Welcome to tonight's webinar, everyone. I'm Dr. Lauren Siff, the moderator for this evening. Before we begin, I'd like to share that we'll leave plenty of time for questions at the end, but you can submit them at any time by typing them into the question box located on the left-hand side of the event window. Tonight's webinar is titled, Optimizing Outcomes and Avoiding Complications in Robot-Assisted Surgery, and is being presented by Dr. Arnold Avincula. Dr. Avincula is a Levine Family Professor, Vice Chair of Women's Health and Chief of Gynecology at the Sloan Hospital for Women, Columbia University Medical Center, New York Presbyterian Hospital, in addition to serving as Division Chief of Gynecologic Specialty Surgery. Dr. Avincula is a leader in minimally invasive surgical techniques and an internationally recognized gynecologic robotic surgeon. He's also developed surgical instruments that are used worldwide. He has extensive experience in treating complex and challenging cases of uterine fibroids, endometriosis, and pelvic masses. Dr. Avincula has served as Medical Director of Endometriosis Centers at University of Michigan and Florida Hospital Celebration Health prior to joining the faculty at Columbia University. Dr. Avincula is extensively involved in research and has authored and coauthored a number of book chapters and articles in peer-reviewed journals, as well as training surgical fellows throughout his career. Additionally, Dr. Avincula is Medical Director of the Miriam Michael Jaharis Stimulation Center for Columbia University College of Physicians and Surgeons in New York Presbyterian Hospital. He's also a fellow of the American College of Surgeons and past president of the AAGL. I'm pleased to turn it over to Dr. Avincula for tonight's presentation. Well, good evening, everybody. And thank you, Lauren, for that really kind introduction. Very honored to be able to be invited to participate in your webinar series and give tonight's presentation on robotic surgery. It's my hope that the folks who are tuning in this evening will be able to pick up a few pearls with regards to ways to optimize their outcomes, but also to avoid running into complications, which is certainly part of what we can occasionally see as surgeons in the operating room. The following are my disclosures for this evening's presentation. So basically from an objective standpoint, I'm gonna basically go through surgery starting with what we would normally do at the beginning all the way to the end. And so basically talk about port placement, docking, peritoneal access, talk about the different types of instruments that we can use in the robotics platform, various tips and tricks for managing and minimizing complications you might run into, as well as some tips and tricks related to dissection and suturing when performing actual procedures. And just basically having a practical approach to one of the more commonly performed procedures in robotics, which is hysterectomy. One of the main driving reasons for spending some time talking about how to optimize your robotic cases and avoid complications is the fact that there's a lot of sort of media and publicity around complications related to robotic surgery. And to be honest with you, a lot of it is stuff that we encounter as a part of doing surgery, has really nothing to do directly with robotics, but certainly there's a subset of complications that we see that are directly related to the use of the robot. And I think it's important to understand these nuances so that we can avoid them because often what you end up seeing when you Google robotic surgeries, a lot of legal firms looking for cases where people have been wronged by their surgery. Now, certainly in gynecology, there are a lot of procedures that are applicable to robotic surgery. It's essentially the whole gamut of what we do in GYN surgery. And in particular, as you can see, pelvic reconstructive surgery is certainly an area that has a lot of robotic applications. What I'm gonna talk about tonight is basically relevant to whatever platform that you use in robotic surgery. So whether you're utilizing the SI system or the XI system, much of what I'm going to say is agnostic to either of those platforms. If there's one thing that I will say about my philosophy regarding robotic surgery, it's that I go into the operating room with a glass half empty mentality. And although that sounds very pessimistic, the reason for being that way is it forces me to think about all the things that can potentially go wrong during an operative procedure, whether the robot's being used or not. But in this case, most definitely when we're using robotic technology, it's good to try to anticipate places where you could potentially have a hangup. Certainly one of the most important ways that we can optimize our outcomes and avoid a complication is just to make sure that we really need to be there. And so I always like to start things off by saying that we definitely have to have a good rationale or goal for being in the operating room, applying robotic technology and performing a procedure. That ultimately means having the proper indication. It's also important to know that when we do robotic surgery, the robot will not compensate for deficits in knowledge base or skillset. So we always have to remember not to put the cart before the horse and not to overlook the fundamentals when it comes to applying a new technique or a new technology. As I said before, if you can't drive, then certainly putting you behind the wheel of an expensive car is not going to make you a better driver. And certainly robotics is similar in that way in that it doesn't replace lack of knowledge, skill or judgment. So at the end of the day, you still have to know your anatomy, the technical aspects and the surgical nuances of the procedure. That really to me is the centerpiece of minimizing any potential obstacles or complications. But with that being said, there's a lot of low hanging fruit that we can pick when we do robotic surgery. And I'm going to start right away with just talking about some simple things like patient positioning. One of the things that I've noticed through the years as I've gone around the country as well as around the world teaching is the fact that a lot of times people go into the operating room and they are sub optimally positioning their patient. And to me, it's really critical that you have access to the perineum, for example, particularly if you're doing pelvic reconstructive surgery. So having the legs externally rotated and the hips abducted definitely helps provide access. And that really means lighting up the ankle with the knee and the contralateral shoulder. If you do that, it's going to naturally externally rotate and abduct the hips. Also having the patient appropriately positioned towards the end of the bed is critical. And as you can see in this cartoon drawing, this patient is too far back onto the operating room table that whoever's going to do this case is going to run into some problems with, for example, uterine manipulation or just accessing the perineum because they're not all the way at the end of the table. So these are subtle things that need to be compensated for at the beginning of a case because once you drape the patient and you bring a robot in and you attach it to the patient, you're not going to see these things afterwards. And so also having a little bit of hip flexion is important as well because that minimizes the risk of hyper extension of the hips, putting you at risk for a femoral nerve injury. As you can see here, when you're optimally