commitment to learning. We're going to work with cadavers and teach and educate and do lectures all the time. We're always picking up pearls that we can add and continually improve our strategy that we use and then we can share that with other people. I bring this up to say that some of the things that Aaron is going to show and some things that I'm going to show are very different. There's not really a right or wrong. I think it's just great to have different ways of doing things. My feeling is if you're a right-handed surgeon, you're going to have both of your robotic arms on the right. By contrast, you could have both of your hands on the left and you could have traction and traction and then operate down the middle. To me, I want to have my static retraction by my assistant and then I want to have traction, counter traction with my two robotic arms so I can operate down the middle with my scissors and then switch that out for a suture cut later on when I'm suturing. That setup for me makes the most sense. I think for these difficult cases, if the case calls for a fourth arm, you need more surgeon in the patient. The static retraction, the moving the bowel, I'm going to leave that to my assistant. For the dynamic retraction where I'm continuously toggling back and forth between my third and fourth arm, I want that in my dominant hand. That's just the way that I've been able to enhance my efficiency and develop, as we'll go through in a minute, a team target for a very efficient type of procedure with essentially no loss of economy of motion throughout the entire surgery. The other thing that I would point out is take advantage of your free ports. In the belly button, that doesn't leave a scar. You have another port that doesn't leave a scar, which is the uterine or the vaginal manipulator. Many programs, you'll train under someone and that is the only way to do it, but have an open mind as you watch us and we go through this presentation to see if maybe there's another strategy that you could employ that might work better for you. I think Erin and I both feel that you want to take advantage of that free port so we can manipulate, we can get traction, counter traction through our vaginal manipulation and we both utilize that to, I think, the maximum ability during our surgeries, specifically sacrocopalpexy. Absolutely. Rick, we have a question from Amy Askew. She says, can you discuss the benefits of straight across port placement versus the W configuration? I think it's different for both of the robots, so for the SI, I just do what the patient gives me. If I can do straight across, I will without arm interference and I feel like her abdomen is more narrow, then I may go into the W or M configuration. To me, it's based on the patient's abdomen. Yeah, I completely agree, Erin. When I am using the SI, at this point, I only do it for simple cases where I'm not going to use the fourth arm because in our market, we have 18 robots and one SI, so it's rare that I get on the SI. But to answer the question, yes, when I do an SI, I always do the W or the M configuration and the reason for that is I like to maximize horizontal and vertical spacing between my one and three arm on the patient's right side and I feel that minimizes collisions. Now, you have the luxury of maybe going straight across, as Erin mentioned, on a patient that gives you more real estate, but when you have limited space to work with, you're going to have to use the M or the W configuration to make the SI work. With the SI, you actually don't want to use the M configuration and here's why. Your collisions occur between the two and the three arm on the SI, so your camera and your right upper quadrant and when you get too much vertical spacing, that's when those two arms will collide, so it's actually designed, the SI is, to have the straight across configuration or if you feel you need a little spacing, you know, maybe two or three centimeters out of alignment for that flattened McDonald's arch, as I showed. Excellent. So, what are some tips and tricks for success? Let's get into the details so we make sure we all have great outcomes for our patients. We're going to talk about building a team, practicing with simulation. Yeah, and I think it is very important to make sure you have a flight plan and you do the exact same procedure the same way every single time. And we'll continue, there's a number of themes that are going to continue to come up as we lecture today. Themes, yes. Right. So, traction, counter-traction, you know, very, very critical. Cut through what you can see through one cell layer at a time and do the same thing every single time to the point where the surgery itself becomes habituated. You really need, whatever the surgery is, hysterectomy, sacral colt, pixie, burge, you need to be able to sit down at the console and it has to be second nature, it just has to flow. It really shouldn't require any cortical input. As you're going through your learning curve and you get to that 50th case, you should be getting close to the point where the learning curve starts to plateau and it becomes automatic. What we don't want is we don't want to have a starting point of three and a half, four and a half hours, and then you get the vestigovaginal adhesions, then you get the cul-de-sac obliteration and you're staring at a six-hour surgery. That benefits no one. So we really need to get to the point where the entire process is essentially automatic and you can save your troubleshooting, your cortical problem-solving abilities for the patients that don't read the textbook and they give you these challenges. Watch your own videos. Again, Aaron and I have this important privilege of being able to lecture and teach. In doing that, we're always going back and we're learning from what we did, what could we do better. I'm not talking about saving five minutes in a case. I'm talking about saving five seconds from one movement to the next. I think we can get to a point, as Aaron's about to show, where you can break down and look at every single step, but watch your own videos and learn from others. Yeah. I love that automatic phrase that you mentioned, and I do think using the robot is very much like driving a manual transmission car, and you shouldn't think about it just like driving a manual transmission car. You should be thinking about maybe where are you going? Is the car in front of you stopping? Not am I changing from gear one to two? So that should be automatic. So let's talk about our teams. I'll say my team is not smaller than Rick's. It's just socially distanced. Okay. I want to highlight Stacy. She's my right hand in the OR. This is my best robotic scrub, and she's just amazing, makes my life wonderful, and we take care of patients together. And Rick, is this your- I agree. I think... Yeah. So this is pre-COVID, full disclosure, focusing mainly on the XI robot there. But yeah, so we have built a team, as Matt had mentioned, we have a case observation site where surgeons come in, and as much about the surgery, as much about to see the challenges that can arise, as it is to look at the efficiencies, not just of the surgeon doing the case, almost more so the team, and this coordination, this collaboration from CEO to housekeeping. How do we all work together to build a team? Yes, absolutely. So practice with simulation, practice in the lab, especially if you're not at your 50 or more cases a year, you're doing multiple cases every week. Get fast at the easy steps so you have time to dedicate to the hard steps. So together with my partners, we decided to build a sacral copal pexi simulation model due to some of the challenges we had in teaching brand new fellows hard steps like sacral dissection, especially without a teaching console. This can be very challenging to watch and to teach. So in making this model, we had to develop and learn about a hierarchical task analysis. And for me, this is one of my favorite takeaways from the study. In order to teach simulation steps, we first had to define the steps. So we had a focus group and met and determined all the steps of a sacral copal pexi, and each step had sub steps and so on. So not to have everyone memorize or go through each of these, but this box plot is just to show gosh, look at all the steps you have to think about. While you're in the operating room, all these things a surgeon has to be thinking about. It's very complex. And you have to do this while you're leading and teaching in the operating room. To simplify this, I'd recommend that you do this for yourself at home. Make a list of each major step you do, then list out each key sub step for that. Write it out, then do your case the same way every time, and perhaps even time yourself at each step. This will take away the variability and add efficiency to your OR, and your team will know what to expect as you continue with this repetition, and then they will shine as they anticipate next steps with you, and they'll feel good about their job. One caveat I do have to this is just sometimes it's important to do the hardest step first. So you may always do the sacral dissection first, but gosh, this is a really big uterus and let's do the hysterectomy first this time. Or you can't see or feel or even guess where the sacrum is. You might want to start there to see if this procedure is even possible. You don't want to do all your dissection, leave that for the last, and then have to abort and have another procedure for that patient. Anterior vaginal dissection, we're going to talk about that quite a bit later. That might be the most challenging step in a post-histocopalpexy. You might want to start there. Now, at the end, there will be a short quiz where you'll be required to write out all those steps from memory. Not multiple choice. That's right. So what Erin just mentioned does bring up a critical point is that, you know, we just said do the exact same thing the same way every single time, but you have to have adaptability. You have to take what the patient gives you and manage those things. Now, sometimes it's easier to do the easy stuff first. Sometimes it's better, as Erin mentioned, to tackle the harder things. I need to know if I'm going to be able to do this surgery, complete this surgery with a four centimeter thick presacral fat pad. I want to know right now if I'm going to be able to do that, whether that's your first step or not. So always keep that in mind that there are some challenges that will arise, and we need to be adaptable to be able to do that. Now, that being said, as we're doing the case, as I tell the residents and fellows, you know, the easy ones are hard. The hard ones are impossible, right, unless, you know, you've habituated the process. So in our case, and we'll kind of show the flow diagram here, we're going to start at the promontory. So the most logical next progression would be the right pelvic sidewall. So we'll do that dissection. The uterus is, or the vagina is already antiverted. So then we'll go and do the rectal vaginal dissection. Then we'll flip that down, and in my case, we'll split to a 30 down camera, and then we'll do the anterior dissection. So the entire, we've set the table. Then we introduce the mesh. So we were just on the anterior, so we're gonna fix the anterior. We're gonna go over the top, then we'll fix the posterior. I like to close as you go. So at this point, I'll actually close the bladder and rectal peritoneum, and I'll start to stitch up the right pelvic sidewall peritoneum about halfway. Then I'll fix the mesh, the apical arm to the anterolongitudinal ligament, and then we'll close the peritoneum we're done. So if we break this down, it's essentially a eight-step process. And I think it's critical to have a goal or a target. So for us as a case observation center, as we'll see in the next slide here, we have team targets, okay? So if we break down each of these steps and we allot a time around five to 10 minutes per step, we'll see here that each step, when we add them together, will allow us to get off the console in about 50 minutes, to complete skin-to-skin in about 90 minutes. And when we include the total time, bringing the patient in, positioning, prepping, intubating, extubating, get out of the room for a seven o'clock start before nine o'clock and do that consistently. Now, of course, that's the goal, that's the target. We don't always get there, but if you don't have this, if you haven't broken this down, if you don't have a clock in your head, you may allow yourselves to kind of let time get away from you. And that's how you look up and you're like at three hours, you're like, how did I get here? So I think it's good to have a strategy. Absolutely right, couldn't agree more. Timing each step I think is crucial to understanding, you know, keeping yourself on track. So let's talk about hysterectomy. Rick and I both do this a little bit differently. Do you do a total hyst, do you do a super cervical hyst? What about the data? What about kind of your preferences? So I think we can all agree the main reason many of us may shy away from a total hysterectomy is the risk of mesh exposure, right? So in 2004, we have a PFDN comprehensive review outlining mesh exposure rates of 3.4%. Sometime later in 2006, Dr. Wu presented a retrospective cohort of abdominal copepaxi, mesh exposure rate of 5.4%. We had higher rates in hysterectomy patients, but that wasn't statistically significant. And then we