Welcome to the Oggs Urogynecology Webinar Series. I'm Dr. Katherine Husk, member of the Oggs Education Committee and the moderator for today's webinar. Today's webinar is titled, Incorporating Vaginal Hysterectomy into the Armamentarium of the Minimally Invasive GYN Surgeon. Our speaker today is Dr. Roseanne Ko. Dr. Roseanne Ko serves as the chair of the Department of Obstetrics and Gynecology at the University of Arizona College of Medicine, Phoenix. Prior to 2023, she was head of the section of medical gynecology and minimally invasive gynecologic surgery at the Cleveland Clinic in Ohio. She is the immediate past president of the Society of Gynecologic Surgeons. She is board certified in obstetrics and gynecology and subspecialty board certified in female pelvic medicine and reconstructive surgery. Dr. Ko focused her clinical and academic career in the field of pelvic surgery. She was involved in the early use of robotics in gynecology and has published on the techniques and appropriate application of this technology. She writes and teaches extensively on the adoption of surgical innovation and techniques to facilitate the performance and teaching of vaginal hysterectomy. In 2015, she founded the FMIGS subsection of the Fellows Pelvic Research Network, a fellows forum with senior mentorship for the conduct of multicenter trials to elevate the quality of fellows research work in MIGS. She served as the president of the AAGL Society of Reproductive Surgeons Fellowship Board in MIGS. While in this role, she worked to revamp program site requirements, learning objectives, and core curricula for the fellowship and work towards ABOG recognition of MIGS as a focused field in OBGYN. She served for 10 years as one of the four senior editors for the Journal of MIGS, and she has over 90 publications in peer-reviewed journals and book chapters and serves as a research mentor for the residents and fellows. A few reminders, the presentation will run around 45 minutes. The last 15 minutes of the webinar will be dedicated to Q&A. Before we begin, I'd like to review some housekeeping items. AUGS designates this live activity for a maximum of one AMA PRA Category 1 credits. To claim your CME credit, you must log into the AUGS e-learning portal and complete the evaluation following the completion of the webinar. This webinar is being recorded and live streamed. A recording of the webinar will be made available in the AUGS e-learning portal. Please use the Q&A feature of the Zoom webinar to ask the speaker questions. We will answer them at the end of the presentation. Please use the chat feature if you have any technical issues. AUGS staff will be monitoring the chat and can assist. Dr. Koh, you may begin. Sorry about that. Thank you so much, Dr. Huss, for having me and the program committee for inviting me to speak on the topic that I'm extremely passionate about. This is my disclosure. For the next few minutes, what I would like to do, being a urogynecologist and background in training, I'd like to talk about why vaginal and what are the indications that would make our patients more eligible for the vaginal approach and focus primarily on the eligible non-prolapse indications. Let's talk about, as well, redefining the patient selection criteria for the selection of patients for the vaginal approach, how it is that, as a urogynecologist now focusing my practice in NAICS for the last 10 years, how we have incorporated innovations and brought in techniques that I've learned from my background in urogynecology and also available techniques that are present in order to be able to provide the benefits of the vaginal approach to our patients who do not have prolapse. I will focus a few more minutes to demonstrate the critical steps to the vaginal hysterectomy, that of the difficult anterior entry, particularly in patients who have had multiple C-sections, morcellation of the large uterus, and then how do we tackle the adnexa when they need to come out. We all know about this well-cited literature from ACOG that the vaginal approach is still associated with the best outcomes and fewest complications, least amount of complications compared to the laparoscopic or abdominal hysterectomy. Because of this, it is still the preferred route of hysterectomy for benign cases. We have seen from literature, so this is a slide that I give credit to Dr. Dan Morgan from the University of Michigan, that the vaginal approach is $3,000 less per case compared to a laparoscopic procedure and about $5,000 less per case compared to a robotic procedure. At a single institution at the Mayo Clinic, they showed the significant savings if a deviation from the vaginal hysterectomy were to be done in a period of five years. Unfortunately, the national trends in the United States would show that vaginal hysterectomy