positioned, you're going to have good access to the perineum and you're going to have the ankle and the knee and the shoulder basically lined up the contralateral shoulder and that externally rotates and abducts the hips. And you can see the 170 degrees subtle flexion at the hip. Another important thing to think about is how you're going to prevent your patient from slipping in steep Trendelenburg because often you need to have access to a large portion of the pelvis, particularly the sacral promontory and you need to get the small bowel out of the way and the large bowel as well. And so being able to put your patient in the appropriate Trendelenburg is critical. So you have to think about these aspects of the surgery before you even get started. And as you can see here, going back to that previous photo, you can see that in this patient, we're using a specialized pad and the patient's arms are padded and tucked. You see 170 degrees of hip flexion, but that patient is secure in the bed before we do our robotic surgery so that when we go to Trendelenburg, that patient should not move. And there are a lot of products on the market that can be utilized. I'm just listing a few examples here of products that people may incorporate into the operating room to prevent that type of slippage. I tend to use the one on the left. For our operating team, it's very reproducible, easily placed. It's very quick when we do it and our patients don't move when they're properly positioned on that pad system. But one of the ways that you can really minimize the risk of movement on the bed in Trendelenburg is just making sure you don't use excessive amounts of Trendelenburg. And a lot of the studies in robotic surgery, they've seen Trendelenburg to as low as 16 degrees being able to accomplish your procedures. And so I really think that often there's this reflex phenomenon where people say, well, just give me all the T-burg that you can give me and they don't really need it. And if you just look at the operative field and as you're going into Trendelenburg, once you see what you need to see, just stop reclining the bed. It'll go a long ways for minimizing slippage on the bed and your anesthesiologist will love you because it certainly helps them from a ventilatory perspective. I'm gonna talk a little bit now going from positioning to just thinking about your instrumentation that you use. Certainly one of the ways you optimize your procedures is just by making sure you have proper instrument selection. And in my operating suites, we typically standardize all of our trays to minimize the confusion with instrumentation. And it's really important to really study the different types of tool tips that are available on the robotic platform because some are quite optimal for GYN surgery and other ones just definitely are not gonna help you and are actually gonna complicate your procedure. So this is just an example of one of the tray systems that I utilize where we basically keep all of our endo-wrist instruments that are specific to GYN surgery that we found helpful, all of our laparoscopic access instruments, in addition to our vaginal access instruments, all in one tray. It makes table setup very quick and easy. And this is an example of a setup for a SI system. And you can see all this fits in that little container. And then we look at the time, I'm just using SI instruments as an example. These for my team are typically the instruments that would be most applicable to a gynecologic surgical case. Now we don't use all of these instruments at one time during a case, but we may average three to four instruments per surgical case that we will incorporate. And as you can see here, it's important to have good needle driver selection, a good pair of scissors, a bipolar device. You know, for those of you who do things like reproductive surgery where you need a tenaculum to do myomectomies, you need to have one of those and just heavy grasping forceps. These are the types of instruments that over the years I've found quite helpful and much more specific to the kind of pathology that we see in gynecology. But as I said before, a lot of this is applicable to whether you use an SI or an XI platform. So if you use an XI platform, the same instrumentation exists, just slightly different cartridge housing. You can see that there are different types of bipolar. So you have to study like which type you like, like I used to use a PK dissecting forcep on the SI, but I found an analogous one on the XI system that's a long bipolar grasper. There are things like vessel sealers, et cetera. So I think it's important to kind of familiarize yourself with the instruments that are available. Often I see people struggle in surgical cases because they have the wrong instruments. And I'll show you that in some videos a little bit later. Next is thinking about peritoneal access on your cases. One of the important things that I'm gonna mention today is just the use of products like AirSeal, for example. It's a insufflation system that allows you to maintain pneumoperitoneum and not lose it during a robotic surgical case. It also evacuates smoke, which is an added bonus. So you never accumulate smoke in your operative field. But as many of you may have appreciated in terms of doing robotic surgery, if you lose pneumoperitoneum doing a robotic case, it can be quite frustrating, particularly if your instruments aren't attached to the robotic arms. Because when that happens, because the trocars are fixed to a robotic arm that does not move, when the belly wall collapses from a lack of pneumoperitoneum your trocars can all of a sudden become pre-peritoneal or even out of the body. So AirSeal is one of those technologies that actually has overcome that nuisance of losing pneumoperitoneum during a robotic surgery. It's not something we typically see on conventional laparoscopy because when you evacuate all your pneumoperitoneum, the entire abdomen and all the trocars collapse with it. But that's not the case with robotic surgery. So I think it's something to think about as a way to minimize those risks and also help evacuate your smoke. Peritoneal entry is one of those tricky things where there are a lot of studies out there that have looked at the different ways to enter. I typically do a towel clip technique for getting in. And you can see just in this photograph that I'm using a towel clip to grab the umbilicus. I evert it and I place the varus needle into the abdominal cavity and obtain my pneumoperitoneum. Once I obtain pneumoperitoneum, one of the things that I typically will do is then perform either a left or right upper quadrant entry, depending on which side of the patient I'm docking the robot. The reason I advocate for placing your initial optical port once you insufflate into the upper quadrant is that it allows you to get a survey of the operative field and to make sure there are no adhesions in the area that you're going to be operating. And you can optimize your port placement that way. This also will then serve as your assist port by being in the right or left upper quadrant. Now you always have to make sure that when you do this, you've decompressed the stomach, that the patient doesn't have any hepatosplenomegaly, and that you know the patient's past surgical history. But you can see this is just a view that I've had from the left upper quadrant. Obviously this is a large uterus during a hysterectomy case. I'm scoping out the operative field and I'm placing my other trochars. I can see that right at the area of the umbilicus, there's some peri-umbilical adhesions, but I'm not