had our two year care outcome data. And this is what a lot of people quote is, whew, we're not gonna do hysterectomy, look at that mesh exposure rate. Well, we did have different products back then, thicker mesh and permanent suture. So a more recent study, this is the PACT trial or Permanent Versus Absorbable Controlled Trial is a study of minimally invasive copepaxi at the time of total hysterectomy using a lightweight mesh. This is a multicenter trial. All women, again, had to have a total hysterectomy. However, cuff closure techniques were not standardized. At one year, there was a 6% mesh or suture exposure rate with no difference between the groups. Our group here at Atrium Health in Charlotte was asked to participate in this study. And before the study, most of us all performed super cervical hysterectomies. We changed our technique for this study. And I do think there was a little bit of a learning curve for getting into the exact right plane after a total hysterectomy. One of those mesh exposures was mine. And I think it was due to a split thickness anterior wall dissection rather than cuff closure issue. I've learned from that. And to my knowledge, I really haven't had any more issues with that technique. I will say all of the partners in my group do continue to perform total hysterectomy after being in this study. And now that the study's concluded, none of us have gone back to doing super cervical hysterectomy. So for me, there are variables that I consider other than the mesh exposure rate. You have the risk of morcellating or removing unanticipated pathology or the workup required to screen for that, either ultrasound or endometrial biopsy. If a woman has a longer cervix and maybe Rick would perform a total hysterectomy in that situation, but even if you have perfect support, the cervix may still be protruding into the vagina and she can still have bulge symptoms. The woman might complain of continued cyclic vaginal bleeding if she's premenopausal. There's a higher risk of recurrent anterior wall prolapse. And I kind of think about, well, if she ever needs her cervix out, I don't wanna be the one to have to do that surgery. And then she still has to get pap smears. So it's not all about the mesh exposure. And I do talk to my patient about all of these factors. So that being said, here's an example of my technique. And I'll say just like Rick with timing things with an easy hysterectomy and cobalt pexi, no surgical history, normal BMI, we should be able to do this in an hour of console time, 30 minute hyst, 30 minute cobalt pexi. I'll do the anterior dissection as I'm doing the hysterectomy. As you can see, it's almost done here in less than 30 seconds. You just kind of spread that down. I do like a cold cut technique. See, I'm not using any energy whatsoever to dissect that anterior wall. It is an avascular space. I find that when you use energy, that fuses the tissue and brings it together. We wanna separate it and make it go apart. So we want to let this area bleed as much as possible. We want to not cause a thermal injury to the vaginal cuff. So just highlighting, we're definitely taking out the cervix here. That's how I'll keep my pneumoperitoneum stable while we're taking the uterus out. And then you can see the cuff there is still bleeding. It's not white. It's nice and red and pink. I'll do a one layer cuff closure. I don't want to devascularize the cuff by kind of obscuring blood flow to that area. So I'll do a one layer, not a two layer cuff closure. If I'm doing a uterus sacral suspension, I will do a double layer cuff closure, but I just don't want mesh against that. You can say it's not like four throws forward, four throws back. It's nice and close together, one layer cuff closure. We are analyzing data from our institution. It's not published yet, but we have about 600 patients with this technique and less than 1% mesh exposure so far. So more to come on that. Yeah, that was great, Erin. I think your hits took 90 seconds. So that's impressive. So look, there's a couple of questions. We want to keep the flow going, but I'll briefly address. There's a question from Tess Krause regarding coding. So I have a document that has all the Uruguayan codes with the respective globals, the respective RVUs and everything that we can share with Matt. We can distribute that. We have an anonymous question. What are your respective procedures of choice if you are unable to do a copal pex? Sacrum, not accessible. So the simple answer to that is never happened, right? So we're all going to have these challenges and that's what we talked about. And I think it does bring up a good point that I usually discuss later on in this deck, but the concept of duly consenting. So I'm at the point in my practice where I'll give anyone a go, right? They could have had umbilical hernia repair with mesh and a splenectomy. I'll still put a varicin, drop in a camera, you know, you get surprised. Like I tell my, you know, my residents, surgery is like a box of chocolates, right? We never know what we're going to find. So you could have had, you know, just like a roadmap on the abdomen of prior surgeries or you could have a virgin abdomen and the roadmap may have no adhesions and the virgin abdomen may, you know, have had PID or something and it's just a complete cul-de-sac obliteration. So you don't know, so I'll give it a try, but I think it's important to duly consent. So if I have a case where it's a challenge, it's a challenge not necessarily because of a surgical issue, but perhaps a medical issue. There are concerns about adiposity or COPD or Trendelenburg. I will consent them because I don't open. I mean, I opened, well, I opened, right? Everybody opens, right? So I opened one in 500. So I haven't opened in four years, but my alternative is not going to be to do an open colpopexy. If I put the camera in and it looks like three hours have you used a license before I can start, I'm going to consent them to do either a colpoclesis or a sacrospinous, some retroperitoneal procedure where I don't have to contend with that, but I'll make sure that that is on the consent so we have that option. I don't know what you're. I don't know if anyone can hear me right now. The, yeah, okay, I think I hear you now. Can you hear me? Okay, yes. I'm not sure how much of that I got, but. I think, I think got all of it. I heard all of it. So the, I would completely agree with you. Dual consent is key. I think having a patient wake up and surprised they didn't have the surgery that they thought they were going to have is what you'd like to avoid. I'll compare and contrast. Sometimes I'll do a robotic uterus sacral suspension and sometimes I'll do a sacrospinous fixation. Chances are, I'm probably not going to do a copolysis as an alternative because they're having the copolexy because they want to be sexually active. If they don't want to be sexually active, they have a large prolapse. I may just do the copolysis on the front end. But again, just discussing that with your patient, deciding a backup plan that makes sense. And I think we have lovely native tissue options that we can use as a backup plan. Perfect. So this is, I think, a 2013 OGS review that I attended. And, you know, Dr. Karam showed this slide and basically the conclusion of which was sacro with a hysterectomy at the time of sacro, 8.6 erosion with supracervical and sacroplexy 1.7, so five times greater erosion. Prior to that, for me, it was kind of a mixed bag. Sometimes I'd remove the cervix, sometimes I wouldn't. And after that, I just decided, you know what? I think this is going to be better for me to just leave cervixes. And I've kind of done that. Now, of course, you know, it's individualized. So there are examples and, you know, Erin did a great job of showing the examples where you wouldn't want to leave a cervix. But for the most part, I am doing a supracervical hysterectomy and sacrocopalpexy. So, you know, when we have a idea or a thought about something, we're going to look for data and we're going to evaluate things that support our preconceived notion about things. So, you know, in the CARE trial, their hysterectomy with sacroplexy and smoking were specifically identified as risk factors. Now, you know, we have to take all this into context. We have to understand the heavyweight meshes that were used and, you know, open surgeries, as opposed to the robotics that now facilitates minimally invasive surgery. And then, you know, I've done some studies showing no erosions with supracervical and 14% with TLH. So I enjoy, you know, doing that surgery so much that on a post-hysterectomy sacro, if I get a donor cervix and put that on the top of the vagina, I would just because it's the perfect substrate to separate my mesh from the vagina. But there are a couple of points that, you know, Erin had pointed out that I think are very important. If you choose to do this, if you're going to leave the cervix, you definitely need to evaluate and do everything you can to ensure that you're not gonna end up having some undiagnosed pathology, right? That's not an M&M that I wanna be in, right? So you did this quality of life surgery and you disseminated an adenocarcinoma. So if you're going to do this, they have to have up-to-date cervical evaluation with pap or colpo, whatever needs to be done. They have to have ultrasound. They have to have endometrial biopsy. And we have to do everything we can. And even then, there are gonna be circumstances where there's going to be undiagnosed pathology. And it really comes down to what you can live with, right? And what you feel in your hands provides the best possible outcome for the patient. And if you feel that that is a hysterectomy and you've got a strategy and a technique and outcomes that support that, that is what you should go with if you feel that super cervical. And Aaron brought up Culligan's recent publication. So this is a large, very large case series and predominantly super cervical at the time with sacrocopalpexy, some post-hyst sacrocopalpexy. And there were no erosions. So, I mean, again, it's a case series, but I think it's important to understand that it may actually go beyond the argument of leaving or taking a cervix. It may have as much to, if not more, to do with the type of mesh, the density of mesh that you're using, that we're all using lightweight meshes now. And I think we're gonna continue to get data that does show high success rates with low erosions. And doing everything in a minimally invasive fashion, less contamination. But I feel pretty strongly that if you're gonna choose one method, you just have to understand what those risks are and certainly have the ability to go back and forth. Some patient, you may choose to wanna leave a cervix and your patient may not want that. They may want that removed. And so just be adaptable, be able to do that and have that in your toolbox as well. In the cases of cervical elongation, sometimes the cervix itself is five centimeters. So you wanna remove that. Or I've had cases where I've actually leaped off the bottom four centimeters and then done a super cervical with sacral copepaxi. But the beauty again is that we have all these options and you can pick and choose what works best for you in your practice. So before we move on to sacral dissection as our next step, we have a question. Do you think that the approach of hysterectomy makes any difference in erosion rates, i.e. vaginal hysterectomy versus laparoscopic hysterectomy? You know, maybe we're gonna feel that in one minute. We're gonna change slide decks in about two slides. So that'll probably be the perfect time to kind of feel that one. Okay. So moving on to the sacral dissection, we're gonna focus on instruments that we like to use, anatomy in this space, and then tips and tricks for challenging dissections. We're going to look at specifically do not spread unless you can see through the tissue. One trick I like is find the hypogastric nerve and work backwards, and then be aware of large vasculature. So these are the instruments I'll tend to use from left to right. Breisky, we're all familiar with this. We have an EA-sizer, normal size, and then I have a giant EA-sizer that helps distend a large vaginal vault. Yeah, typically they say everything's bigger in Texas, but we don't have that big EA-sizer they have in Carolina there. So I like to use the one on the left here. This is called the Hoyt on the vincula arch. And, you know, it's interesting. I feel that there's so much technology and innovation and engineering that's gone into all of the colpotomizers for hysterectomy. And yet, as your gynecologists, we're like, well, what do you want for vaginal manipulation? I don't know, whatever's in the tray. Give me a sizer. When we have a device here that's actually engineered, it's designed based on MRI studies to be the ideal shape for the colpopexy. Now, I would also say- I'm going to just move to the next show while you keep talking. Absolutely, yeah. As we'll show in the next video here, we're going to do kind of a side-by-side comparison, but the other great thing about this particular manipulator is it's designed to work with a device called the Ally, which is kind of a robotic vaginal manipulator. We talked about teams earlier, and, you know, part of having an efficient team is doing the same surgery and taking care of your team members, you know, giving them, you know, appropriate compliments and helping them. So