off their phone up here. Good morning, everybody. It is my, first of all, I would like to thank the scientific committee for inviting me to speak at Augs. It is my great pleasure and privilege to talk to you today. And I will talk to you about the complications of laparoscopic surgery. These are my disclosures. I come from University of Louisville. It's a place where they did the first artificial heart as well as first hand transplant. And the place where the two most exciting minutes in sports take place, Kentucky Derby, every first week of May. And also where Muhammad Ali was born and we have this magnificent museum that glorifies his life as well as human rights achievement. So if you ever drive through Louisville, I would encourage you to stop by and just visit this museum. At our department, we do have a Uragan Fellowship ran by Sean Francis and Kate Merriweather. And we have three fellows, Ryan and Keita and Olivia, that I believe are here. What we're known for is the longest running cadaver course in the world. I was the first one, together with Bob Rogers, who started doing laparoscopic surgeries on cadavers. And this course is organized through AGL. And the next one will be in May of 1718. So there are a lot of people that talk about complications of laparoscopic surgery. They usually talk about somebody else's complications. And I've been teaching residents and fellows for over 30 years. And so all of these videos and complications that I'm about to present are actually my own complications. I do take a statement that they were created by either residents or fellows. But I do take a full credit for them. So the only way you're not going to have complications is if you stay out of the operating room and don't operate. There are situations when we are in the operating room and we are getting these extraterrestrial signals that something is wrong, but we are so focused on our work that we just can't recognize the tree from the forest that we see. And this next video actually explains what I mean. We have a sound, please, thanks. So if you, if you, I have to laugh at this video every time, and if you do not want to be overrun by a truck in the operating room, then you better pay attention. So there is a, the only way to screw up during surgery is by two things, either disregarding anatomy or disregarding the technique. And it's very important to pay attention to all those things. So Chaperone in France did a very interesting study where they, in 2002, when they looked at 30,000 patients, and they basically concluded that one out of three complications was in the very early stage of surgery, of laparoscopic surgery. So putting the truck cars in is very important. And then one out of four present complications was not recognized. So it's okay to have a complication, but you have to recognize it during surgery in order to minimize its impact. And then also that the surgeons, the risk of complication was directly proportional to the complexity of the surgery. So there is more chance if you're doing fourth stage endocase or very complicated peripheral reconstruction that you may have complications. But some of my worst complications really happened during, like, tubal ligations. And I'll show you those slides. So surgeons' experience is a very important factor. And in decreasing the bowel injuries, they also concluded. And also, the more experienced surgeon, they were able to do less laparotomies and fix these complications by laparoscopy. But the question is, who is really an experienced surgeon? We don't have any standards. So what we do is we take standards from the airline industry. And we say that about, you know, unless you've had 10,000 hours of training, you're not really a good surgeon. So the question is, would you trust this guy to fly you a plane? I do have a badge and the uniform. So any of you have read this book or do you know who this guy is? It's a New York bestseller, author Malcolm Gladwell, who wrote the book, Our Tires, explaining why successful people are successful. So it takes several things. And this, just like, I'm going to pull a very short, oh, can we have a sound, please? It's not just a matter of, well, this person's a genius, this person has the amazing ability. It is actual practice and hard work. You know, so a bunch, a group of really brilliant psychologists in the field of expertise research have sat down and tried to figure out, how long do you have to work at something before you become really good? And the answer seems to be, it's an extraordinarily consistent answer in an incredible number of fields. And that is, you need to have practiced, to have apprenticed for 10,000 hours before you get good. So every great classical composer, without exception, composes for at least 10 years before they write their master plan. Mozart? Mozart is composing at 11, but he's composing garbage at 11. I mean, he doesn't produce something great until he's 22 or 23. He could show under 9, I think, to 71. If I asked you how long did it take you when you were doing this job before you felt comfortable and good at what you were doing? 10 years. 