in any of that because I started out in the left upper quadrant as my first optical port placement, and I can survey the operative field. So there's definitely value in making that sort of a consistent practice, which is something that I do on a regular basis. Ultimately, when you put ports in, location, location, location, just like real estate is extremely important. And you really need to be able to know where your ports are, particularly when you do robotic surgery. Now, that's one area where I could definitely go into at least an hour just on port placement. And for the sake of this presentation, I'm not gonna be able to go into that much detail, but I just wanna emphasize that, understand the patient's abdominal wall anatomy, take advantage of the real estate that you have and optimally place your ports. If you do that, then you're gonna have good outcomes in terms of your ability to not be restricted in terms of your use of the robot and access to the various parts of the abdomen and pelvis. This is just an example of a shot that I took of a patient with all the arms of the robot, all four arms of the robot, plus an assist port. It's a smaller patient, as you can see from the ruler placed on the abdomen, but this is an umbilical port placement. This is a left, slightly below the umbilicus, but this is my left hand, my right hand, or what I would basically be as my retracting arm. This would be my right hand, my retracting arm, my left hand here where the arrow is. And then you can see here, this is the assist port in the left upper quadrant. So if I were to put instruments in here, for example, on the left lower quadrant, trocar would be like my bipolar. My assistant would provide suction periodically through the assist port in the left upper quadrant. My camera would be at the umbilicus. My scissors would be in the right upper quadrant trocar, and in my right lower quadrant trocar would be something like a grasper to retract and give me some exposure. But you can see that I've optimized the port placement, and I'm taking full advantage of this patient's abdominal real estate, even though this is somewhat of a slender patient. For a lot of you who may be members of AAGL, one of the ways that you can really get a deep dive into the details of how I do port placement and docking is to access a webinar that I actually did with Mike Pitter a few years ago that talked about port placement and docking with both the SI system and the XI system. And we basically go into details about how you place those ports, how you bring those arms in, and how you optimize the pitch and the yaw of your instrumentation so that you can get full access to the abdomen and pelvis with minimal collisions and allow your bedside assistant to be effective at helping you. So I'm gonna jump now to things related to uterine manipulation, which I also think is a critical component of robotic surgery and is often overlooked. And as you can see, a lot of the things I'm talking about, about optimizing the robotic cases and minimizing complications are things that you need to think about before you actually start the case. So positioning your patient, how you're gonna get peritoneal access and put ports in and dock the robot. And then uterine manipulation. I honestly think that these three things in and of themselves probably are more than half of the factors involved in the success of your robotic surgery. One of the things that's important is that when we do robotic surgery, if you're doing surgery with either an SI or XI system, is you wanna be able to be comfortable docking the robot from a lateral position, either what we call angle docking or side docking, because you want access to the perineum. If you don't know how to do that optimally, you're gonna disadvantage yourself in a significant way because you won't be able to have a bedside assistant sitting between the legs, helping you with exposure, elevating the vaginal cuff or the uterus so that you can do your surgery. Now, there are a lot of different manipulators to choose from. This is an area that I'm extremely invested in because I find that probably 70% of the success of a hysterectomy case is dependent on the person who manipulates a uterine manipulator down below. And there are a lot of ways that you can facilitate that. One of the things that we often utilize in our operating room is a positioning system. So if you don't necessarily wanna put somebody between the legs, you can certainly use this, I call it the iron intern. It's like a medical student's best friend in terms of having something that holds your uterine manipulator in place. This is a screenshot of the arch handle with a roomie tip before we actually placed it in the patient. But you can see that this would hold that and it's pneumatically controlled with a foot pedal so that you can release it and then adjust it and position the uterus where you want and it's gonna stay there. Or if it's the vaginal vault that you wanna position, you can do that as well. And the system would work with, for example, the Hoyt sacro-tips, which are a way to delineate the vaginal vault during a copeplexy, where you don't have to rely on somebody to hold the vagina steady while you're sewing mesh to it during a copeplexy procedure. So these are ways that you can actually optimize your procedure, minimize the number of hands involved in the case and gain some consistency in your operative procedures. It also is a way to emphasize the importance of making sure that whoever's manipulating that uterus does so with the appropriate amount of tension, or if they're manipulating the vagina, does it with the appropriate amount of tension. Now using a manipulator with a copatemizer is useful, but it's not helpful if you don't have any tension, because part of the goal there is to be able to elevate the uterus. Basically, as you take your uterine vessels, as you see in the red here, you wanna elevate those structures away from the critical ones like the ureter so that you don't inadvertently injure it. And certainly one of the huge advantages of having an appropriately placed uterine manipulation system is the fact that as you can see in this cartoon drawing here we're able to preserve the attachment of the uterus sacral ligament to the posterior vagina. And I'm gonna just jump to this conventional laparoscopic video. I found an old video of mine that was in my library where I actually had a very nice view of that cartoon drawing. And you're gonna see here as I transition to the part where I'm going to finish the copatomy. There's the copatomy. You can see the uterus sacral ligaments below right here outlined by my cursor. And you can see how they're attached to the posterior vagina because it's an intrafascial hysterectomy. So I didn't break that uterus sacral ligament. It's still attached to the posterior vagina which I think is a huge advantage of proper uterine manipulation with an appropriately placed copatomy cup. Now, let me go to an actual video here to show you like the importance of these copatomy cups for facilitating isolating your uterine pedicle but also for making your bladder flap. And to me, these are like critical nuanced aspects of really having a good outcome when you're doing robotic surgery. Now, this is on an excise system. I'm using a monopolar scissor with a long bipolar grasping forcep. I notice I'm gonna have my assistant really push that uterus in. As they push it in, it makes the delineation of where that bladder reflection is much clearer. And I think it's always wise to make your bladder flap going from a medial, I mean, going from a