if we can assist them, and I'll get back to that in a second. In this video, I just want to point out, on the right is the EASizer, so you can see the instrument tips are touching, and you can see this is the same patient. So in the same patient with two different manipulators, you can see how much more distance we have with the Hoyt, how much more that flattens out the vagina for fixation of the suture than, you know, just the regular EASizer. So I think it's a much better platform. Going back to my other commentary, and this would be an example of, you know, a supracervical, so we're going to be using the colpotomizer or the delineator manipulator here at the beginning of this case, but the point is to illustrate this integrated system where the manipulator connects to this robotic arm that attaches behind the Allen stirrup, and your assistant can actually just position and then go and then rest. So, you know, if they don't have to sit there and push in for two hours, right, you can get static, predictable retraction. I mean, that's a win for everybody. Frankly, you could probably even reduce the FTE in your OR by one, and your, you know, bedside assistant could do manipulation now. And then one of the other problems is, you know, during your hysterectomy or during your colpopexy, how many times have you said, push in? Oh, I am pushing in, and then, you know, you reach down, it's like, okay, see, you weren't pushing in as much. So this is just a, I think, a really good tool, and we have this as ubiquitous. So every case, just because we see the value for that and the kind of the integration with the entire process. Before we move on, we can probably field that question, if you want to repeat that question. Do you think the approach to hysterectomy makes any difference in erosion rates, vaginal versus laparoscopic? So- Yeah. Yeah. It depends on how you're answering that, whether you mean vaginal mesh, or whether you mean as it compares to the sacral colpopexy. I personally would never do a vaginal hysterectomy and then do a sacral colpopexy. So, but I definitely feel that the erosion rates are going to be higher because on a vaginal mesh case, which we don't do anymore, you're placing vaginal mesh through an open incision. Correct, and while the rates may be good in some studies, meaning doing a vaginal hysterectomy and then going and doing a colpopexy, some institutions have had good outcomes with that. There are also actually erosion rates in those case series or some other studies like that. So for me personally, I'm not going to perform a vaginal hysterectomy and then go perform colpopexy. I'll do everything from above and keep the mesh out of the vagina. Yeah, I totally agree. And I think the largest retrospective study, the L trial had like an 11.8% risk of erosion for anterior mesh, despite superior object and subjective outcomes compared to native tissue repair. It's kind of a moot point because we can't do mesh, but yes, I think it plays a role, placing it vaginally. Yeah. So when we think about the sacral anatomy, I just absolutely love this paper by Meadowgood and her colleagues. This is a cadaveric study looking at the anatomy of the presacral space. And I literally think of this every time I'm in the operating room. The left common iliac vein is way more scary to me than any middle sacral artery could ever be. And on average, it's two and a half or so centimeters from the presacral promontory. And the lateral vasculature you see at S1 and down right over the edge there is two centimeters to either side. So you really have a two by four window that you're often opening blindly in the depth of adiposity to that area. And so just being mindful of where we are and what's going on in that space. Here's another view really highlighting the disc. And really, this is gonna be a challenge for anybody to place a copepaxi suture either above that disc or below that disc. Yeah, I think the other thing to highlight in this particular photograph, what we see is the middle sacral vein draining right into the left common iliac vein, which in this case is actually, this is an important concept, is this anatomic variation, right? So this LCIV is lower than most that you would see. But when it comes to the idea of, I think a lot of people spend time worrying about the middle sacral vessels, it comes off the aorta. Well, the middle sacral vessels, you isolate anywhere L5 to S1 or investigate if that makes you feel better or just go lateral to it or directly under it. When you get into trouble is what you see down by S2-3 where this beautifully demonstrates the anastomosis of the middle and the lateral off the poster division of the hypogastric. And this is where you would see a broken vessel retracting into the sacral hollow causing the bleeding where historically we talk about bone wax and thumbtacks and all these things. And whereas technically, it's probably anatomically superior to have S2-S3 fixation, for my money, I'm gonna stay away from that increased risk of vascular injury and stay on S1. Correct. Me too, couldn't have said it better myself. S1, S2 all the way. So now we're gonna start looking at some different videos of these different dissections. In this video, we're gonna have three different examples. I'm gonna isolate and look at the ureter first. That's gonna be lateral. And I look up to see my uterus sacral ligament and straight back from that is where I'll start my dissection. That's how I can tell I'm gonna be, rectum to the left, ureter to the right. I'm gonna just look for that uterus sacral ligament. Now traction, counter traction is key. You should see this pop open as the pneumoperitoneum opens the retropubic space. And there's three different techniques we're gonna look at here. Spreading, finding the hypogastric nerve and working backwards and then just being cautious of large vasculature. So here's an example of a spreading technique, palpating, okay, I think the sacrum's right here. Maybe, maybe not. I'm gonna kind of push and see, pick up just a little bit, maybe retract a little. What I like about that technique is you can see the tissue gently move over the sacrum right here. And because it's moving, you can see through it. That's a safe place to pick up. So we're gonna pick up right there. And what I don't like about burning is it fuses the tissue. So rather than opening the space, you're kind of sealing it shut as we're trying to dissect. So that can be challenging kind of layer by layer. And that can take some time. It's not wrong, layer by layer can work, but it can be tedious and can take some time. And sometimes you can get in the wrong plane and you don't really know what's under that to the left. You can't see through what's under the left. And that could be that vein we were just talking about, could be right under there. And we just don't know. Just double checking. Yep. If I can say, yeah, that's great. I think what, and I don't wanna interrupt your flow, but here you're gonna kind of stretch that out with enough counter traction, traction, counter traction, the patient will always tell you where to go. So listen to the patient. So this is it. So finding some more traction to this space, just changing how we retract. There's the opening. Look for the opening. So there's the opening. We're gonna make that opening even larger. And then voila, there's the sacral area, free, clear, easy, and fast. So just listen to the patient and you can see how if we had retracted or try to spread on that vessel, she could have had some bleeding. So this is another example of a technique. Can't really feel the sacrum. You can see it, maybe guess it's there, but it's kind of spongy to that area. The instrument's bouncing right back at me. We're gonna pop into that posterior peritoneum, let the pneumo help us and open this up. But what I'm looking for is the hypogastric nerve. So rather than focusing on the sacral dissection, I'm gonna open that lateral sidewall. So I'll skip the pre-sacral dissection all together and I'm opening my sidewall down to the uterus sacral ligament. There is the hypogastric nerve. It is always there. And it always leads me back to the middle sacrum, always. Just like the yellow brick road, we're just gonna follow that back. And so I can pick that up, dissect under it, dissect over it, even though I can't feel anything. I can't feel the sacrum. I can't see the sacrum. I guess it's probably here towards that bifurcation of our vasculature, but here I'm just gonna pick it up. Okay, maybe there's the sacrum. You can kind of see some tension. So I'm gonna pick it up a little higher so I don't have to dissect as much. Up and down to see where a window is. And I'm just gonna open each window. She says, okay, it's safe here. We have areolar tissue. Oh, and you can maybe see the sacrum peeking through under there. I'm gonna go to the other side, and then you don't have to cut that areolar tissue. It'll spread, so you don't have to waste time. Just cut, cut, cut. It'll spread right out of your way. What were you going to say, Rick? Now, this is a great example of the anatomic variation and troubleshooting, means of troubleshooting when these variations arise. And there's our sacrum. So had I maybe spread, it maybe would have been more challenging, but I found that to be a fast technique. And then when I can see the space and I have good visualization, sometimes I'll just go ahead and place a stitch there. I'll cut the needle off and leave the two arms out ready for the mesh when it's time to attach, rather than trying to expose that nice space later on. I'll usually color one suture purple. That happens to be the color of the marker that's in our scrub kit. So then I have two ends of a purple, two ends of a white, and I'm not trying to feed sutures of two different arms through and fiddling around with the suture ends like that. So this is the third video, just showing, again, that anatomic variation that Rick was mentioning. And this is, again, a fatty presacral space. We have the vasculature very close by. And just trying to be mindful of what's under there. You can see something pulsating right there, or at least I can. To the left, definitely to the right, we have our artery. I can feel the sacrum. I can see through that. So as long as you can see through, it's okay to spread. So because I can see through that area, I'm going ahead and spreading on that hard tissue. You guys see that pulsating just to the left? Very large vein. I have to say, earlier in my career, I may have not proceeded. I would just maybe do a uterus sacral ligament in this case. That is a very large left common iliac vein right there. But I do have a little bit of space right there and can place my stitch. And I think for time purposes, I'm just going to move on rather than showing that stitch going in there. I'll just go ahead. And if you want to play the video, we have a question we can answer while we're watching the video. Okay, that's perfect. So Jason Cruff, it's an important question. So how do you safely extract the uterus for a supracervical hysterectomy, morsel it in a bag, or use a sharp coring technique through mini lap incision? So since the great morselator debacle of 2014, you know, we have this risk, this one in 2,000 risk of myelomyosarcoma that we have to be aware of. And I feel that we're all obligated to bag our specimens. So most of these supracervical hysterectomies that we're doing, we need to be wary of that. And they're small, so I don't, so if I'm going to do like a, you know, a 1,000-gram uterus, I'm going to do that through a 35-millimeter extended incision in the umbilicus, a vertical extension. For most hysterectomies that come with a sacral plexus, they're tiny, they're 20 grams. So I'll still put it in a bag, and then I'll just slightly extend my umbilical incision, maybe a centimeter and a half, maybe two centimeters, and then just close the fascia with a Carter-Thompson, and then close that up. Now, with an SI, you've got to have a centimeter and a half incision anyway for the robotic camera, for XI, you're only dealing with an 8-millimeter camera anyway. So you do have to, you know, plan around that and make that incision in the belly button. And if I can say that, that is really brilliant. I never thought of that, Aaron, to do different colored sutures so you're not confused which one is which, if you're going to place them here. And the same themes are going to come up over and over again, is that theme of adaptability. Place your sutures now so you're not going to struggle later. Thank you. So moving on to the posterior dissection, just like Rick, I'll do the sacral dissection, right lateral sidewall, and go straight into the posterior dissection. I find that to be very efficient. And I'll use the Breisky retractor for this. I kind of make a frowny face, I guess, if you want to call it, not a smiley face, like straight across and then down each side. So again, looking for that uterus sacral ligament. I find that sometimes it's easy to get stuck in the habit of pulling the peritoneum away from the tissue under it, and that's exactly not what we want to do here. We want the rectum to stay with the peritoneum and pull both away from the vagina. So all the fat is going to go with the rectum. This is the entire dissection. I haven't cut out any pieces or taken stuff out to make this seem faster. So we're just going to make that frowny face or like upside down smiley face here. And