10 years, yeah. Same with me, right? It's an incredibly consistent finding. And it's really important because it says that we are far too impatient with people. When we sex whether someone has got what it takes to do a certain job, we always want to make that assessment after six months or a year. And that's ridiculous, you know? The kinds of jobs we have people do today are sufficiently complex that they require a long time to reach mastery. And what we should be doing is setting up institutions and structures that allow people to spend the time and effort to reach mastery, not just... So the good news is that you don't really have to be a genius. You just need time and need to be persistent. So when you're looking at the list factors for laparoscopic injury, basically there are like three types of patients that you may encounter, and that's patients with previous abdominal surgeries, multiple surgeries, it's tougher to get in, more adhesions, then difficult and complex laparoscopic surgeries, procedures, as well as patients with very low and very high BMI index. So basically the complications of laparoscopic surgery can become from any aspect of surgery something very benign is positioning of the surgeon, of the patients, the equipment that you have. When I was starting this three years ago, we used to improvise a lot. But now there's no room for improvisation because we almost have any gadget. Then knowledge of electrical injury. We are doctors. We have no clue how electricity works, and we take instruments and start burning and cutting. And then something that can be very, with grave consequences for the patient, is the trocar placement, vascular injury, bowel. So we'll talk about all of these. So basically positioning of the patient. We start very, it's very important to have a patient in the right position and have good stirrups so that they can, the legs can relax without compressing on the perineal nerve and the patient don't slide, be able to put in the tenderloin work, and then also fully catheter for longer procedures. Tucking arms is very important. If you tuck the arms, the surgeon can stand behind. Or otherwise, you're going to operate like this. Or you can comfortably sit on the patient's arm, but it's not going to be very good for the long-term results. So there is a timeline for every complications. Immediately, post-operatively, we're going to have vascular complications. So the way to check it is vital signs and HNH. Two to three days, you may have a ureteral injury complications. And then the bowel injuries, if there is a mechanical injury with the hole, it's going to be apparent next day. But then if it's just like a terminal injury, it may be apparent just a week later. So one thing to remember is that all these things, bleeding, bladder, ureteral injury and everything, as we get away from the surgery, patients should get better every day. And that's the same principle for open surgery. So another thing is we, as laparoscopic surgeons, we have tons of equipment. We have multiple small instruments. Then you have tower. And all these companies have different towers. And I used to operate in five different hospitals. They all had different systems. And you, as a surgeon, should be able to know all these things, how they function. You cannot rely upon the nurse to do that. Oh, okay. This is a problem. It's not. So in this film, I'm showing that we're cutting the colpotomy. And I swear to God, this is a fourth-year resident doing it. And then he was just inadvertently touched the bowel here, which we did just like epiploic of the bowel. So this justifies two things. Always keep your instruments in the middle of the viewing field so you can see it. And then the other thing, we always film all our procedures that, by filming the procedures, we can go back and take a look and see what's going on. So the key is always pay attention in surgery. Uh-oh. Going to have a problem. None of these films may be. They could not run my laptop for some reason. And the whole presentation was put on the jump drive, but for some reason it doesn't work. So insufflation failures are in obese patients, in very thin patients, patients with previous abdominal scars, and also patients with failed insufflation. So if you try to insufflate and you develop this artificial space, you have to use another technique in another place to get in the abdomen. So there are several kind of techniques, and most of the people use transumbilical. When you use varus needle, it's important to make sure that the patient table is flat. If it's in Trendelenburg position, 45 degree of Trendelenburg and 45 degree of your needle placement may make 90 degrees right to the large light vessels. And this is how most of the aortal and common iliac arteries injuries happen that the patient is in Trendelenburg. And then you can choose a direct insufflation, which is very safe method. By lifting the abdominal wall, you're pacing the trocar without varus needle, without pneumoperitoneum, parallel to the large vessels. And this works really good. Then there is Hassan technique that a lot of people work, use. But the problem with Hassan, you have a very small incision, like 3 centimeters, and then a very obese patient, you have like 10 centimeters of fat, and it's very difficult to get in the right place. And then there is a transuterine insufflation that I published like some 25 years ago. We put the varus needle through the cervix, through the fundus of the uterus