lateral to medial, right? So I start laterally and then I go medial to make the bladder flap. It's much easier than starting in the midline. I sometimes see people do that and it really, I think, makes it more complicated. You wanna put a lot of tension on that copatomy cup. You wanna delineate where that space is, that potential vesicular uterine space. You wanna push up on the copatomy ring and then you wanna go from a lateral to medial perspective. And you can see all of a sudden that copatomy ring is becoming much, much more visible. And that's something that you wanna be able to see. I always tell my fellows that you wanna see the naked copatomy cup. You don't wanna see a lot of tissue attached to that copatomy cup. Because if you do, that means that you haven't done your dissection properly. And then the other thing that you wanna be able to do is then skeletonize, right? You wanna release this posterior peritoneum, right? So, and that's the beauty of the robot is it allows you to replicate open surgical technique where we do this in open surgery. We take the broad ligament and we release it and we incise the anterior and posterior leaf of the broad ligament. Because what that's gonna do for you is it's gonna lateralize that ureter, right? So you can see here that my uterines are gonna be up against the copatomy cup and I'm just getting rid of any extraneous peritoneum that we don't need here. Because any peritoneum that you release really ensures that you're not gonna pull a ureter into the operative field. And there's really no way we're gonna get a ureter here because that ureter is gonna be quite lateral. And as you can see here, this is the uterine vascular pedicle. And then once you take that uterine vascular pedicle, you can basically ligate that in its entirety without any concern that you're going to pull a ureter into the operative field. And the beauty of this is that as long as you have your bedside assistant really pushing that uterine manipulator in all the way, you're not gonna have any issue with clamping this vascular pedicle. So this is part of that vascular pedicle. It's kind of wide. So I'm gonna take it in a couple of bites, but here's part of it. Probably a vein in there as well as the artery, but here's the other part of that vascular pedicle. But I'm sealing that right at the level of the copatomy cup. There's no way that there's gonna be a ureter that's gonna come all the way and take a right turn and start heading up along the side of the cervix and uterus going cephalad towards the patient's head. So you can see that this really allows us to get these vascular pedicles pretty nicely. And there we go, that's the uterine right there. And I'm going ahead and I'm desiccating that right now. So that's a safe way to do that. Next, I'm gonna talk about once you've done your lower dissection, you've done your bladder flap, you've ligated your uterines. If you use a balloon occluder, I think it's really important to note that you don't have to inflate the pneumo occluder balloon until you do your copatomy. Sometimes people over inflate this balloon to help maintain pneumo during the beginning of the case. It's gonna throw off your ability to see the copatomy cup top. You really wanna see that thing to help you delineate your borders. And you don't want something like an overinflated balloon occluder to blunt that visualization of the copatomy cup. So really you only need to do that at the time that you're ready to make your copatomy. But as you can see here, and I'm playing this video a little bit quicker, this is what it means to do a very efficient copatomy. I often think people spend a lot of time dwelling and not doing a good copatomy. You can see my ureter is very lateralized there. I needed to do a ureterolysis on this case because it was somewhat adherent. I've ligated my uterines. The uterines there are already ligated and transected and lateralized. And I have a naked cup, right? So I'm gonna come in here and do the copatomy. Now the success of your copatomy is gonna be predicated on having a really good assistant who can provide good upward tension on your uterine manipulator and the copatomy ring so that you can really see the tension and you can see the tissue separate. I think it's important when you do this, and I use COAG, I don't necessarily use COT, but I go quick. I don't dwell. Now this video is sped up a little bit, but not that much. But I don't dwell. I move pretty quickly. I barely touch the tissue. I basically dance or I kind of paint or even tickle. So like the tips of my instrument, the tissue, so that as I put tension on the copatomy ring and we go with the robot and that hot monopolar scissor by pushing, by having the assistant push up on that manipulator. And I just basically use an open scissor blade and use only one blade and I arc to the tissue and I move quick and basically go layer at a time. I don't dwell because when you dwell, you're gonna get more thermal effect. You're gonna get more desiccation and more thermal damage, more char, right? So if you wanna have a nice healthy cup, you can see here that, see how your uterine is nicely lateralized here, that vascular pedicle. I don't run into bleeding in the corners because I've spent the time letting that lateralize once I've desiccated it. Then again, my assistant's gonna lift up on the uterus and I'm just gonna come around. This is the beauty of having a wristed instrument and being able to get in robotically on these tough corners. And again, for a lot of folks who do hysterectomies in the urogyne world, the uteri tend to be much smaller. So this is an even easier thing to do because you're not having to do battle with a bulky fibroid uterus, as you saw in this video here. I also wanna touch base a little bit on supracervical hysterectomy because I know a lot of folks do supracervical hysterectomies and I wanna go ahead and expand this video here to show you that you can also use your copotomy cup to facilitate a supracervical hysterectomy. Now this is an amputation and the copotomy cup is great because if you do your surgery properly and you can see, again, I've lateralized the ureter, a lot of tension, you can see the neck of the cervix, right? And essentially by doing this, you are amputating at a level just below the internal os by doing this, right? So I use the copotomy cup as a guide. I do the entire hysterectomy as if it's a TLH, but then you can still do the LSH. And if you cut right before the copotomy cup, you will create for yourself a very clean transection and your cervix will be just that, cervix. You won't run the risk of, excuse me, leaving lower uterine segment behind. So again, you can see it here. I just go with the monopolar scissor. Now you're probably wondering, how the heck do I, you know, get the posterior part of this incision when I'm doing the colpotomy? Well, I'm going to show you a neat trick. One of the things that you can do is once you hit the cervical canal and you bump into the shaft of your uterine manipulator, what you're going to do is you're going to have your bedside assistant manipulating from below, slowly withdraw the uterine manipulator and introduce the shaft in through the defect that you created in the cervical canal, right? Now, you're going to see that here. I'm just going to let this video play out so you can see what I'm talking about. By doing that, it allows you to basically fracture the cervix at the neck, right? And then you can basically, by antiflexing, you can complete the transection of the uterine corpus off of the cervix. And then you have this really clean cervical