then just almost like even a birch is what I think of, shoot for where you would find the pubic bone or shoot for the vaginal area. And once you see it, then you can aggressively take down the other areas because you know you're safe. If you don't know where that vaginal plane is, you may just be kind of picking at the area. Yeah. I find there's always kind of a thicker band right down the middle, and a lot of times it's easier to kind of dissect on either side of that and then come back because the thicker band, you're like is that rectum, is that not rectum? But use the lateral dissections to kind of inform that medial, that midline dissection. Completely agree. I love doing that as well. We're going to go right and left first and then take the middle last. You can see here I'm not using energy very much at all, just delicately. Only if I have a blood vessel I can see am I using the energy. Because again, that fuses. I want it open. And so without the energy, you should get these nice big bursts as it opens. And when it stops doing that, she's saying, okay, I'm done with the dissection. If you use energy the whole time, she's not ever going to bleed on you. And I use bleeding as her way of telling me it's time to stop. So she's just still letting me make progress, so I'm going to keep going. How far down are you going to dissect, Rick? So, I mean, I'm going to go, again, as far as she tells me to go. Now, depending on how far the poster edge of the scent is, that may play into my decision if I get to the point where I think the dissection is going well. Most of the time that gets me to the perineal body. But if, for whatever reason, there's scarring in there, quality of life, surgery, I'm not going to get an enterotomy, you know, to make sure I get all the way down to the perineal body, particularly if it's not a primary poster defect. Okay. Now, this can be a more challenging step for all of us, I think, the anterior dissection. There can be more scarring to this space. And so the three techniques that we can have, energy, spread, and cold cut, the energy, again, confuse the tissue together, you're trying to open the space. Spreading, you can find yourself in the wrong plane. And cold cutting allows for tissue separation. And then when it bleeds, she says stop. Now, this is how I kind of think of the anterior vaginal wall dissection. Most total vaginal length, 7 to 10 centimeters. Most urethra is 3 centimeters in length. So that gives us, you know, 5 or 6 centimeters to play with for the anterior vaginal wall most of the time. But have any of you ever been in a case where you get 1 to 2 to 3 centimeters down, and you are just in scar, it's fused, she's never had surgery before, and you're like, what is going on? Well, this might be what's going on. Sometimes the urethra can be much longer, and her actual vesicovaginal space is really short. So rather than struggling, getting into trouble, getting into the bladder, maybe just go do an exam, or I've adapted to where I do this exam as I place the uterine manipulator, you can feel the distance from the cervix to the Foley bulb and give yourself in your mind's eye, how long is that dissection going to be for this patient? Is it going to be 2 centimeters, 3 centimeters, 6 centimeters? So then when you're at the console, you have a sense of how far it's safe to go. So this might be the difference of these two patients. So one of the other key concepts, I think, with your anterior dissection, you know, a lot of times on a post-hysterectomy sacro, this is what you're looking at. You've got the vagina, we're going to bring in the scissors, and the dissection kind of goes as planned. The bladder, you know, nicely flaps up, and, you know, we've got a perfect plane to fix our anterior arm of the mesh. But sometimes, the way that it heals, the bladder will go all the way to the apex, and sometimes it'll go all the way and attach several centimeters posteriorly. And this is another reason that I think, you know, it's a great animation there. This is another reason I think it's important to start with your posterior dissection. Almost no patients have had prior surgery in the rectovaginal space. Virtually all patients, and if it's a post-hysterectomy sacro, 100% of patients, by definition, have had surgery in the vascovaginal plane. So use that to inform your dissection, and you'll actually find times where you need to peel the bladder off the posterior aspect of the vagina. You know, whereas if you didn't do that, if you went straight anterior, as the animation shows, you may go straight into the, and transect the dome of the bladder. Absolutely right. I completely agree. We'll go posteriorly first. So here's an example of an anterior vaginal dissection. This patient has recently had a total hysterectomy. You can see the cuff closure here. And this is an example of a burn and spread technique. So a little bit of burning here, cutting, and then spreading, burning, cutting, spreading. And what I'm looking for are two things. I want to see the tissue plane slide easily, and then I want to see the tissue kind of pop open, just like it did on that posterior dissection we all saw together. So right now, I'm not seeing that popping. The tissue's not really popping open. We're able to open it and spread in this area, but I'm concerned right here for a split thickness vaginal dissection. And I think it's easy to do. It's so easy to do, because we don't want to get in the bladder. So then we'll cheat vaginally and get ourself in the wrong plane after all. So you can kind of see more to the right where that's spreading, and each cut you make pops open the tissue, pops, pops, pops. So see how the two techniques, it's almost the same, but just not quite, just such a subtle difference. But you can see how the plane looks so different here, the right versus the left. So we're just going to, now that we know we're in the right plane, we're going to go around and just expand that plane for our patient. And I think I've heard this before by other people giving talks, and I think surgery should be easy. So if it's not easy, go do something that's easy. Stop doing the hard thing. Go do the easy thing. And by doing the easy thing, it might make the hard thing easy, because now we can easily see where that plane is, and we can come back to where it was fused and safely stay in the right plane. And Rick, I know you have some tricks for keeping your eye on the bladder in this, with sometimes filling the bladder. Do you want to talk about that maybe? Yeah. So, I mean, I think it's always helpful to retrofill. Anytime you can distend a hollow viscera to kind of keep it out of your way. And if you were to get a cystotomy, you want to know immediately. So we have the fully drained into a half empty liter of saline, and at any point where we want to fill it, that's off the sterile field, and the nurse just picks it up, and then by gravity or by pressure, fill the bladder. But we have that in every case. We probably only use it, you know, 10% of the time. But we always have it available, as opposed to getting to that point in the case where you absolutely need it. And then, you know, they got to go down to L&D and get sterile milk and try to fill the bladder or whatever other strategy. Now, I know you have another strategy that I think also works quite well. In terms of seeing the bladder, yes, I don't have a video of this, but I'll just move the Foley bulb. And so I'll just ask my scrub to push the Foley bulb into the bladder, and it will nicely delineate the border of the bladder at the cuff and without having to fill and then wait to fill or wait to empty. So for me, I find that that works nicely. And I've had it in cases where I've actually placed a cystoscope to actually illuminate and see where the edge of the bladder is. I love that. That's a great idea. Sometimes I will do cystoscopy mid-case, and I do find that helpful. And depending on the OR room you have, sometimes you can have both screens open at the same time, you can have your robotic screen up and your cystoscope screen up and can see the difference. So here, I'm just kind of measuring. And I use this to put the analogy of the cuff or the apex are not always at the same place. So I'm drawing a line of that's where my apex is. And if that was a supracervical and the cervix was at the apex, I may have a redundant back wall with that. But we'll get to that here more in a little bit. Let's talk about adding the mesh. Yeah. Yeah. Now, this is going to date me a little bit. But when I was, you know, training in residency and fellowship, we didn't have Y-meshes like you kids. We had to cut our own mesh. So we got the gynecare mesh and, you know, we had to make an apical arm and then an anterior posterior arm. And then as we'll see here with the next animation, these were heavyweight meshes. I mean, 44 grams per meter squared. Whereas in the next graphic, we'll see everything that's currently available is a lightweight. And not just lightweight, but less than half of the density of the older meshes, which, you know, that's the data that we see in our randomized, you know, care trial and with these higher rates of erosion. So I really feel that we get a great, durable, long-lasting repair with these lightweight meshes while simultaneously reducing the risk of erosion. Now, all meshes, all these Y-meshes are prepackaged. They're 26 centimeters, 12 on top, 14 on the bottom. When I prepare my mesh, and I actually prepare my mesh, again, referencing efficiency, the second the last truck car's in, I step out. My team will go ahead and dock the robot. In the 90 seconds it takes to do that, I'm trimming my mesh. So I've already kind of had an idea of the length that I need. I usually will trim the anterior arm to about eight centimeters. I never trim the posterior. And then the apical arm, I put a suture for several reasons. One, to pull it through the peritoneal tunnel on the right pelvic sidewall plane, but also when it's introduced, you instantly know which arm is which. So the apical arm is a stitch, the anterior arm is a little shorter, and then the posterior arm is kind of unmodified. And then, of course, we'll do some fine tuning of the mesh after we have introduced it and fixed it. Excellent, excellent. So in a perfect world, I can see that this cartoon, this would be an ideal placement where the seam of the Y mesh is at the vaginal apex. If a cervix or cuff closure, you know, you kind of don't want the cuff closure touching, so I do like a little bit of a gap between that area so the cuff closure's not touching the mesh there. But that would be ideal. Sometimes the patient may find it difficult, the cervix may be more anterior. So if you're always putting the seam on the cervix and place it more anteriorly and the patient has a large posterior defect, you may, once the mesh is attached to the sacrum and this pulls more parallel, you may have excess to the back. Some people accommodate for this by how they place the mesh. They may be shorten it up or travel further on the skin than they do on the graft to accommodate for that, or sometimes placate the tissue ahead of time. And the same thing can happen on the other side. So if you place the mesh too far posteriorly, once this is suspended, she automatically has a cyst to seal postoperatively. So we're not really doing her a service if we're placing the mesh too far back, unless you accommodate for in some way either shortening up the mesh, gathering the tissue, or just fix your seam of the mesh at the true apex of her now fixed prolapse vagina. So what about suture type? That's kind of a hot topic right now. We've discussed Culligan's data, permanent suture with no mesh exposure at five years. So that's excellent. More and more studies are coming out about delayed absorbable suture. And in this first study here, monofilament delayed absorbable was compared to braided with no mesh exposures with the absorbable suture. And then some more studies are coming out with having a continuous or barbed delayed absorbable suture also showing low mesh exposure rates. No increase in prolapse recurrence, it seems, with the absorbable suture. And it can be even faster. And so thinking about efficiency in the OR and also doing no harm, it doesn't seem to be a bad thing to use a dissolvable stitch. We're not risking the integrity of the repair to do that. So here is kind of the configuration that they described in that last study. But there is a gap here in the middle. And that systocele is her most likely area for things to come back. So when I place my continuous suture here, I'll go first across the top. And then I'll just make a circle like this around to get several fixation points. And here's a video demonstrating. It can be pretty challenging to use a barbed suture. I'll talk about that here in a minute. But again, not placing the seam of the mesh at the cuff, placing it at the new apex that we are going to determine for her by the distension. And this is that larger sizer that we have. Although I think I want to try the Hoyt manipulator after seeing some of that great visualization that Dr. Farnham put up there. But see how we're making the seam going to be a little bit more posteriorly where her true apex is. And then I'm not suturing the mesh to the cuff, nor am I really worried about the mesh going through that cuff closure, just really not seeing that clinically. So I'll place my mesh where I want it. We'll