numbers are reducing significantly from 1998 of 25% down to 16.7% in 2010. And then since then, it's come down even lower, down to 13%. Another study here from NSWIP showing that it's down to 11.3%. What have we learned from these hysterectomy trends followed over time? We see that current surgeons, whether in academic institutions or out in the community, they're steering farther and farther away from the vaginal hysterectomy and more towards laparoscopic hysterectomy and robotic hysterectomy. It's good that the abdominal numbers are coming down, but we need to also bring up the vaginal hysterectomy numbers. The perception is that vaginal hysterectomy is much more challenging to perform, more cumbersome, likely because of the lack of adequate training, and that the overall volume for hysterectomy is declining. This is despite evidence, good evidence, that shows that vaginal hysterectomy should not be considered a contraindication when patients are obese, when they've had prior cesarean sections, or that if they're nulliparous, if the need to remove the adnexa is present, and also when there is a large uterus. We actually presented the findings from our study. This was done as the SAVI trial presented recently at SGS to show that most surgeons, and there were over 500, both from the MIGS Society and from the Uruguayan Society, who both stated and agreed that vaginal hysterectomy is important to women's health, that as gynecologic surgeons, we should all be able to perform vaginal hysterectomy. Also, the majority agreed that residents should be required to achieve the competency for vag hyst prior to graduation, and they disagreed that we should eliminate residency graduation requirements for vag hyst numbers altogether. As all of the, as the subspecialties, right, and the different subspecialties, including Gen Ong, REI, Uruguayan, complex family planning, and now complex benign gynecology or MIGS are moving towards subspecialization, it's important that we keep the patient at the center of our care, that as we become more subspecialized, that we stay away from being, closing in on silos and becoming much more narrow in our perspectives. I have, as I mentioned, focused my practice in MIGS with fibroids and endometriosis and pelvic pain in the last 10 years. Nothing is more painful for me as being part of a MIGS division when a 10-week size or a 12-week size uterus with adenomyosis in a patient presenting with abnormal uterine bleeding, and when that hysterectomy is approached laparoscopically or robotically, right, when you and I know that that hysterectomy could more than likely be approached vaginally. I'd like to mention other indications or other situations where I have been involved in order to remove the uterus vaginally. This is in cases where a patient is obese, right, BMIs of higher than 50, 60, or 70, with early-stage endometrial cancer, and our GYN oncologists would prefer that they not be placed in severe Chandellenberg because they likely would not be able to tolerate that kind of a position in order for their hysterectomies to be done. I also think about the patient with nulliparous. I think of a young patient who's been through 10 years of Depo-Provera to manage her abnormal bleeding. She had significant, she has significant mental delay, and the approach was to do it all vaginally so that she could recover much easily, given the fact that she would have difficulty managing the abdominal incisions. The other case that we would be approached to perform the procedure vaginally is in cases where patients have had multiple other abdominal procedures, right, where I know that there would be, I would be coming upon a lot more adhesions from the top than I would from below. These are cases, for example, in patients who've had previous bowel surgery, recession for Crohn's disease, or they currently have a J-pouch. Those patients would be amenable to having their procedures done vaginally. So in the next few minutes, what would I like to do? I'd like to share with you what it is that we have learned from laparoscopy and robotics, knowing that our current surgeons and our current learners are much more comfortable laparoscopically and robotically, and bring that into the vaginal armamentarium while maintaining patient safety and containing cost. I put this troubleshooting page up in hopes that you as fellows, I believe, or young faculty in your gynecology would be able to put together in troubleshooting for vaginal hysterectomy. So I put together my list of my most commonly encountered problems, that of I cannot see well in vaginal surgery, unlike laparoscopy and robotics. How about I don't have anyone to assist me? Our academic half days here at Banner University is on Wednesdays where I will not have a resident present to assist me. How about the uterus