stump, right? And it protects you from getting anywhere near the rectosigmoid so you don't have an injury. And then you can see that because I've isolated my uterine very cleanly, nothing but pedicle, I can desiccate that all I want. I'm not going to be worried about injuring anything. And notice that because you skeletonize everything, when you skeletonize your dissection, you can easily see where the neck of the cervix is and you're going to come through what I call the skinny neck, like the hourglass. You're coming through that hourglass, the middle, the skinniest portion, and you're going to see me run right into that manipulator. You can see, I see the shaft. Now I'm using the vincula delineator here. So one of the advantages of that is while the colpotomy cup is positioned in the vagina, I can actually withdraw the shaft without moving the cup. So you can see that here. Now I'm telling my bedside assistant, go ahead and pull the shaft back, but leave the cup in place. Once the shaft goes in, we're going to shorten the amount of tip that goes in, leave it right there, antiflex. And this is why you have to make sure your patient didn't move on the bed. You want to be able to antiflex. And while the patient's antiflexed, while you're antiflexing the manipulator, you finish the amputation. Now, if your patient slid on the bed, you wouldn't be able to antiflex so much because your assistant would be running into the mattress. The handle of the manipulator would be hitting the mattress pad. But if your patient's positioned properly, you can do a clean amputation. You can see that here. So this is definitely cervix. The uterus is cleanly removed and you can see it's nice and hemostatic. And when you do it properly by putting upward tension on the uterine corpus while you're amputating, you're going to get a reverse cone effect and you're going to see how that cervix cones in. Now again, because I can see the cervix, excuse me, the uterine vessel nicely isolated, I can grab it and desiccate it without running the risk of worrying about where's that ureter because there's no way it's going to be here. That's just nothing but uterine pedicle right there. But you can see here that the cervical stump has been cleanly transected. I'm going to speed this up just for the sake of time. Go to two times speed here and you can see how it's almost concave. That's because it's a reverse cone effect. And then basically if you want, you can either over-sew this or you can just leave it as is because it's hemostatic and that'll just peritonealize. And I know a lot of people do sacroscervical pexies, so you can certainly do that. And here we're going ahead and pulling the manipulator out and you're going to appreciate that reverse cone, right? And if you want, you can desiccate the interior. You can see we left the ovaries behind on this particular case and we'll just go ahead and irrigate here and get the blood out of the field. But you can see that it's a clean dissection and you don't have to worry about, you know, struggling to get that cervical stump and making sure that you don't leave any lower uterine segment behind. With regards to instruments, I want to kind of jump back to the endoris instruments that you've seen in the beginning and that you've been watching in these videos. Instrument-guided exchanges to me are one of the scariest things that happen on the robot. And why is that? Because you're not at the bedside and you really have to trust your team. That's why team training is important. As you can see from the screenshot, somebody was doing a procedure and they needed an instrument exchanged and whoever put the new one in placed it right through the pelvic sidewall underneath the IP and out the other end. Now, the surgeon who shared this video, this picture with me told me that when he saw that, he was like, oh my God, I'm going to be in for a major complication. Luckily, they pulled the instrument out and basically they got lucky. I mean, they missed everything and all they had was a little defect here in the peritoneum of the pelvic sidewall. So that's the importance of team training is understanding how to exchange those endoris instruments that you've been watching in these videos and to do it safely without getting a complication. Because when you don't do it properly, these are the kinds of things that can happen. Now, this is really old footage. This is on a standard first-generation robot, but even then they had safety mechanisms to prevent complications. But if you don't use the safety mechanisms and you do a poor instrument-guided exchange and you jab the scissor in blindly, you're going to get things like a major vascular injury, as you can see here. So team training, critically important. And we know that if you have a good team, your complication rates are going to be lower. But when your team effort is poor, your complication rates go up. I mean, that's just in the published literature. Another thing to worry about that you need to make sure you grow an appreciation for is just the lack of haptics, right? And knowing where your instruments are at all times. This is a really interesting video a colleague from Europe shared with me. They were doing a case where they were trying to deliver the specimen and they were moving really quick and lost track of one of their arms, one of their hands, their right hand. So they're passing an instrument, a specimen out the vagina. There's the specimen. Boom. There's the scissor in the sidewall. Similar scenario as that picture I showed you. Missed everything. Very lucky. But again, they didn't know that the scissor was in the sidewall because there's no haptics. So if you don't pay attention to where your instruments are, which is another important point in robotic surgery, you can have these things happen. So always have instrument awareness. So these little things don't happen during your surgery. Well, actually not little, but big things don't happen during the surgery. I'm going to switch gears now to electrosurgery. That's another important tool set on the robotic platform. A lot of people in the media talk about the robot being a culprit for getting electrical burns. It has nothing to do with robotic surgery. It's really about just knowing how energy works, right? And this can happen with any use of energy on any platform, whether it's conventional laparoscopy or robotics. And if you know this, if you know this little diagram here of a radio frequency generator, setting a current through the patient, going to ground and back to the generator, if you understand this, then you're going to appreciate what you're going to see here in this video, because there are a lot of folks who will often take specimens and cut them in half to try to deliver them through the vagina. And this is a cadaver specimen, okay? So this is not a real patient. This is a cadaver. And what I've done in the cadaver is I have tried to replicate what I was hearing about happening to other surgeons, right? Because I was asking to do a lot of legal reviews for these delayed thermal injuries to the bowel. And so in a cadaver, I decided to replicate taking a monopolar scissor and using it to split this uterine specimen in half right here. So I've got two arms holding the specimen, and you can see here what we're going to appreciate is three rules of energy of electrosurgery, that radio frequency current, particularly monopolar, needs a complete circuit, that everything goes to ground, right? And it has to get back to the grounding pad, right? So, and it's going to follow the path of least resistance. So it's got