pass in the barbed suture. You have to be careful using this because the barbs can get stuck on the mesh. And then that can cause some interference or fiddling around with things. It's nice to be able to keep the needle in your right hand so you're always ready to go. I don't like to drop it if I don't have to. And I'm not going to pull through here. That wastes time. We're just going to go on and do our next stitch. And every time you're sewing in a straight line, you don't have to pull things through. So I'm going to sew straight across first. Then we're going to pull our suture through. And then we're going to switch directions and go straight down. I think one tendency for all of us as surgeons is to make our sutures tight. We've been taught that. No air knots. They're bad. And so we're going to make our suture tight. But doing that in this situation actually can bunch your mesh. And I don't want a bunched mesh. I think that's going to put her at risk for a mesh erosion to have a more density of a mesh in one particular area. So more often than not, I'll leave loops of barbed suture. Free and open. They're going to dissolve. It doesn't matter. I want my mesh flat. I don't care if the suture's flat. And so I think some of those tips, if you want to think about those, if you decide to practice this technique, this, see that loop right there? It is not flat. There's a little bit of a loop there just so that I don't bunch my mesh. Now, coming across the top there, I'm not going to go in a straight line like I did at the vaginal apex. Just technically, that's challenging. But that just means that I have to go through and pull the mesh every time because it's not in a straight line. So that is just one of the caveats to doing that. So we're going to come around the side. I'm going to come straight back up. As in a straight line, we're going to pull this all the way through and turn back around and come straight back. We're only going to do one needle in for each side. So that's a safety issue as well. Can you see the video? On my end, the video is paused. Okay. All right. Yeah, I'm sorry. My internet dropped out for a second, but it's paused on the center. Okay. Okay. Try again. Hold on now. I still have a frozen screen. Can you guys see the video? Oh, there we go. Okay. Just go. So this is an example of a super cervical hysterectomy with mesh. I don't know if you can hear. I don't know if my audio is coming through here, but this would be a fixation. Okay, this would be a fixation with individual sutures. I like three rows of three. If you're going to do sutures, every suture has to take less than one minute in order to kind of get in under that 15-minute mark for the fixation. And we're usually well under 10 for both anterior and posterior fixation. But we place the anterior mesh, then we flip the apical arm anteriorly to get out of the way, flip to a 30-up camera. Now, you'll also see that for this fixation, I leave the delineator manipulator in. Number one, it saves time because we're not changing manipulators. And number two, it's actually kind of the perfect manipulator for the cervix. It fits exactly around the cervix, and it just delineates that area quite well. But I like about three rows of threes, so nine in the front, nine to 12 in the back, and then three on the sacrum. And that can be done in a way that I feel is very efficient. Once the anterior and posterior arm are fixated and we've trimmed any additional mesh, then we're going to bring the apical arm through the tunnel. Some people tunnel, some people open up the whole way. I kind of do a little hybrid where I leave a small tunnel. And for me, that kind of keeps me honest. It prevents me from over-tensioning the mesh, and that little suture on the top end kind of helps pull it through there. So these are my suture preferences. If I'm going to do a super cervical hysterectomy, I'm just going to use Ethabond for everything, frankly, because it's never going to erode all the way through a cervix. So anterior fixation, posterior fixation, promontory. I use an OCT2 needle, and I have everybody slightly bend them. There is some, like a laparoscopic trocar, a CT2 needle will get caught. A robotic trocar, it will glide down. And an eight-air seal, it will glide down. But we just bend all of them, so there's never an issue. And I'm not talking about scheme and needle, just a slight bend. If I'm going to do a post-hysterectomy sacro, the data is showing that there's really not a difference in erosion rates. I don't think we need permanent sutures. No difference in success rates. So I use like a polyglycolic acid or monocryl or vicryl profile for the fixation of the anterior and posterior. And then if I feel like, for nostalgia, putting a permanent suture, I'll do that in the mid-portion on the front and the back. And then the promontory, of course, use a permanent suture. I do like to use a barbed suture for peritoneal closure. I really think that that speeds things up. And so I like Stratafix just because they're both tapered needles, but it just glides through tissue better, so I like the Stratafix. I'll use a six-inch for the bladder and vaginal re-approximation and a nine-inch for the right pelvic sidewall and sacro-promontory re-approximation. Thank you. Here are my suture preferences with the associated needle types. And with these needles, there's no need to bend them to get them in or out. They'll go through an eight-millimeter robotic port. I will say I don't use a five-assistant port, so I use an eight-millimeter robotic port to assist without a cobalt pexi, and I'll use an air seal port if I'm doing a hysterectomy. So now we'll look at a video of the posterior mesh attachment. So to get this in position, I'll hold the mesh so my assistant can't help but fall in the apex so the seam lines up perfectly, even if it happens to not be at the cuff or not be at the cervix or whatnot. So we've assigned our new apex, and that's a description of that. If I can do the whole case with a zero camera, I will. Obviously changing 30s up and downs is a lot more laborious in my robot situation. So I like to use a zero camera if I can. But if you can't, you can't, and you need to use the instrumentation that's safest for the patient. So while we watch the suturing, the techniques are gonna be similar, straight lines and pull, straight lines and pull. Once I have a straight line across, then I know I have traction and counter traction, and I can trim any excess mesh I may have. I won't trim the tail, or excuse me, I won't trim the suture on the backside at all until I can see what it is in the patient. I did that once and I regretted it. I had all this dissection space and not enough mesh to fill it. So now I'll just always trim once I'm inside there, and I'll just pass that back. But while we just watch the video, we do have a few more questions. So back to your last video of suturing and pulling the tunnel, Dr. Farnham, it says, sorry, the video froze a little. Can you explain the tunnel you made and to pull the wire and the mesh to the sacrum? Yeah, so as I said, there are tunnelers, people that tunnel the entire way from the pronatory, and then there are openers that open the whole way. I kind of do a hybrid. So I open all the way to the insertion of the uterus sacral and the posterior aspect of the vagina, the cervix, and then I leave about a centimeter to two tunnel. And you can certainly just not do that, not leave a tunnel, and then kind of have direct cephalad traction at the time where you're ready to fix the apical arm of the mesh, the anterolongitudinal ligament. But I like to just have that natural suspension along that right pelvic sidewall. And I feel that having that not full length tunnel, but that short little tunnel kind of helps keep it along that trajectory. I've certainly seen cases where, you have to get used to visual haptics. Eventually you get an idea of how much pressure, how much tension results in the suspension that you want. You'll probably have to scrub back in the first 50 times to feel the tension, and sometimes we still do. Eventually you'll kind of get a visual understanding of what the actual haptic situation is with the robotics. But there is a, I feel there can be a tendency to kind of over-tension if you're not forcing yourself, forcing the apical arm to kind of go up along that right pelvic sidewall. That's just the strategy that I've used, and I felt that that's worked well. Okay, for time, I'm just gonna move on to the next video. Erin, there was one other question from Erin Mitzold, I think, if I'm saying that right. Just if you get into that vaginal plane split thickness, do you repair it? It depends on how thick it is. I certainly would not fix a, put a mesh fixation suture in that spot. And if it seems pretty thick, or if I know her vaginal thickness at the start of the case is thin, then yes, I will place a stitch there. I would use a 2-O-Vicryl to close. Otherwise, if it was like in the video I showed, I wouldn't do anything for that particular one. I just would make sure I didn't put any tension on that. I wouldn't put a mesh fixation suture right above that to pull that area even more. I have another question for you, Dr. Farnum. What is your thought on infection rate with ethabond? Yeah, so I'm not aware of literature that has specifically looked at different types of permanent suture and has had a statistically significant difference in risk. I think you just are gonna use the permanent suture that you're comfortable with. You know, Gore-Tex, as we see here, is a great option as well. Some people use Vicryl on the promontory. I'm not bold enough to try that yet, but I, so I feel that you're gonna use a permanent suture. I've not had any, you know, in my 500 sacrocobalt hexes I've done over the last 13 years, I've not had any significant issue with infection. I think we've had one infection, which we'll actually talk about here. And I don't think that was even related to the mesh actually, or to the suture actually. So, you know, we could talk about different types of, the AMET classification of Gore-Tex, you know, and Ethabond, and different types of meshes, but I think you just use a permanent suture. And like I said, I don't know that there's a difference in infection rates. So we're just gonna keep playing these videos in the background, and I love how we have some dialogue and we can just talk for this. For my peritoneal closure, I just wanted to speak before that to tensioning the mesh. What I'll ask my assistant to do is push in all the way, and then she backs up maybe two, three centimeters. Then I hold it still, and I'll go to the perineum and just look and see, does it look too tight? Does it look too loose? And I may make minor adjustments from there until we get it just right. Then with closing the peritoneum, you could see I didn't start all the way at the uterus sacral ligament peritoneum. I started a little bit higher. I think when you start right at the, excuse me, right at the uterus sacral ligament, that can kink the ureter. So to avoid that, I start just a little bit higher, and then this retracts for myself, and I can just follow down this area. Closing this posterior peritoneum is essential as you can easily get an internal hernia if you leave a gap there. So either, some people don't close the peritoneum at all. If you choose to do that, that's one thing, but if you close the peritoneum, you have to close it all the way or else you're opening yourself up for disaster in that. Many people do practice and not close the peritoneum. So I think like some of the other factors we've talked about, you have to feel comfortable with your risk profile, the risk benefit of each step that you do. That was perfect timing. So we, yeah, that was perfect timing. We have a chat question from Samantha Margulis regarding what are your thoughts about not just not closing the peritoneum? So, I mean, I feel that, certainly you've got this foreign body, clearly small bowel obstruction is a risk of sacrocoballifoxy. Anything we can do to reduce that risk, I think we ought to do. Time-consuming step. There are probably ways to save time other than not closing the peritoneum. I would agree with you. Being inefficient in other ways is how I choose to save time. But again, your own risk profile that you're comfortable with or not. Another question from the chat, Dr. Myers, when you place your sacral sutures, this is from Dr. Eskew, how do you manage the sutures until you're ready to place them through the mesh and secure them? I just toss them over to the side. They do stay out of the way of the repair. I think coloring them has really been helpful to me to make sure that I'm not tying one stitch to the other. I'm tying both ends of the proper stitch. Erin, I think we're in a transition. Yeah, I'm gonna stop sharing so that you can pull up your deck. Perfect. And you'll just have to let me know if this is skipping or if we need to repeat any of these videos. I'm gonna show a slightly different technique on peritoneal closure. And I'm gonna highlight a couple things, the simplest of which is just that fourth arm integration. So you can see that I have my suture cut on my three arm and the progress on the forearm. And as Erin was mentioning earlier, I never dropped my needle because once you drop the needle, you have seven additional steps to regain control of your needle for the next throw. And that is just poor economy of motion. So