is large? How do I take that out vaginally? There are adhesions from previous cesarean sections. How do I tackle the difficult entry to the anterior cul-de-sac? How about when I need to take the tubes and or ovaries out? And then we'll come upon a list of solution in the end. And I encourage you to come up with this list on your own. So let's start with patient selection criteria. For me, the patient selection criteria really is short. I shortened that to PPE, that of pain, pathology, and your exam, right? So for pain, if there is a previous diagnosis for deep endometriosis, or the patient has pelvic pain that's acyclic, meaning non-cyclic, that has not previously been evaluated for deep endometriosis, perhaps these patients would be best approached from the top, either laparoscopically or robotically. And I put the large question mark now for venodes. I've seen amazing, talented venode surgeons who are tackling deep endometriosis cases all vaginally. So I'm not sure how much longer I can keep this criteria up. In my hands right now, I'm still approaching these cases from the top laparoscopically. Pathology, when there is a high suspicion for cancer, such as with a suspicious adnexal mass on imaging, advanced stage or endometrial cancer, as I talked about. Also, the concern for uterine line, my sarcoma should be considered and kept in mind. And I'll talk to you a little bit more about that. Exam is extremely important. And when I do my exam, it's really the access to the lower uterine segment to me that is most important. We all know sometimes how a clinical exam can be limiting. And so I liberally use an exam under anesthesia. I'll show this to you where I would put the patient before the patient is prepped and draped, I would perform an exam under anesthesia. This is a case of a patient who has a normal size uterus, but has had two previous C-sections. And you can see how it is just completely stuck to the abdominal wall. This is her under anesthesia, where I put the cannaculum on the cervix. And then just by tugging on the cervix, the whole abdominal wall would depress. I know that this patient has the uterus stuck to the abdominal wall. And indeed, in this case, it was only just two finger breaths or one finger breath below the umbilicus. So this is a case that I tackled laparoscopically, knowing that I would have great difficulty going through all of those adhesions with my instruments from below. So this principle of an exam under anesthesia is demonstrated very nicely from this study from the Mayo Clinic in Rochester. So Dr. John Gebhart and his team showed how an exam under anesthesia, conducting these in patients with uteri between 13 to 16 weeks, or have had more than two or equal to two previous C-sections, when they did the exam under anesthesia, they were able to bring in an additional 15% over to the vaginal arm, so that of all of their patients, they were able to successfully perform a vaginal approach in about 70% of their patients, right? So remember the benefit of an exam under anesthesia before you commit to going from the top. Imaging findings is one that I also take into great consideration. There's been multiple systematic reviews looking at the atypical features of concerning uteri involving fibroids, and these have been published. I have engaged our radiologists here at the Mayo Clinic, at the Cleveland Clinic to say, help me, right? Because I know that there is no 100% way in which we can pick up every case of Lyme myosarcoma. However, if imaging findings are suspicious, if the endometrial biopsy is atypical, then that's a case that I will refer over to our GYN oncologist, such as this case, a patient who came to me a few years ago. She's 65, has known, had known fibroids, but all of a sudden became symptomatic with pressure and discomfort. She did not have any vaginal bleeding. So here we are. I know that she had a single dominant myoma from her previous images, menopausal. I went ahead and asked for an MRI, utilizing this Lyme circoma or fibroid protocol. And this is what our radiologist mentioned in their report. And this is what the images found, right? Heterogeneous signal, very atypical, no discrete borders. The LVH total and isoenzymes were also elevated. And indeed, she ended up with disseminated metastatic disease up to the liver and also her lungs. So you can just imagine that without a suspicion level, right, this patient would have undergone a vaginal hysterectomy in my hands with morcellation, and I would not have done her any good at all without having first evaluated her for a sarcoma. So these are the risk factors for uterine sarcoma that I always keep at the back of my head. Older patients, Black patients, patients who have been exposed to more than five years or more of tamoxifen, history of pelvic radiation, and