to have a complete circuit to go back to the grounding pad, and it's going to follow the path of least resistance. And you're going to see here, as I fast forward this towards the end, another principle, or I would call fourth one being shown here is just current density. It's going to concentrate a current. So I'm going to jump ahead here. And so you can see that we're holding the specimen up, and it's difficult to replicate. But if you watch towards the bottom of the specimen, as we're sending energy into this tissue, that the current is being conducted by the tissue to the bowel, see that it's frying the bowel. And that's because when you when the electricity leaves the scissor, it has to go back to ground, it needs to complete circuit. So it's going to travel through the patient to get back to the radio frequency generator. And it's going to follow the path of least resistance, which isn't going through the instruments that are holding the specimen, it's going to go through this area. And then this is an example of current density, where because the current is concentrated, you're getting a tissue effect. Now, if this entire uterus was sitting on top of the bowel, and you were trying to hit it with energy, nothing would happen, because there's the current density is completely splayed out. But because it's concentrated to just a little bit of tissue touching, as you can see here, again, I'm going to play it a little bit of tissue touching, it's going to cause a frying effect. But when we were trying to do this with a lot of tissue, I'm going to go back here, when there's a lot of tissue touching, you don't get that effect that easily, right? So I have a lot more tissue touching. And I'm just not getting it's hard to replicate. If you let the whole uterus lay on top of this, you're not going to get that much of an effect, it's going to be difficult to get any kind of energy transfer. So I just want to share that with you, that that can happen with electrosurgery, you can also get things like insulation failures, that's another thing that can happen. And you can see that here, this is a scissor being utilized. And you can see as the scissors leaning on the sidewall, there's a that's a pinpoint burn, because there's a break in the seal. So these are the kind of things that can happen with the use of electrosurgery during robotic surgery. We'll jump ahead and skip through that. So that's to not shock too many people watching this. Now I'm going to switch gears to suturing. Another important skill set that's critically important when we do robotic surgery. And I'm just going to jump to the importance of not only having good suturing skills, but also picking the right instruments. And, you know, I'm going to use a copepaxi. And apologize that there may be a little bit blurry in terms of the graininess of the video. But I think you'll get an appreciation here of the importance of, if you're going to sew, for example, mesh to the vagina, it's important to have good suturing skills. As you can see there, I preload a lot of sutures, so I don't have to rely on a bedside assistant to introduce it. But I'm going to let me just fast forward this a little bit here just for the sake of time. I'm going to play two times speed. You can see here that I'm using a nice heavy needle driver, right? This is called a mega needle driver. I've shortened the tail. I'm making loose loops so I can do intercorporeal knot tying. But with the proper instrumentation, which is a heavy needle driver or a meg, what they call a mega needle driver, and something called a long tip forcep, I can do intercorporeal knot tying very quickly, right? And not bumble through it and struggle. Because one of the things that people often assume is that if you have a robot, you're going to be able to sew well. And to be honest with you, when I watch people learning on the robot, one of the most painful things to watch that can be quite cumbersome is people trying to sew in the robot who don't think about the tool selection that they have and then understand the principles of how to suture. So you want to shorten the tail. You want to minimally manipulate your suture. And again, by using this long tip forcep, I don't have to overly keep grabbing my suture and reloading. I can quickly do intercorporeal knot tying, as you can see here. And then once I'm done tying my knots, I can actually cut the suture myself, right? Because I've got a cutting instrument, this mega suture cut needle driver. And again, that allows me to be efficient because I don't have to rely on somebody else to do that. I can do it myself. And again, by keeping your tail short, I don't have to worry about somebody having to trim my tails, right? So notice again, I'm going to do a pulley system, pulley the suture through by minimally grabbing the suture. I don't have to inadvertently accidentally cut it. And again, I'm just, you know, doing good intercorporeal knot tying technique. So I just want to show you that the importance of having good instrumentation is critical to the success of your suturing. And, you know, when it comes to things like closing the vaginal cuff, that's critically important because we know that there's a higher rate of dehiscence with laparoscopic surgery. And even the Mayo Clinic had a high cuff dehiscence rate just from their experience with doing robotic surgery. Now, you know, this is not something that we've seen in our group. We basically have a dehiscence rate that's in line with all the other routes of surgery, such as vaginal and abdominal. But I think it's critically important to make sure that when you are doing suturing, that you leverage the technology to be able to allow you to do those things well, right? And so this is just an example, this is in a lab, but I'm just showing how important it is to be able to leverage good suturing skills. I replicated in a lab setting where we're teaching people how to optimize their movements under the console, in a porcine model, a vaginal cuff closure. And so you can see here that we're using barbed suture. We are, in this case, we've tandem two needle drivers for running this barbed suture, but we're going to use the third operative arm to provide some retraction. See, it's going to allow me to retract the suture. It elevates the simulated vaginal cuff. I can reload my needle, hold it out of the way, bring the third arm in to pull my suture through, retract, bring my needle back in, take out another bite, suture, reload, toggle back out. And you can see how you can get very, very efficient. And basically you have an economy of movement because you're leveraging all your instrumentation. I'm not dropping the needle at any time. And with the economy of movement, you gain efficiency. And those are critical aspects to being efficient and optimizing your outcomes with robotic surgery. Right. And so to me, as you can see here, this is something that you want to be able to try to accomplish with your instrumentation, with how you leverage the robot. And again, this is just to show you how the importance of when you close the cuff, also making sure you get those angles, you can use barbed suture to do that. Here we are going now to an actual case where it's really important to know, like, have a good bladder flap, use good instruments to be able to hold the vagina up for yourself. And again, if you do that properly and you have a good cuff that you created, and again, you can see the uterocyclic ligaments still attached to the posterior vagina. You can do this very efficiently and you can minimize your movements. And I'm going to thread the eyelet