we have the fourth arm, we can utilize it to kind of help ourselves do that hand over hand pull through of the suture. This is a six inch stratific. So that's more of a luxury at this point. Nine inch, you're gonna have a little bit more of a tail that you need to pull through. So I'm gonna re-approximate the bladder and that rectal peritoneum kind of in a horizontal closure. And then separately, I'm gonna bring in a second suture and I'm gonna run that up the side. You can see there's that tiny little tunnel that I created to bring the apical arm of the mesh through onto the right pelvic sidewall. Now here with a nine inch, you can definitely see how that fourth arm is holding that tension. So it's tenting up the peritoneum. I think it's critical to just get the very edge of the peritoneum here. You can be 90% of the way done with the procedure and then kind of get a little sloppy. You can actually accidentally catch a ureter or kink a ureter if you're not careful. And so there are plenty of things that we actually need to worry about during a sacrocopal plexus. We certainly don't wanna manufacture reasons to have challenges. So I'm gonna only run this about halfway up and then I'm gonna park this on the anterior abdominal wall usually in the medial umbilical ligament and just hold that there to get it out of the way. Otherwise it can kind of dangle in my way as I'm doing the fixation, which I won't show here because Erin has many beautiful videos demonstrating all of that that we've covered. But once I have achieved an appropriate level of suspension and tension, then we're gonna go ahead and use the same suture to close the promontory. Sometimes if you have a little oozing, you can use this little hemostatic material called snow that is great to, you put that on an oozing, not an arterial bleed, but an ooze. You come back five minutes later, it's bone dry. So that is a very handy thing to have around in your OR. Now, when people come for case observations, they wanna learn strategies to be efficient. Sometimes the most challenging cases that we have, that's where we learn the most. It was about three months ago, I had a individual come from Melbourne to do a case observation. And in that particular case, we had a thousand gram uterus, we had to ligate the uterine to the hypogastric. They clipped it aggressively and ligated the uterine that started bleeding. They brought my scissors back in, they stabbed the inferior epigastric that started bleeding. And it's the challenges that arise that I think we learn the most from. And at the end of the case, my scrub tech who stabbed the inferior epigastric was like, well, he came all the way from Australia, didn't you wanna show him some good cases and challenges? So, but I think that is another point that we don't shy from challenges. We, our patients are our best teachers and we learn from them. And sometimes it's just the words, the language we assign. That was a terrible, horrible, horrible, hard case or what a glorious challenge. Think how much better of a surgeon I am for having gone through that challenge. So, complications. I have had the privilege of lecture with Dr. Mario Leteo, he's an oncologist at Sloan Kettering. He's a big guy, he's from Brooklyn. He's like, there's only two types of surgeons ain't got complications. There's people who don't operate and there's liars. So, you do enough surgery, eventually you're gonna get a complication. In a systematic review of robotic sacrocolopexy, that rate was actually 19%. When we take out erosions, we take out fever and UTIs, it was still about 11%. So, these things happen. We have to prepare for them. The complication avoidance is always the best strategy, but we do have to have a plan to manage and deal with these things. So, cystotomy is gonna be the next most common after erosion but we can see that whole list. A lot of stuff is in play here. Small bowel obstruction, ureter injuries, and a whole host of other medical complications, MIs, VTEs that can happen during this procedure. So, if we look at some of the more grave things that can happen, we break it down by region. On the promontory, we talked about the left common iliac vein. The disc space, we'll talk about that. On the right pelvic sidewalls, we're doing a right pelvic dissection. Again, Erin had a beautiful video of the dissections that she did. One of the things that we need to mention is that we stay right on that uterocyclic ligament and that will keep you about three centimeters mutal from the ureter and it'll keep you about two centimeters to five centimeters, depending on the anatomy, away from the sigmoid. We need to tent the peritoneum, get traction, counter traction, till one cell layer at a time and we can usually avoid, well, I would say we will universally avoid complication to those organs on the right pelvic sidewall. In the vascovaginal plane, obviously, the most common complication we're gonna run into, aside from escherosis, is gonna be cystitis, we have to be aware of that. And again, the vagina's in play as well. Now, this is the presacral anatomy. Why is it the left common iliac vein? We spend a lot of time talking about the aorta when we talk about great vessel injury. I mean, if you are anywhere near the aorta, which bifurcates at L4, you know, you're kind of off the mark. So the great vessel that's in play here is the left common iliac vein because it empties into the IVC, which is on the right side of the aorta. So it has to drag across L5 to empty and there can be anatomic variation. So we're used to looking at it like this. And we had several of Erin's videos where we looked at different anatomic variation. In this particular case, we have another challenging, you know, about a three centimeter of presacral fat that we have to negotiate to get down to this point. You know, I just usually will follow my anatomic landmark, go from the bifurcation of common iliac, about three centimeters medial, where I'll typically find the lower edge of L5. And this is what I find instead. So that's pretty massive. It's fairly intimidating. And if, you know, we can have a rapid fire chat response, we can ask the audience, what do you do here? So, I mean, you know, clearly you look around, going any further cephalide is not gonna help me in this case, but I'm just kind of looking around to make sure that anatomically what I'm doing is making sense, clearing up some space. And we'll talk a little bit about exposure because of course that's critical a few videos down. But what would we do here? So in this case, I just did a uteroscleral suspension, a high uteroscleral vault suspension. If I had this case to do now, I think I probably would have gone ahead and fixed the apical arm of the mesh to S2. But going back to one of the points that we're making earlier, this is something that I wanna know now at the beginning of the case, so I can decide, I don't wanna attach my mesh and then come back and find out, oops, I've got nowhere to put this. So what would happen? This is an old internet video, but this is actually a pre-sacral anorectomy. The surgeon believes they have this pure hypogastric plexus, but it is actually the left common iliac vein. So complications happen, as we discussed, it's not necessarily seen to have a complication, but having a strategy and recognizing there's a whole other issue. If you get a complication, don't put your suction irrigator and make a small defect into a large defect and definitely don't bipolar the left common iliac vein. All right, so every great talk needs some humor, some hubris and some humility. So I think we've done the first two. So here is an example of some of the things that challenges can arise. You can get a little peek of the left common iliac vein over on the left side there. I'm gonna advance the video a little bit. I've done three sutures already, which by any imagination is plenty of fixation, but for some reason I decided to go for four. Keep in mind, you can always control the entry point better than the exit point on your needle. I've already desiccated the middle sacrals. That is in fact the left common iliac vein, the lower margin. I just nicked it, but that's bad, right? So what do we do? You have a strategy. So massive transfusion protocol, bust out the 5-0 proline, get the abdominal hysterectomy tray in case you have to open, call the vascular surgeon. But I think this is an example of the many examples where robotics is particularly helpful. How does all bleeding stop? Same way diamonds are made, pressure and time. The great thing here is I can hold pressure with my third arm and I can go about coming up with a strategy for how I'm going to manage the issue. Is it done bleeding? Nope, that didn't do it. Okay, what next? We had the privilege of having Dr. Javier Magrina is a world renowned oncologist from Mayo come to lecture at Texas Tech. And I'll do my best Magrina. He's like, Rick, the great thing about the robot, you are operating, you get into a great vessel, you take your robot arm, you hold pressure, you take your head out of the console and you go change your underwear. Then you come back and you deal with the bleeding. So sage advice. And again, highlighting one of the great benefits of the robot. So I can hold pressure and then go do something else. Now at the time I wasn't doing the close as you go technique but in this particular case, I had something else to do while we're holding pressure, while we're getting all of the other elements of our strategy in place to deal with and manage this. Now I happened to have seen an AGL video the year before where an oncologist put a hole in the IVC and he took some flowable thrombin and he put that on the defects and then came back 10 minutes later and it was bone dry. He suctioned it out and it was completely dry. So we're holding pressure, we're getting everything else ready anyway. So we may as well use that strategy. Another thing I'll say about the robot in the event that you had to do a laparotomy, it's not like you undock the robot and then the patient's just bleeding from that vessel the whole time until you can open the abdominal wall down to the peritoneum and access that site. You can actually undock everything except the arm that's actually holding pressure, get in and then mechanically release that arm such that you're having no additional bleeding. And we're gonna, rest assured, we're gonna talk about all the possible visceral injuries that can happen with sacral colpexy. But there's usually not a clock on those. There's a sinking feeling, but the most sphincter tonic time that you're going to have during a sacral colpexy is dissecting around the left common iliac vein and in a case like this, actually getting into it and then having to deal with that. But one of the things that actually helps you negotiate that and mitigate some of that is to have the ability to hold pressure and clamp the tissue that's bleeding. Now, in this case, we've done basically everything. We threw some snow, we did some flowable thrombin. Now we're doing a thrombin fibrinogen product. I think the kitchen sink is next. We would normally send this patient home four hours post-op. Clearly, we kept this patient and did two five-minute crits for six days. I'm kidding. But her post-op crit was actually better than her pre-op crit, and then it was stable on day one. And she did fine. But we had a strategy in case that didn't work, in case we had to use the 5-0 proline to close the defect, but this worked in this case. Okay, now on this one, again, we would ask for some audience participation. I have had one enterotomy in the last 15 years on sacrocolopexy. It was actually in the vesicle-vaginal dissection for a patient who had had prior colon surgery. This is a video that I got from a colleague of mine during his learning curve, and he was gracious enough to share it. But I think it's very critical to take from this and extract the learning points. So if anybody would have any comments on, there's at least four issues with this particular video. So just to, can I just orient? So they're doing the sacral dissection and that right-sided tunnel, right? That's the dissection where we are here, right? To set the table, exactly. So that's where we are. They're doing the right pelvic side wall. Now, I don't know if anything's popping up in the chat, but essentially the technique is off. What we've talked about for the last hour and a half is traction, counter traction. Don't cut through unless you can see through, and basically just paint brush with the scissors, take one cell layer down at a time. We'd also point out that, you know, you wouldn't want to have done the entire attachment of the mesh prior to doing the promontory and right pelvic side wall dissection. You would have already wanted to do that. One of the other things that is a particular challenge here is once you get an aneurotomy, you know, you've contaminated the sterile field. And for my money, I don't believe you can then do a mesh foreign body. I think you have to have an alternative strategy. Now, perforation of other hollow viscera we'll talk about as far as, you know, whether you can or can't proceed with the intended form of the mesh. And I think Aaron would agree if you have an aneurotomy game over, you know, exercise plan B. For sure. Okay. I would say that we spend an inordinate amount of time in training kind of warning people of the challenges or the pitfalls of the dissection of