inside, and we used to do it on the very obese patients, because the original laparoscopies were done through the cul-de-sac. And this shows the needle through the uterus. And then Joe Childress in 1994 republished the technique of Palmere, and it became really very popular, placing the needle in the midclavicular line, and that is probably the safest way to do the surgery on these patients. So in general, using Palmere's technique, no patient is too big. We have a lot of obese patients in Kentucky. After all, we are a headquarters for Kentucky fried chicken. And this patient here, my fellow, is standing on a step stool. This patient was around 200 kilos. And also there was no previous surgery that abdomen is inaccessible using left upper quadrant technique. Again, this particular patient had 20 laparotomies previously, and she was sent to me for a left ovarian remnant. And we went in the left upper quadrant. Interestingly enough, we didn't really find a lot of adhesions, and we were able to insufflate. This was done by my colleague and ex-fellow, Dr. Bissett, who this patient had 14 surgeries. So one thing to remember, it's important. Doug Hurd did a study where they looked at the interperitoneal pressures. When you put the trocar at pressures of 15, this is your distance between the retroperitoneal structures. When you increase that distance, the pressure to 25, that increases the distance and makes the surgery very safe. So in the very early stage of surgery, we always increase the pressure to 25 and then do the surgery. So if you get in and you find this kind of scenario and the patient does not have ectopic pregnancy, then you need to put the deep turn down work and push all the bowel back and look at the promontory. So here we have a right common iliac artery. We have a promontory right there. And this is the trocar injury. And the reason is that my female resident put the finger along the trocar, and she has short fingers, and there was this much of a trocar down, and she jammed the trocar directly in the promontory. So basically, what anatomists, any of the fellows in the room, would like to comment what structure did we miss here? Left common iliac vein, because it goes right here. So we missed that. We were lucky. So this shows the left upper quadrant technique that we put the techniques in. And then we always put the 5-millimeter scope and clean the adhesions from the umbilical area. So in this area here, there is no way we could have safely entered the abdomen through a umbilicus area because there was like bowel adhesions right there. So if you take any take-home message from my lecture today, is whenever you have a difficult patient, and those are with previous abdominal scars or those that are very obese, then you should try to do left upper quadrant technique because it's probably the safest for the patient. Oh, okay. How do I go back? Can you turn me back, please, one slide? So one thing is—can we go back one slide, please? I don't know how—I mean, I don't have control. That's why I love to—okay, here. All right. So one thing is when you do these procedures in left upper quadrant, you should always put the OG tube or NG tube. In this case, we put the trocar in. The tube wasn't in all the way, and we found ourselves looking at the inside of the stomach. When you see something really red, most likely it's stomach. So we freaked out. We called general surgeons, and they said, oh, that's nothing. We do it all the time. We take stomach biopsies. So we just—we went ahead and we sutured. She came for tubal ligation. We kept her in hospital one more day, so we just used an imbricating suture. And that's basically what I learned. The principle of surgery is you make a hole, you close the hole. So in order to close the hole, you need to have to suture. So this is basically how it works. So when we're talking about vascular injuries, there are three types. One is from the abdominal wall bleeding by putting the trocars in the wrong place. Then intraperitoneal, depending what you do, and it's mostly ovarian, uterine, arteries, depending whatever procedure you do. And then retroperitoneal injuries are the worst, and these are dependent really how you put the trocars. And basically there is no lawyer in the world that is going to defend you if you have any injuries placing blindly the secondary trocars. So once you put the first trocar, it's okay. You can hit anything and pretty much get away with it. But if you're putting a secondary trocar and you're not doing it under direct vision, or if you have any injury, then probably that's a litigation case. So there are two structures, arteries, on the abdominal wall. It's the inferior pegastric and superficial. So the inferior pegastric is always visible from below. You have to see through the trocar. You cannot transilluminate. Here we are transilluminating. I'm showing where the inferior pegastric is, my finger, and you can't see this is the wrong, that's not it. So you have to always put the trocars under direct vision in order to avoid inferior pegastric. If that happens, there are several techniques. You can take a large needle and close it like that. The bleeding is like big, it's like Niagara Falls, see, coming from the abdominal wall. Or you can have these suture passers and then tie incision