autosomal dominant syndrome of hereditary leiomyomatosis and renal cell carcinoma, also a history of childhood retinoblastoma. Rare, unusual, but I've actually encountered patients with this condition. So we published previously that the use of an endometrial biopsy actually detected close to 60% of leiomyosarcoma preoperatively. Going into this study, I thought, well, what's the benefit of an endometrial biopsy for leiomyosarcoma? I've always thought that you cannot detect that, but up to 60% to me is significant. And our study showed that hysteroscopy with sampling actually increased that detection rate by as much as threefold. So let's think of the great benefits or features that laparoscopy and robotics have, and what are those features that we can bring into the vaginal approach? Top in my head would be that of exposure, where everybody can see, the entire world can see what's happening, visualization with magnification, ergonomics, the ease in performance of the procedure, and then the presence of simulation for training. So let's think of these features and how we can address each one of them and bring it into the vaginal approach. Vaginal surgery, don't get that out of shape. So this is a video that Dr. Kate Woodburn, now attending at Wake Forest, did when she was a resident with me at the Cleveland Clinic. It's been published in HR, looking at how we have brought in the table-mounted retractors. It's a vaginal retractor system. It's called the Magrina-Bookwalter system, and I have been using this for over 10 years now. Every one of my vaginal hysterectomy will include this so that my residents, my fellows, are actually paying attention to learning the procedure instead of having to retract. For me as well as an attendee and a faculty, I would much rather be focused on teaching rather than retracting for the entire case. I will say that to me, this is a game changer, particularly in patients who are obese, right? The buttock is much more protuberant, that I don't have to worry about who's going to assist me and how will I be retracting. With this Magrina-Bookwalter table-mounted device system, I can do a case with just my surgical tech with me when I don't have my residents or fellows available. Another system that I have brought into the vaginal OR is that of a table-mounted camera system. This one is by Carl Stortz. It's called VTOM, but Olympus also has a separate one. So when I put this camera on, it's a 90-degree camera. I'm then able to show simultaneously or project it to all of our monitors in the OR so that my assistants are looking at the monitor instead of bending out and crouching into this tiny opening. Anesthesia, our circulators, our scrub nurse, they all can see what's happening. Even our medical students, when they're not directly assisting, are able to see the anatomy of what it is that we're doing. There are these modified retractors that Dr. Magrina had developed with Dr. Bookwalter. And this is narrated by Dr. Woodburn. So if you want to learn how to utilize this, please feel free to refer to that AHRQ video article. So this is the kind of images that we're able to see. We also record every one of these videos so we can use it later on for teaching. So just to show you, our assistants are looking directly at the monitor. I've actually placed these monitors now on each side rather than between the legs so that the assistants are looking directly in front instead of having to bend down. Also, define your instruments. When I have a table-mounted retractor system, I don't have multiple retractors in my set. You don't need 160 vaginal instruments in your tray. You just need your pickups with teeth, your rations, your fine geralds, your heavy mails, your fine nets, your suture scissors, your tenaculi, and then your haney and your uterine IP clamps. I also have a bayoneted morcellation knife handle. You will notice that I only use long instruments in vaginal surgery, again, because I'm going after the non-prolapse cases where it's not uncommon that my clamp will be completely in the vagina, needing at least seven to nine centimeters up in order to get to where I need to go. So now let's get into the difficult entry into the anterior and posterior cul-de-sac. For me, I don't know about you, so I took six years after residency to be in private practice and then an additional three years later before doing my fellowship in urogyne. It took me that length of time to be really comfortable and confident with anterior and posterior entry without losing sleep anymore the night before a vaginal case. So I'll talk about how important the initial incision is to set you up for success, developing the uterovescal space, entering posteriorly first before addressing your anterior entry. So in the case where I told you about the nelliparous young woman whose