the presacral space. And I'm not saying that's without, you know, purpose or without warning, but people I think have an inappropriate fear of the middle sacral vessels. And for the reasons we mentioned, they're kind of a non-issue. As long as you're dissecting down one cell layer at a time, you will always identify them. On the promontory, when you're pulling up and tenting up the peritoneum, there's no amount of tension that's going to pull the middle sacral vessels off of the anterior longitudinal ligament. So you will always dissect down to them once you identify them. If they're in your way, you can desiccate them and then move on. Or keep them out of your way and put your sutures in a place that don't involve the middle sacrals. What we probably don't spend enough time on is talking about the vascular vaginal dissection. And again, you know, I have some video envy. You know, I may have all the fourth generation technology, but man, Aaron's got some good videos. So for this video, we're getting into the veins. And, you know, I feel like this is a very good dissection. I think that one of the things we have to be aware of is that the lateral margins of your dissection, that is where the tissue bunches up. And that is where a vulnerability lies where you may end up not being able to go one cell layer at a time and dissect as precisely as you would otherwise want to dissect, or at least just exercise more precaution as you're doing this dissection. This also, we mentioned retrofilth earlier. I think it's important to have that ability. At any point during your case, and in this case, as we're doing the dissection, we did have the bladder retrofilth. So if there is an injury, you immediately recognize that injury. So you don't turn a one centimeter defect into a five centimeter defect. It's important to tag the defect. Now, it is unlikely that you lose track of this particular, you know, cystotomy in this area. I think it's more important for maybe, you know, cirrhosal bowel injuries, when you're doing an enterolysis for adhesions at the beginning of your case, to tag that if you ever wanna come back and fix that with, you know, 3-OSH-micro. The other thing that you wanna do immediately, you know, if you already get a cystotomy, is to do a cystoscopy. It's critical to identify, because you can't always tell the proximity. You can't determine the proximity of this injury to the ureteral ostea from above. So we wanna do an early cystoscopy and identify the potential need to stent and to be able to identify the course of the ureter. So as, you know, we don't wanna take a, so we say, an inconvenience and turn it into a catastrophe, right? You don't want to take a cystotomy closure repair, not know where your ureters are, and then in doing that closure, kink one of the ureters and then have to go back and take down your sutures or, you know, re-implant or turn it into a bigger problem that then you necessarily need to have. So I think that you would always like, so the standard would be a bicoral running two to three-layer closure. You have to re-approximate on your first layer, the mucosal edges. In this case, it was just easier for me to do interrupted, so that's what I did. I mean, at the end of the day though, you need to have a watertight closure that needs to be tested. And then of course, you're going to leave in a Foley catheter. You know, my strategy is to leave it in for a week. I will then actually get a confirmatory moiety cyst urethra gram and do a cystoscopy. And if it meets a closure by all three of those measures, then, you know, we'll leave the catheter out and that's the end of it, if I'm suspicious at that point. And of course, a thermal injury is a very, very different animal than a sharp cutting injury. You know, Aaron did mention several times that we are mainly doing cutting sharp with the scissors. If we're going to use energy, it's going to be the yellow pedal on what's called auto cut, not dry cut. And that essentially is an electronic scalpel. So there's virtually no thermal spread. If you do get a thermal injury, then you're going to have to talk about excising, you know, half centimeter around that. So you don't have a breakdown of that tissue later on. And I might just fast forward a little bit in the video, unless we have other questions or comments. Dr. Farnham, I was just thinking in the case of time, it looks like we have about nine minutes left. And just wondering if you wanted to go to your birch video to squeeze that in before we finish, or if you wanted to share other things before that as well. All right, well, thanks. It's good to have the clock. I'm going to basically expedite all of the other videos, only show the main points. I only include this video to show, you know, how we would, as we normally do during a sacroculture, actually how we transect the ureter and reanastomose it. Now, this is actually a porcine lab that we had done for an energy demonstration. So we took advantage to go ahead and practice reanastomosis. But you would do that reanastomosis over a stent. And I think for the purposes of time, we'll skip the rest of this video. I will also kind of advance through the majority of this video, just to kind of show the main purpose here. Take one back here. We're going to advance this. And this is just to show, sometimes with atrophic tissue, you have to be careful with how delicate the tissue is. You know, for those of us that have done enough surgery, we've all been there where they're pushing too much and they can actually perforate. I wanted to show you an up close view of the hoit. That's not how I wanted to show it to you, but we just have to be aware that that can happen. And, you know, to practice, I think at this point, mindfulness and forgiveness and teach this as a learning point. And, you know, hopefully that doesn't happen again. This video, again, I'm just going to show very briefly. We talked about protecting the ureter. What if we could actually, you know, see the ureter? Currently, what we'd have to do is place a stent, a lighted stent, or place ICG through a stent up the ureter. And you can kind of see the course of the ureter over here. On the other side, this is actually, I'm the principal investigator on a phase two study trial right now for a new dye that is actually IV administered, renally metabolized ureteral fluorescent dye. So it's an analog of ICG, but it actually gets renally metabolized and highlights the ureter. Again, currently, this is our publication on our phase one preclinical trial, but we're in phase two, hoping to complete by the end of the year. And then by the end of next year, phase three, so that at any time during a case, you could just IV administer, flip over to Firefly and see the ureter. For the sake of time, again, briefly mentioned L5. You can see how this looks. You can see on an MRI study, the disc and how that is a drop-off right on the promontory and where S1 picks up. And you can see here, example of a discitis, that complex material there on the edge of the disc is an unfortunate complication of putting a suture through the disc, which virtually, even if you do that routinely, you'll probably never have a problem, but one out of 50, one out of 100, that's gonna turn into a pretty debilitating complication. And so to the extent that we can avoid that, we wanna avoid that. I'm gonna skip this. I'll probably just talk through it, but basically you can suture the epiploica to the left pelvic sidewall to give yourself exposure of the promontory. If your problem is with the small bowel, you can introduce a Ray-Tech and basically wrap the small bowel. And kind of move the entire small bowel and mass. So those are two little strategies used for that. We're gonna go right into the BIRCWH video and probably won't show, again, the whole video for the sake of time. But my feeling about the BIRCWH is that this is an important procedure to kind of have in your back pocket. As we talked about at the very beginning, the nation of mesh phobia is beginning to resolve. The conversations are getting shorter around utilization of mesh or non-existent. But there are patients that have real or imagined reasons to not want mesh people, patients that have had a personal complication with mesh or have known somebody who've had a complication. And so certainly this is something, this is not my go-to. My ratio of retropubic sling to BIRCWH is probably 10 to one. But I think it's important to have. And I think it's important to do it often enough that we can knock this out in 20 to 30 minutes to compliment sacrocolpexy or uteroscleral vaginal waltz suspension. The time that it becomes a bit of a challenge is if it's just only an end-to-end continence surgery and you're comparing a 15-minute retropubic with a 45-minute to 60-minute BIRCWH when you include the time for docking and everything else. But this is a nice little add-on if you're already robotically docked for a uteroscleral vault or a sacrocolopexy. And as we can see here, distending the bladder is important. We stay between all umbilical ligaments. As long as we're between that, we're gonna stay out of the obturator canal. The uracus, usually we wanna take that down in the midline to fully expose, although you could leave that intact and you can just kind of dissect on either side. I mean, certainly there's a lot of, the plexus of Santorini provides for a lot of negotiation around vessels. If they can be left intact, we'll leave them intact. But this anastomosis of the superior and inferior vesicle arteries can be impressive. Although, rarely is that an issue as long as, again, we take one cell layer down at a time, traction, counter traction, judicious use of monopolar coagulation for vascular connective tissue. And as long as we're adhering to the strategies, this is rarely ever a surgery where there's any significant amount of bleeding. You know, I know you do this in your practice. Erin, what's your strategy for doing the birch? I think for me, I'll just insufflate using the air for the pneumoperitoneum using that port. And so I'll take that from my assistant port and hook that up to the Foley catheter balloon, allows for rapid insufflation. And then pretty soon after I make my initial incision into the peritoneum, I'll go ahead and let that empty so that the bladder, you know, just kind of isn't in my way. So I think those are the main things, but I mean, the dissection and procedure is very similar. I think you're doing a nice job of displaying that here. One of the questions from the chat is, do you place mesh, either sling or copalpexy in chronic smokers? So the only, you know, when I've had an erosion, it's almost always when there's a risk factor and they're a smoker, or they have some autoimmune disease or something. So I've kind of changed my technique over time. It's not for me personally, an absolute contraindication if I feel that that's the most appropriate surgery for that patient, but relatively, I'll try to avoid that. It certainly wouldn't be my primary repair if I thought that either a sacrosplenous or a cobalt cladius or a uterus sacral would adequately also, you know, address that patient's individual level of defects. What we saw there was as we're getting to the point where we've reached the posterior aspect of the symphysis pubis, and we're starting to get Cooper's ligament to come into vision here, the staff will go ahead and drain the bladder. Because at this point, you know, we want to reach the endopelvic fascia or the, you know, that's this periurethral vaginal fascia. And it's usually pretty clear, right? I mean, bladder is this, you know, pink color. The fascia is a glistening white. It is, you know, possible to inadvertently put your stitches into the bladder. So, but, you know, the patient will tell you, the patient will tell you where to, you know, place your sutures if you will perform this dissection one layer at a time. I will say, I use a 30 degree scope for every single surgery. This is the one surgery I like to use a zero degree scope because the angulation is just a tiny bit too steep on the 30 degree. And you have to continuously kind of flip it back and forth as we're doing here. But I do like the zero for this one. You can see kind of that spongy Cooper's ligament on that superior margin, the posterior aspect of the symphysis pubis there. You know, word of caution, there can be an aberrant branch of the obturator artery that creeps medial right about where you would put your sutures. We've all seen that with retropubic slings, where, you know, we have our exit sites exactly where they need to be for our trocars. And we just get a hemorrhage coming down that we have to deal with. If you're in the right place, you know, you're not in the obturator canal, you're not getting some other vessel. That's almost always just this aberrant vessel. Now with robotics, with the birch, you get the benefit of being able to kind of visualize and identify and as needed desiccate if there does happen to be a vessel there. And at this point in the dissection, you know, we're kind of employing all those same strategies that, you know, traction, counter traction. In a moment, we're gonna see, as we've done on the other side, your assistant kind of elevate. Now, you know, this is kind of like the trust fall. You have to have a relationship with your assistant because you're about to put a suture, you know, right on top of their palpating finger. And people have talked