under and over, above and underneath. And then also you can put this, I've tried this like twice, it didn't really work very well. So all you have to do is just tie and cut this suture next day. The patient will be fine. They may have bad hematomas, but they're going to be fine. You don't need anything else. So when you're talking about retroperitoneal injury, that is on a different beast. So aorta recognition is the key to survival. Direct compression on the aorta is, you know, open up the patient always. Grab the aorta, preferably below the renal arteries. Do IV, you know, fluids. Do not open the hematoma because it's going to compress on the bleeding. And then the key is cold vascular surgeon, really. So this here, don't ever try to do this. This is an old video from 1994. And we violated every principle of surgery here. There was a lady that came with pelvic pain and we only saw this small adhesion to the pelvic sidewall, I swear. And we didn't have scissors on the plane. As I said, we used to improvise a lot. So we used the monopolar needle. I swear to God, my second-year resident, she moved like she's got Parkinson's disease. And look here. At one point, she hit the external iliac vein. And so this is like a type of bleeding we got. At that time, I didn't even know how to suture or anything. So we just got a blunt probe and we plugged it in and a big hematoma formed. But then it stopped. And we did the CT. And then we did the CT next. We took the patient out. She was fine. We looked her in recovery. Everything was good. We monitored her. So we got away with this injury, but I would not recommend that you do it again. So for aortal, nowadays I would open it up and suture it laparoscopically. Whenever placing the trocars, the key is really not putting the abdomen in Trendelenburg. So once you insufflate it and put the trocar and the patient is in Trendelenburg, you have a high chance of hitting either artery or... So this patient here was done in the surgery center outside of the hospital. We're doing a tubal ligation. And I'm done with the tubal ligation, and I always look what is going on. So I see this big mass here, and I'm thinking maybe she's got like a pelvic kidney. I look on the side, and then I see some blood in the gutters. I turn to anesthesia. I said, what's her blood pressure? He said, I can't measure it. The cuff is not working. So then I see this thing here, right there, and I freeze, like right there. So that's an injury with the trocar to the retroperitoneal vessels. So I'll just tell you what was going on through my mind at that point. So the first thing, yeah, of course, reaction. And then let's withdraw the trocar and pretend nothing happens. So if you do that, your patient is dead, your career is dead. Then the vasovagal reaction hit me, and I felt that somebody stabbed me with the trocar. And then I became very religious, but that didn't help either. Then finally I recognized I need to get a vascular surgeon. We transported her. She survived. I survived, and that was so. So you would say now, why didn't you do Hassan technique? So this is the only video that's not mine. Actually, one more. I got it from a colleague from Europe. So on a very thin patient, there are a lot of thin patients in Europe, using 11-blade scalpel, they got directly into aorta. So you can see that. And then, like, to make things worse, they're, like, kind of, you know, sucking, and they're, like, trying to coagulate with bipolar. You should never do that. They did open the patient. She survived. Now, this thing is also not mine. I have no idea whose it was. I apologize if the author is in the audience. But, oh, can we go back, please? One more. Can I go back one slide? It is a, okay, so this is a robotic surgery. You would say, why don't you do robotic surgery? Because you would have less of these complications. So here they're putting robotic instruments in. Basically, you can screw up with every procedure if you don't do it right. There is no procedure is a complication proof. So look at here, I'm just, look at the time it took the surgeon to kind of watch the thing or get scrubbed and, you know, take care of this. They forgot that they should place the, one of the robotic instruments and at least hold this, but they pulled the camera very quickly. So at least you can kind of, on robotic surgery, you can pull, you can place your instrument there at least to compress the bleeding. So this is a very old video that I was teaching one of the community physicians how to do TLH. This is a harmonic scalpel even before ACE came out. And harmonic is a very delicate instrument. You need to know how to coagulate. So this guy was like trying to coagulate, but it just wasn't successful. So I'm holding the camera and, you know, I get blood. So this is unedited video. I pull it out. As I put it back in, I get like Japanese flag again on my camera. And then finally, I clean it against the bowel and go and intervene with the grasper. We stop the, at least stop the bleeding temporarily. I don't care if I grab the ureter or anything. Then we use the suction irrigator, clean it, bipolar, and so on. So now talking about bowel injuries, and in urogyne, you kind of work close to the bowels. It's, you know, usually they're not from varicose needle. The most important