introitus was extremely narrow, how was I able to do her procedure vaginally? This is a technique that Dr. Magrina taught me, and it's a very simple superficial relaxing incision. So not an episiotomy incision, right? It is just a very superficial relaxing incision that is no deeper than two or three millimeters past your mucosa, not even getting to the endopelvic fascia, right? That little bit of extension provides me with an additional two centimeters so that I can put all of my retractors in place. With a thin, long vessel sealing device, I can also then go after the pedicles without worrying about not having enough vaginal access. That incision around the cervix to get into your anterior and posterior cul de sacs, I like the elliptical incision rather than a completely circular incision. Why? Because I am getting ready for, I want more space in order to remove the large uterus that is beyond where our initial incision is going to be. So this is a point that I think is important, much more important for my MIGS fellows than it would be for you, the Uruguayan fellows here. I emphasize how it's important to completely detach the vaginal attachments from the cervix, right, in order to access the vesicle uterine space. What I find is that my learners would stop a little bit prematurely, then they start going through this space and then entering into the bladder rather than the vesicle uterine space in order to access the vesicle, the bladder flap or the vesicle peritoneal fold right here. So with a difficult anterior entry patient who's had multiple previous C-sections, I like to enter posteriorly. First, release my uterus from the 3 to the 9 o'clock position until I've gotten much better distances before I will go in anteriorly. Think of using your sharp dissection and then also proceeding from the lateral to the medial approach, just as you would from an abdominal hysterectomy in a patient who has had previous cesarean sections. So let's go back to this video. First, it's a laparoscopic approach exactly on that patient whose uterus is attached to the abdominal wall. Let's show you how it is that I approach these cases. So I've gone through the utero ovarian pedicle. I'm developing the, excising the peritoneum of the posterior leaf of the broad ligament. From that, I will then go anteriorly and isolate my uterine vessels right here. The bladder is still attached, right? So this is the same principle and the same approach that I would use for a patient with multiple C-sections and attacking it from below or approaching it from below. Going after posteriorly first, releasing the posterior leaf of the broad ligament, going after the uterine vessels before I will go in anteriorly to get into the anterior colostac. Let's go ahead and show you this video now. So here we are with our elliptical incision. I will just advance this. I go straight to the cervix. So one nice clean incision. I make sure that it's perpendicular to the angle of the vaginal mucosa right here. I would go ahead and detach the vaginal attachments from the cervix here with a heavy male scissors. This patient has had two previous C-sections in the past. I will now go in posteriorly. I've not gotten in anteriorly yet. So with one big large incision, we'll go in posteriorly. I'll put in my longer posterior blade so that no one needs to be hanging on to that weight speculum anymore. I use my vessel sealing device and I prefer the Ligature Maryland because of its articulation. It's the same tip that I use for all of my laparoscopic hysterectomy. I find that I can dissect better. Some things to think about when you're using the vessel sealing device vaginally. Again, same principles as when you're using it laparoscopically or robotically, right? You don't want to put a lot of tissue between your jaws because otherwise you're not going to get a good seal. Isolate your vessels different from the clamping, cutting technique and suturing technique. When you're managing with a vessel sealing device, you want as little or isolating your vessels so that you don't get bleeding in between. Also, we don't do this retracting of the clamp when you're using the vessel sealing device. I try to stay parallel to the cervix so that I stay close to the cervix. I remember that this is a hot tip, right? That there will be some lateral thermal injury. So I'm very cognizant of that. I use my suction device to quickly suck out the heat and also retract the bladder pedicles for me and also the tissues that would be closest to the ureter. So here I am in the lower uterine segment already. You can see how I'm approaching the vessels from posterior. I'm staying below the three o'clock mark so that I don't inadvertently injure the bladder, which is above the three o'clock location. I'm now ready to go over to the other