with this barbed suture that I'm anchoring things with. I use a 2O V-Lock 180 that's 12 inches on a GS21 needle to close my vaginal cuff. And for me, this is a very efficient way to do my vaginal cuff closure. You can see I've grabbed that uterocyclic ligament there. And again, this is just allows me to close the vaginal cuff in a very efficient way. And also, as you can see there, to really secure that corner, right, boom, that's going to cinch down and my vaginal cuff corner is nicely secured. Right. And again, I think the rate of dehiscence with all modes of hysterectomy is pretty low, and you can even have it lower than that if you just think about technique. And of course, learning curve is key, right? I mean, your learning curve is critical. Even just doing hysterectomy, the learning curve for a robotic hysterectomy is as high as 91 cases in the published literature. So there are a lot of things that go into that, but you always have to appreciate that there's a learning curve to applying the robot to whatever it is that you want to apply to, whether it's a copepaxi or hysterectomy or a reproductive surgery. And that learning curve is endless. And, you know, depending whether you're fellow or resident or attending, that learning curve keeps going. And I'm probably on learning curve 50 at this point because I'm constantly trying to improve my technique. And you're going to have to go through learning curves if you introduce new technology in the robotic platform. So if you're going to do single incision surgery, or you're going to use a new robotic platform, there's a learning curve for all of that. And I think one of the ways that we can definitely help ourselves get through that is with surgical simulation. And, you know, like airline pilots do, it's something that we really should be leveraging more in terms of putting in the time. And, you know, I'm a big advocate that you've got to put your time in, you know, the quote unquote 10,000 hour rule, like they talk about in Malcolm Godwell's outliers, but you also have to do it with some proper instruction and good intent. So just doing things over and over again, but if you do it poorly is not a good idea. And I, you know, sometimes we see examples of people who they do a lot of surgery, but they are doing it wrong every time they go into the OR, you certainly don't want to be that person. So you're going to put your 10,000 hours in, you want to do it with some good directive, some good guidance, and there are a lot of ways to do that. I think the days of see one, do one, teach one are a bit antiquated. I think you should see one, you should probably simulate one, and then go back to watching one simulating again, and then going and doing it before you ever get to teaching one. I think didactics are important. Our use of things like virtual reality simulation are really taking things to the next level, as well as augmented reality. And to me, that's where you really take off in terms of our ability to really leverage technology. And on the robotics platform, you can do that there are a lot of things that are available with a variety of different companies that create things that can actually take procedures like hysterectomy, for example, and break it down into various components, right? You can take these different surgical simulators can do that. I was fortunate enough to be able to be part of a project where I got to develop a hysterectomy module that did just that. It provided some didactics, it integrated anatomy, it integrated the procedure that the that the trainee had to learn. But it also integrated, you know, virtual reality on top of an augmented reality, and emphasize the psychomotor skills that you need to learn so that you can actually develop those skills before you before you apply them in an actual real patient. So you can see here, if I jump ahead, there's a lot of different skill sets that you can practice. In addition to having answer to answer some questions while you're doing the doing the exercise. And you can see here how that is replicated just in this, like you saw that cuff closure video, where you can practice on the simulator, those same psychomotor movements before you actually have to go and do the actual vaginal cuff closure. So I think simulation really is a nice way to augment your learning when you're picking up all these skills, and it works. You know, Pat Culligan did a really nice study several years ago that looked at the use of surgical simulation. And the predictive validity was fantastic in that those individuals that spent the time getting to benchmarks set by, you know, the experts, by the time they, you know, by the time they did their first real cases, they were they were, they looked like they were experts, you know, and to me that that's, that's a very telling when when you look at the data in comparison to people who did do any of the simulation. And so I think it's really important to understand that there's data to support that a lot of the credentialing and privileging guidelines that exist today emphasize the need to incorporate simulation into your into your process, right, into gaining those privileges and even maintaining them. In the last minute or so here, one of the last few things I'd like to make a comment on, it's just the importance of when you do robotic surgery of setting some guidelines or guardrails, I should say, for yourself. My fellows and my trainees know that I'm a big stickler about something called a 30 minute rule in my operation. What I typically will do is, when I'm in the middle of a difficult case, and I'm struggling, I'll look up to everybody in the room, and I'll tell them, listen, I'm having a difficult time right now. If I'm not at point B, if I don't go from point A to point B, in the next 30 minutes, somebody's got to yank my head out of the surgeon console. And we've got to powwow and come up with a new game plan, figure out what we need to do to make progress. Because if there's one thing that you're at risk for in robotic surgery, it is tunnel vision and being caught up in the surgeon console and forgetting that two hours have gone by and you're still in the same spot in the operative procedure. 30 minutes to me is a good rule of thumb. It's also a good rule of thumb when you're working with trainees. I'll often tell them you have 30 minutes to get through that component of the operation. And if you get done in less time than that, then keep operating. And if you don't, then I'm going to sit down, I'm going to take over and move the case along. And so I think 30 minutes can apply in a lot of ways, but it's been one rule that's helped me avoid complications. But in the end, bottom line here, and I know I've thrown a lot of stuff at you, I think success with robotic surgery, it really relies on thinking like a chess player. You've got to have a strategy that goes from start to finish. You've got to understand the setup, the instruments that you utilize, both those that are relevant to the robotic platform and those that complement the robotic platform. And many of the complications, as I said before, are not directly related to the robot. They're part of what we would normally see in GYN surgery, but are definitely preventable if you think about being well-prepared, not overlooking fundamentals, respecting the learning curve, and ultimately incorporating things like simulation and emphasizing team training. And with that, in order to save some time for questions, I'm going to end right there. So Lauren, I guess I'll turn things back over to you. And again, just thank you again for the