thing is like patient symptoms. If they have sharp abnormal pain, you should know they may have bowel injuries. Small bowel injury, bands go up, leukocytes down. C-reactive protein is good test. They need antibiotics. They need surgery. So Bronson looked, and depending, minor procedures, low risk, higher procedures, more risk of bowel injuries. Delayed diagnosis is the worst thing. So you have to get CT with contrast right away. And this is scenario. They have adhesions. You put the scope in. So this happened in 1995. Joe Childers just published the article on, where do I get, okay. So look here. I was pulling the scope out, and my nurses told me, what is that green stuff coming out of the scope? We operated for 45 minutes. I took the ovary out on this lady, and then I listened to my nurses. I said, I didn't see any green stuff. I took my 5-millimeter scope on the side, and look here. We went through three loops of bowel, and on the apnexectomy that we would have missed unless my nurses told me what was that thing. So I'm just like in the interest of time. So anyway, we called general surgeons. They came in. They gave her a huge incision, but she was fine, and we got, I mean, we treated her. So this next video also, it's about 10 years old. My fellow is operating, and I swear to God, I wasn't even scrubbed. And we're taking the uterine artery on the right side, and he's now repositioning the instrument and now catching it again. And look here. He picked up sigmoid colon that we all missed in the operating room, and he burns the sigmoid colon. So I call in general surgeons, and then trauma team was on, and you know what? Try to avoid trauma surgeons. They have no clue about laparoscopy. So they said, okay, you need to open her up. I said, I can put stitch laparoscopically. They said, no, we would really open her up. So they opened her up. They put the stitch, only one stitch. I said, I could have done this laparoscopically, and he said, yeah, you could have. So this next video actually shows when you're in trouble, you better get somebody who is experienced to get you out of trouble. Überlebensberater. Mayday, mayday. Hello, can you hear us? Can you hear us? Can you hear us? We are sinking, we are sinking. Hello? This is the German Coast Guard. We are sinking, we are sinking. What are you thinking about? So here, I'm doing a case with a fellow again. And I have to admit the fellow was too slow, so I said I'll take that. And here, bang, I hit the bowel. I didn't recognize it. So I make sure I hit it again to make sure that I'm in correctly. So then I recognize there is a bowel. And then we said, okay, let's go and try to clean all this bowel down. So you had a very good bowel prep, you can say. And so we clean, we take the bowel. She had direct adhesions of the bowel to the wall, which is very, really challenging. And it's very difficult to miss. Anyway, so we cleaned all of them that we call general surgeons in. And this time, our general surgeons are really good now. And they made a very small incision. Unlike the First Lady, they open her from the xiphoid all the way to the pubic bone. This one, we just did like a six-centimeter incision. We fixed the bowel, and we were able even to run the bowel. And you can see how small the incision was. So next, I was doing a TLH with a resident. And at the time of colpotomy, she cut the bowel here. So there is a very small cut. We call in general surgeons. I said, I'm going to close this. He said, yeah, just do it laparoscopically. So I told for the interest of these lectures. And I figure one day I'll be teaching to the Uruguayan crowd and vaginal surgeons. So I told the resident, okay, just finish the surgery. We'll pull the bowel down in vagina, and then we'll fix it vaginally. So at that moment, we pulled the bowel down. And for those of you that don't know how to suture laparoscopically, I'm sure you know how to suture vaginally, right? So we're suturing vaginally. And then the general surgeon walks back in, and he says, what are you doing? I said, we're fixing the bowel through vagina. He said, are you crazy? And that's my resident. So this is way before orifice surgery, you know, we were doing these things. And then we really got good at it, and we basically started doing bowels ourselves. And this is just like we call in. I'm not advocating that you should do it yourself. You should call in as many people and put their names on the chart as possible. You know, solution is dilution. But here in this case, I do a lot of endometriosis cases, and this was one of the cases, you know, that I called like hand grenade in the pelvis. So we did resection and the shaving of the bowel. And instead of just doing a air test, I always put like methylene blue through the Foley catheter, and then we found that she had a huge defect. And this is we didn't even call general surgeons in this case. This is just my fellow suturing the whole thing, and we fixed it. So the key again is just to know how to suture. So now you're talking about urinary tract injury. This is very important paper in my mind. It was published in 2014 that during laparoscopic hysterectomy, we thought that the incidence of urinary injury was much more than. It's actually 0.7. 