side. Again, releasing all of the attachments of the cervix from the vagina. I'm coming upon the descending branches of the uterine vessels here. And then again, pushing the ureter attachments and the bladder attachments with my suction device so that I can further isolate the vessels right here. Okay, so now we're going to tackle the scar, scarring the bladder tissue that's densely adherent to the lower uterine segment right here. I like to do that sharply so that I can push it up. The trucers will look beefy red. When you cut into it, it will bleed like stink. When you cut into fibrous adhesions, it will be thick like this fibrous tissue right here and won't bleed as much. So I'm retracting that very bluntly, just gently bluntly. I'm seeing yellow tissue, yellow fatty tissue stays with the bladder. So I will dissect inferior to that area. Okay, so again, pushing the trucers farther up so that I can find an area where I can go in and enter anteriorly. I'm going to take these adhesions down further. So trying to get the uterus to come down a little bit more towards me. And each time I will encounter the uterine vessels. These are the ascending branches now. So I will go ahead and tackle that. And the uterus, as you can see, is coming further down. Let's go ahead and there's more vessels right there. Let's go ahead now and just show you how we will be tackling the adhesion centrally. So I'm past the lower uterine segment. I've got my vessels right here at the three to nine o'clock position. I go ahead and use my vessel sealing device, and I found my opening past the layer of all the adhesions right there. Okay, so Dr. Korten at Parkland did a very nice study utilizing the cadaveric model, and they found that in the number, I think it's 21 cadavers, the average distance from the initial cervical incision to entry into the anterior cul-de-sac is about three and a half centimeters, three and a half centimeters. You will see here this patient has had two previous c-sections and that distance is going to be markedly increased, right? So again, going from lateral to medial, I've got really dense adhesions right here, but I've found that opening already anterior, no not anterior, cranial to where my adhesions are. So I'm going to continue to dissect that very similar to what we do laparoscopically, except we're tackling this all from below. You can do this sharply with scissors or just with quick bursts of energy and your vessel sealing device. I'm going to push these, get past these adhesions and now we'll retract. I'm seeing some yellow tissue right here. I'm going to dissect below it this time using a pair of scissors cutting below and there you go, we're in. Okay, heart rate comes down, ready to go to home base now. The rest of the procedure should be pretty straightforward. Let's go on now to taking the uterus down. So in the next few minutes, how do we take down a large uterus? You saw my technique. I like to go after the vessels first laterally and go as far as I can before I dive out the cervix. It's not uncommon that my entire length of my knife may be in the vagina when I'm starting to morselate before I get full descensus of the uterus. The idea is for decompression of that central mass, right? At the end of my morselation, this is the contour that I want to have left behind. I protected the bladder anteriorly, I protected the rectum posteriorly and utilized the lateral contours of the uterus to keep me from getting into the danger zone, right? So I'm decompressing what is there essentially just as when you're pouring an apple, think of it that way. So this is another uterus that we were able to remove from below, again maintaining that contour of the outer edge of the uterus in order to keep us safe. So let me just go ahead and show you this. Let me just pause right here. This is a patient who is 46, nulliparous, one of our clinicians at the hospital and she wanted a vaginal approach. She presented to the ER with a hemoglobin of eight and she wanted her hysterectomy. She's got a six centimeter submucosal myoma and a seven centimeter fundal intramural myoma. She's asking for a vaginal approach because she wants to go back to the cold pool right after her surgery. So here we go. We've gotten the vessels laterally, right? I've not entered anteriorly because that myoma is keeping me from getting to the bladder flap or the vesicle uterine fold. So I'm starting to go ahead and morselate. I use my Schroeder, so not a single-toothed tenaculum, it's a double-toothed tenaculum. I've got my 10 blade and I will core and do serial wedges from the central mass, right? I've got my cervix forming my lateral boundaries. Here I am already accessing that submucosal myoma and I will proceed. I start at the 12 o'clock position and then I go all the way around to 10 o'clock. I twist the