about using sizers or briskeys to do this. I just don't think there's a good substitute for the human finger to be able to, you know, do that. Now, if we're doing it laparoscopically, we would simply use our own finger. I suppose you'd go to Home Depot and get a thimble and sterilize that. But, you know, we prefer just to have a nice trusting relationship. We're gonna glide through the tissue and get an adequate suspension. One of the other things I'm highlighting here, all future developments, including that ureteral visualization dye that we mentioned, are coming out on the fourth generation XI platform. So this is what's called Endoscope Plus. You know, in my mind, this is basically 4K vision for your robot. We see that on the left with the XI, and then we see on the SI, we see, you know, the normal vision, which we thought was great until you get the Endoscope Plus and then you never wanna have, you know, the regular Endoscope again. So I think that we all have kind of our secret sauce as far as what's the appropriate amount of tension to accomplish, you know, an adequate suspension without placing the patient retention. I can say, you know, knock on wood, I have not had to go back and take down sutures. This is the one time in gynecology where we want a true suture bridge, a space between the two things we're suturing, the endopelvic fascia and this Cooper's ligament. And of course, two is better than one, the literature shows, so we do two on both sides. And we had a question about ethanol earlier. You know, that's just my go-to permanent suture of choice. You know, other people feel comfortable with Gore-Tex, but I think that's dealer's choice. So I'm gonna go ahead and end this video for the sake of time as well. So we have a minute to talk about transition into practice. A couple of highlights, you know, for many of you, this is extremely relevant. You have to, hard decision to make, you know, do you go for the big bucks of private practice? Do you do the workman mentality in a group practice or all the glory of the academics or some hybrid of those options? I think if we had some parting words of wisdom, I think case selection and currency are gonna be two things that I would advise you to go home with. You need to make sure you're doing enough cases that your team has a comfort level with you that it's not just about you getting your skillset, it's about your team getting the reputation so that all of the compliment around you can produce a consistently efficient result. There are currency recommendations, but personally, I would say 30 to 50 cases. What do you think, Erin? Yeah, I agree with that. I mean, I think we can reiterate some of the advice we kind of gave all along, but one of the things that I really did kind of without meaning to when I first started out was I would look at the OR board to see who else was operating that day. So I would know how risky can I be on this case? Are there zero general surgeons next door, zero vascular surgeons around me? Everyone's orthopedic? Or is my favorite general surgeon down the hall or I didn't have a colorectal surgeon right next door? So it's nice to know what your surroundings are before you take on maybe a big case and it gives you guidance for how quickly you may convert to maybe a uterus sacral or use your plan B, or if you have the guts to go for it that day. Yeah, and I think you need to figure out who you are. Some people want to go straight in academics and start teaching, but it's a different ball game when the attending's not on the other side of the table. So number one, always patient safety, but take those challenging cases as you develop your skillset. Now, as you're first starting, I would say don't do patients with a lot of prior surgeries, maybe stick to sacrohists because those patients haven't had that surgery in the vascular vaginal plane, at least some of them, and kind of get your routine down on those easier cases before doing some of the more challenging ones. And I know we were supposed to leave time and I apologize unreservedly to Matt for not leaving enough time, but I did briefly want to mention the intuitive ecosystem. This is a longitudinal relationship. We have resources like the one today with partnering with societies. There's a training algorithm and a pathway, but you're not done there. So there are case observation opportunities. There are master program opportunities available. Beyond that, you will have the ability if you collect your own data to submit that and intuitive will take that and they will research that, compare that to benchmarks and give you a report card. How are you doing compared to published benchmarks? That's useful for us as presenting, but also I think that's very useful information for you to have in your own practice as well. Completely agree. Unfortunately, we don't have a lot of time for questions. As far as contact, if you wanted to take out your phone and take a picture of our contact information, I actually put a QR scan, so that'll pop up. If you tap on that, that'll take you straight to my YouTube channel, which has a lot of patient and physician resources, but certainly we're available. And I, again, can't thank Erin enough. This has been a great collaboration. I don't think I wanna co-host with anybody else ever again. It's been such a great experience, but, and again, thanks for intuitive, Augs, and all of you. We don't get to do what we do without you guys. And I really appreciate, learned a lot from your questions today. Yes, thank you for the opportunity. We appreciate intuitive and Augs for the opportunity. Rick, thank you for your patience over the last couple of weeks. And we've been sharing videos and practicing and just setting up for this. I've learned a lot. Matt, I'd just like to call you onto the line and see if, is there anything else you'd like to add? Yeah, no, well, first of all, thank you, Dr. Farnham and Dr. Myers for me personally witnessing the weekends and evenings you both sacrificed with your families to put content together. I wanna really thank you guys so much for what you've done here. I think this has been very valuable content. Thank you, participants and fellows for the engagement with the question and answers. I think that was also fantastic. And as this is recorded, if you don't mind, Dr. Farnham and Dr. Myers, I do have Aaron Thomas from Academic Marketing on the line and we will make this better. I wanted to provide direct specifics as far as support goes to these fellows as you guide, as you transition towards graduation, as you get a education, what can Intuitive offer you as far as support goes moving into your practice? So I know we're kind of wrapping up, but since it's recorded, if you don't mind, we'll just take another five to 10 minutes for those of you who can stay. I'll hand it over to Aaron to go over those and conclude right at the end of that. Thank you. Thank you, Matt. Thank you, Dr. Myers and Farnham. And for those of you who need to drop off, feel free. We can follow up with an email afterwards as well with a link to some of these resources and next steps to help you with. I'll be doing an abridged version. So this will just take about three to four minutes here just to go over some quick resources here. Usually my presentations is a little bit more lengthy, but we'll kind of compress it just for sake of time and respect today on a Friday. So let me just share my screen real quick here and we'll kind of just dive in. I'm just gonna really ladder on to after what Dr. Farnham and Myers were talking about as far as intuitive resources goes. Let me just share my screen. Skip some of my colorful slides here and kind of dive right in, but kind of building off of back at the ecosystem that Intuitive has, of course, we have a whole host of learning and training and technological resources. But beyond that, we have some programs that will help you on your transition from training into practice as well. We have a program that we call Surge On and each one of these buckets kind of represents some of those stages that you'll be experiencing while you're going through your interview support, graduation, earning training certificates, learning continuums and advanced trainings. And at the bottom right of this little snapshot here, there's a couple of key links. So if you have questions for academics, if we can help put you in contact with your clinical sales representative or custom pathways, feel free to reach out to us. We're happy to help make those connections. There's also an opportunity because we have so much to offer for everyone to opt in to gain support. And what we'll do after this course here is send an email with an opt-in survey link to this Surge On additional pathway of career development support. And if you take the time to fill out the survey, it ensures that we can provide you with the right resources at the right time that are of interest to you. It helps us learn a little bit more about who you are so we can personalize and customize that experience beyond just the technical training and the clinical areas, but into this pathway of additional support through training and your transition that bridging into practice here. So what that means is that you'll all receive an email after the course with a chance to review these services. You can select the elements that you're most interested in that are relevant to you. And then based off of that information, we'll follow up with those personalized programs we've identified that are available and valued to you as well. And so just to kind of compress here, we have a whole host of information. There's really three takeaways. I'm gonna skip past these slides here and kind of just get to three proven methods that we've seen our trainees and fellows and folks transitioning to practice. You can take away some key actions with you today after this course. So the first thing that we would recommend is to connect with your clinical sales representative. We call them a CSR sometimes at your institution. So as you may know that we have a team of intuitive reps assigned to every hospital throughout the country and their focus is to provide you with the technical training, the practice support and guidance and offering the right resources at the right time. So if you've not done that already, I really encourage you to establish communication with that CSR. If you don't know who that is, I'm happy to put you into contact. Matt and I are happy to be in contact with who those folks are. So please feel free to reach out to us. We're here to help. They can sit down with you. They can walk you through our technology training pathway. You can share where you are with respect to your training, your case experience and they can assist you if you have any practice related questions that you may have as well. So the second piece that we would say that's a proven method and a call to action is register and explore intuitive learning. So we have a da Vinci surgery community, a host of resources to get up with peers, to expand your skill sets and intuitive learning is constantly growing. So this is where technology training plans are, self-led curriculums, training videos, clinical videos with narration and procedure steps as demonstration and simulation exercises as well where you're working on skill development and proficiencies. And the third is to opt into that Surgeon program. It's specifically designed for senior residents and fellows and junior faculty in the first three years of practice there. So if you opt into that Surgeon, it takes respectfully seven to nine minutes for the survey, but we can really custom tailor some of those key touch points while you're transitioning to practice and through your training through fellowship today. So thank you so much. And this is just my snapshot as well. My name is Aaron Thomas. If you want to just take a screen cap, you can text me, reach me my personal work email address there, or of course through our academics programs it counts as well. So we'll follow up with an email with our contact information and a little snapshot of those resources for you as well. But to save a little bit of time, I'll just do that a bridge summary, but Dr. Farna Myers, Matt, Nicole, thank you guys so much for having us today. We're really proud to support this course and support you the next generation of surgeons. Thanks everyone. So Nicole, we'll pass it over to you if you have anything else or Matt, do you want to close us out? Thank you all again. You know, that will conclude today's session. This will be recorded. Look out for any communication both from, for the off and from ops for any access to this recording afterwards. So thank you all. Nicole, we can go ahead and conclude the session. So thank you. Thank you. To me, I've stepped out. Thank you. To me, I've stepped out. So yeah. So Dr. Farna, I'll leave as and attendees, please go ahead and exit the call. I'll go ahead and leave right now. Enjoy your days and enjoy your weekends. Thank you for having us. Thank you so much. It was such a pleasure. Thank you. Nobody wants to leave. We're just going to talk for another two hours. It's Friday. We'll get back on. Thanks guys. Bye bye.

sacrocolpopexy

patient selection

surgical techniques

hysterectomy

surgical team

simulation models

detailed surgical plan

sacral dissection

traction

counter-traction

robotic-assisted surgery

complications

Surgeon Program

support

resources