opportunity to share a little bit about robotic surgery and my experience on this webinar. Great. Thank you so much, Dr. Venkula, for this presentation. We do have a few minutes now for questions. And again, you can submit those questions in that question box on the left side of your window. Go ahead and submit those there. I have a couple questions for you. So the first one was a question of how do you load your, what do you use to load multiple sutures at once to kind of minimize or maximize your efficiency? Yeah. So what I do is like, for example, when I used to do a lot of, at Columbia, I'm grateful I have some great folks that do the urogyne procedures. So I don't do as many as I used to do when I practiced in Florida. But one of the things that I do, whether I'm doing a myomectomy or a vaginal cuff closures, I will estimate how many sutures I need. I cut them to the appropriate length if it's not a barb suture. And I just, what I typically do is I will, you know, spiral them with, with an empty needle driver loaded on one needle driver. And I dropped them by my convention in the right pericolic gutter. So I'll put my sutures that are unused in the right pericolic gutter. And once I use a suture and I cut this and the needle off, I placed the needle with a tail on it in the left pericolic gutter. I tag it in the peritoneum. And so when I'm done with the surgery, what I basically will then do is I come up to the patient, undock the robot. And the first thing my team does is hand me an empty needle driver and the laparoscope. And I pull those needles out that are pinned to the side of the peritoneum. So for example, when I used to do sacrocopopexy, I knew that I needed three, three, 12 inch Gore-Tex sutures that were cut to 12 inches each. I needed three of them. And with those three sutures, I could get 12 interrupted sutures out of those three sutures. So I knew that I just needed three, three of those and I can get 12 interrupted sutures to play six sutures on the front of the vagina and six sutures on the back for the posterior fixation. So it's just a way that if you, if you're good at suturing, you don't cut and break suture easily, you can plan ahead, anticipate the number you need. I just introduce it before I dock the robot. You know, we put it through one of our ports, whether it's your assist port, if you use a big one, I typically put the largest port at the umbilicus so that I don't have to put a big assist port in the upper abdomen. And I preload my sutures and I take them out at the end. But you just have to have a good convention for where you put the new suture, where you put the old suture and tacking the needles so that you don't lose them intraoperatively. Great. Thanks. We have a question from Dr. Holthish. Arnie, thank you for your leadership in MIS surgery. My question is philosophical. If you're stranded on a desert island and had to do an MIS procedure, which would you pick? Stray stick laparoscopy or robotics? And what do you predict for the future of MIS surgery, laparoscopy and or robotics? Well, I mean, for me, I mean, well, if I'm stranded on an island, the likelihood I'm going to have a robot, there's going to be pretty low. But for sure, if I was on an island, I had to pick one or the other, it's definitely going to be robotic. Because I just believe that, you know, conventional laparoscopy has really extended our ability to transform surgery so that we can do a lot of things now by minimal access. But the one thing that I've grown to appreciate over the last 18 to now going on 19 years of using a robot in my surgical practice is that it really is probably the best tool we have right now for being able to treat a large of a breadth of pathology as possible, minimally invasively. And I just think that, you know, if I can't get it done robotically, then I know I've exhausted every potential option to do it minimally invasively and what's left is going open. So for me, it's really more about minimizing the likelihood that I'm going to have to convert to an open procedure. And by being able to approach things with the use of the robotic platform, is in all honesty, my preference. And I, you know, I don't think it's the future. It is the here and now. But for sure, the future is only going to get better. I think the technology is going to become what we call smart technology. So I don't think we can get any less invasive than putting like one hole in a patient with some of the stuff that's out there now. But I think it's really now leveraging on top of the robotic platform, what we call sort of intelligent or smart surgical software, for example, things that are going to help us avoid cutting a ureter, or being able to identify, for example, major blood vessels at the sacral promontory. I think that's the kind of stuff that while we're operating minimally invasively, being able to have better guidance while we're operating in the operative field is going to be the way to go. Okay. Next question. What do you think is the most challenging thing in robotic surgery to teach residents or fellows? And do you have any tips or tricks that make that easier for you? You know, I have to say that teaching robotics to residents and fellows is one of the hardest things I've had to do through the years. One reason is because even with a dual console, you know, you really have to learn to let go, right, on this platform, because it's very different than conventional laparoscopy where you're at the bedside, and you can quickly intervene with certain situations. So, I think that's one of the difficulties involved. I definitely find that it's easier to train fellows just because fellows are with you all the time. There's a repetition that exists inherently by the fact that they're doing surgery continually. With residents, it's difficult because of the episodic nature of their rotations. I will definitely say, though, that starting them out early in their intern year with a strong emphasis on the importance of bedside knowledge, I know a lot of people poo-poo that, and they don't want to put the time in, but we really emphasize that right out of the gate, and really spending time going into the OR if you can, off hours. Time on the simulator, you know, I know it's difficult to get that time with residents and fellows, but that's critically important because when I see fellows spend the time when they first start fellowship on the simulator, it quickly shortens their learning curve in the operating room. I mean, I'm a huge believer just because I see it firsthand. Again, it's just repetition. It's taking that time of being in the OR and doing some dry labs where you go in after hours, practice docking the arms, practice suturing on a towel. There's no replacement for just suturing with actual suture, learning not to break it, developing your visual haptics. You know, it's a challenge, and it's just pushing and constantly getting them on the system and in the OR. That's great. Thank you, Dr. Venkula, so much, and everyone for joining us today. On behalf of the Augs Education Committee, we really appreciate these great webinars and all of your participation. Our next webinar is going to be August the 14th, titled Overactive Bladder in Older Women, and will be presented by Dr. Leslie Rickey, but please enjoy the recorded version of this, and we thank you again. Have a great night, everyone. Thanks again. Have a good night.

robot-assisted surgery

outcomes optimization

complication avoidance

patient positioning

instrument selection

uterine manipulation techniques

surgical simulation

team training

electrosurgery complications