specimen and lop at the top. So it's really just two movements. My fellows tease me, right? They hear my voice saying twist and lop, twist and lop. And so this becomes a little bit more efficient. I minimize leaving behind any fragments when you're doing this morselation. So sometimes morselation can require up to 10 changes of your blade, sometimes requiring more than 30 minutes up to an hour of morselation. But the technique really is no different with a 12 week size, 20 week size, 30, 32 week size users, as long as you maintain these principles. Morselation should not be bloody. If you're starting to get a little bit more oozing, then pause and go after your vessels laterally, because that means that the uterus is coming down even more so that you're better able to access those ascending branches. And that's exactly what I'm doing right here, right? The uterus is now coming down. That six centimeter submucosal myoma has come down. The uterus is descending a little bit more. I'll take out this myoma that's coming at me. And then I will go after the bladder flap. Now here it is, right? Entry into the anterior colusa, easy. Again, heart rate comes down at this point. You should be ready for home base. I'll bring in the anterior retractor and attach it to the bookwalter device right here. How do I make sure I'm in the abdominal cavity or pelvic cavity and not the bladder? So I utilize the back end of my rations and just push it up. If I get urine coming down, that's bad news for the day. But I also know I won't be able to see loops of bowel with this case, right? Because I still have that seven centimeter myoma up top. So I will go ahead and proceed to morselate. I will pause and go laterally to go after the ascending branches because I don't want to lose a lot of blood in this case. And once I've done that, let me show you the end of this case right here. So going after the upper pedicles, now that it's coming down, this uterus is decompressed and able to put the haney across my triple pedicles, right? My uterovarian, my fallopian tube, and my round ligament. And that's the contour of my uterus, just demonstrating that to you. You all know about the benefits of an opportunistic risk-reducing salpingectomy. How do we do this? This is from Dr. Ridgway's study showing that we're able to reduce one diagnosis of ovarian cancer in every 225 patients who's undergoing a VACHIS, and one death from every 450. So in a busy mixed surgeons practice, this is to me significant. It is overall less costly. That minimal increase in time is about 11 minutes, with minimal increase in complications. So how do we do this procedure? This is also published in the Granger, and also I advise you to do that if you'd like to look. Very similar to our laparoscopic approach, we transect the round ligament. Why? And I'll show you why. It allows the specimen to come closer to the field and away from the lateral wall. So we always do a round ligament transection, right, with our abdominal his, and laparoscopic, and robotic his. So same procedure that we do vaginally. I would go ahead and make an opening in my mesosalpinx after having identified the fimbrial end of the fallopian tube. What does that allow me? It allows me to remove this entire tube, the tube in its entirety, without leaving behind a stump of the fallopian tube proximately, right? It's very painful for me to see patients later on with adnexal masses or cysts, and all it is is a stump of a fallopian tube that had been left behind from a previous tubal ligation or a previous self-injectomy. So I go ahead and then re-excise. So I've got the portion of the uterovarian, the fallopian tube, the round ligament is already out of this pedicle. What's remaining behind in our haney is just the IP. No, not the IP, the uterovarian ligament right there. The round ligament is already released. I have my vessel sealing device out, so I will go all the way to the fimbrial end. I find this technique much easier in allowing me to access the fimbria, especially in patients who have had previous tubal ligations, because oftentimes it can be even farther higher. I always inspect my specimen at the end to make sure that I've got the entire specimen out, particularly the fimbrial end. When do I use V-notes, right? For me, V-notes is most helpful to access the adnexal when it's difficult. I know that many of you already have been exposed to this, so I won't belabor this point. You all know about the robot that's used for the vaginal approach, which also can be helpful for these cases. We need to be more vigilant about bringing simulation in to facilitate learning for our learners, just like in laparoscopy and in robotics. We are the vaginal champions in the field of GYN surgery, so my hope is that you can have these opportunities available for our students. Here we are, having engaged with the engineers, we used a VR platform to simulate what a vaginal hysterectomy would be, so that our learners who are not as exposed to this procedure would know the anatomy and also go through the steps in their mind using this approach. This is my troubleshooting page, so we talked about the use of retractor systems with a self-retaining vaginal retractor, the use of an overhead projection with the camera system, long instruments, a liptical incision, the superficial relaxing vaginal incision. Please remember to suture that and close that incision back up, okay, so don't forget to do that. How to manage the large uterus, we spent some time on that, and then tackling the adhesions from previous C-sections, going from lateral to central, just as you would with other approaches, and then using the round ligament technique or D-notes for your annexa when you're unable to complete the procedure from below. We are having a second phase to the SAVI trial, hopefully implemented very soon, where we will engage academic institutions on a multi-modal, longitudinal training program that will include online modules, hands-on component, and then a proctorship. If you're at all interested in joining us on this study, please let me know, I would love to have more participants in that study. So key points, vaginal hysterectomy is a minimally invasive procedure. We as urogynecologists should be the champions for this vaginal approach. We need to break silos to cross the bridges and show our colleagues how it is that the vaginal approach can be utilized in cases that often approach them rather than us. Think of adoption of the new patient selection criteria and incorporation of technology and new techniques into this field. I hope that that is helpful to you all. I'm open for questions. Thank you so much for your attention. Thank you so much, Dr. Ko. It's now time for questions. As a reminder, please use the Q&A feature of the Zoom webinar to ask questions, and we'll close those to the speaker. I think as we're getting ready for questions to kind of roll in, I was hoping that you could speak a little bit more about how you decide when to transition to doing morcelization or morcelizing, sorry, morcelizing the uterus or bivalving the uterus, like when you're transitioning to that in the case. Right, so I will disclose that in 90% of my cases that I am morcelating. So first of all, I've done a thorough preoperative evaluation to make sure that my suspicion level for cancer is extremely low, right? I've done my preop endometrial biopsy as well, so that I feel confident with the morcelization, with the morcelation, oh my goodness, and then I like to be able to secure the pedicles, right, with the haney. I still use the haney before I would use my vessel sealing device for that triple pedicle, because I don't like it ebulsing and getting up into the pelvis so that I'm chasing it. So again, to disclose, if it's greater than 10 week size, 12 week size, I'm often morcelating so that I can get that triple pedicle securely. Great, and how do you decide when to use sharp dissection versus energy in a difficult anterior entry, like some of the ones you presented with a thicker scar, other things like that? Okay, so if I'm not that confident that the detrusors are far away, I will do my sharp dissection, right? If I've already pushed it up higher and I know that it's just dense adhesions in front of me, I'd go ahead and use my vessel sealing device. Great, sorry, let me just see. Just wanted to make sure if we had any other questions from the audience. One thing that I sometimes ask is when do we decide to convert, right? When you're, when you have a large uterus or in a patient who's had multiple pre-c-sections and the uterus is densely adherent down the wall. So when I'm having loops of bowel come to my field instead of uterus coming down, that's when I would start thinking about, you know, asking the team to go ahead and bring out the laparoscopic tray, go ahead and set it up because we will be moving up to the top very soon. Sorry, my puppy's minding the strut outside. Any other questions? I think those are all our questions. So, on behalf of AUGS, I'd like to thank Dr. Rosanne Koh for this excellent webinar. Be sure to register for our upcoming webinars on June 19th. Join Dr. Christy Borowski as she presents a webinar titled Neurophysiology of the Micturition Cycle and the Neurogenic Bladder. Follow AUGS on Twitter and Instagram and check our website for information on all upcoming webinars. Thank you all for joining and have a great evening. Thank you, Dr. Koh. Thank you.

urogynecologist

vaginal hysterectomy

minimally invasive GYN surgery

patient selection criteria

surgical techniques

VR simulation

risk-reducing salpingectomy

surgical education