0.5 is for bladder injuries, and 0.2 for ureteral injuries. So it's pretty good, not really high numbers. And all of these can be fixed laparoscopically. So here's one of my fellows doing TLH, and we see ourselves looking at the Foley catheter. So we just, and it's not a big deal really. We sutured very nicely. In the interest of time, I really have to speed this up. So we closed. Bladder is the most forgiving organ in the human body. That's what I learned. And you can really whack off half of the bladder, and the patient most likely will be fine. But the key is also how to. Sometimes we do find ourselves where we find a, and this patient came just for hysterectomy. We had no idea that she had a bladder nodule. So we looked at it. We figured out that she has a huge nodule in the anterior compartment, and then we went in the space of retios. Then we did cystoscopy. This was a 3-centimeter nodule in the bladder. I never use catheters in the ureters. There is no need to do that. It's just more difficult to do urethralysis except in these situations when you have to resect the bladder. So we resected the bladder. We put the catheters in. And this is one of the rare situations where it's really fun to get into the bladder on purpose. So we just open up. We use harmonic scalpel. We open the bladder, and we just went inside. So you can see where the trigone is. You can see the catheters as well as foley. So we resected the nodule, and then again closed the bladder, and end of the story. So the most common predator to the ureter is the gynecologist, according to the anonymous urologist. So when we do surgeries, you have to see where the ureter is. The best place to see it is in the pelvic brim, and just follow it down. Ureter is like a snake in the grass. You have to look. It's there somewhere, but you have to look for it. You can see the relationship between the uterine artery and the ureter, the relationship between the ureter and the uterus sacral ligament, and if you stay away from it, it's fine. If you're getting any problems, there are two ways. You can put these tents, which I don't really like, or you have to know how to do urethralysis. Always after hysterectomy we do cystoscopy, which is we do poor man's cysto. We clamp the foley, and then we use the three-way foley to fill it up, and we use a 5-millimeter laparoscope, 30 degrees, to inspect the bladder, and we do it on everybody. Unfortunately, in the U.S., this is not standard of care, and I've done a lot of litigation cases where if you've done this, you homework, at least you decrease your chances of being sued. So the thing is always, and this is one of those cases where we did forever. We waited, waited, nothing. Then we went finally and decided to cut the lateral stitch. I'm lost here. My mouse is not responding. Oh, here. So we cut the... I can't find my mouse to run the... What is that? You guys in the back, can you help, please? It's amazing in the back. It's amazing in the back. I'll tell you, this procedure, you know, the whole operation, I was there. There is like a huge amount of equipment and these very talented guys that do this for us. I would be lost. So anyway, we took the stitch off the bladder of the... We took the stitch off the cuff, vaginal stitch, the lateral stitch, and then we did the cysto again and the patient was fine. So the key is then really to make sure that doing a cystoscopy after TLH is very... Are you working on it? All right. Doing cystoscopy after TLH is very important. While we're waiting for him. Yeah. Can you tell us how it is that you recognize the bowel injury? You talked about methylene blue and the... Okay. What I do, I put the Foley catheter in the rectum with the 30 big balloon, and then we inflate the big balloon in the rectum, and then we put the integral Carmen and we just shoot in the rectum from below. And we also put a grasper so that the contrast doesn't go all the way high. And then this way we can identify the injury to the rectum. So all of you have probably seen the scenario where you put... Oh, no, not seen. I've never seen it. This is first time like five years ago. And, again, it was just... They put the trocar to the bladder too low. And this is new procedure that we're trying to describe. It's called cystoscopy of the abdominal cavity. Where, you know, they call me back and I went in. They put the trocar too low, so we had to close the bladder. So I went in the space of Retzius and closed that. And it was true and true injury really through the bladder. So it's very important to do this. And this is a second kind of injury that we picked up after hysterectomy by just doing a cysto. And that's... Oh, okay. So the key really for a gynecologist to know how to do urethralysis. And recently we were doing lab for fellows in the Midwest, and I was doing cadaveric dissection. I was very surprised that few of the fellows have never done urethralysis. And when I was talking to my first-year fellow, she said, I've already done like 20 urethralysis in two months. So it's very easy. You pick up the peritoneum. You use the scissors. Let the pneumoperitoneum do its magic. And then you just like... And then you follow the ureter. In this case, we use harmonic scalpel. We always put the active blade away from the ureter. And then you can see the ureter, uterine artery. And in this case, she had endometriosis that's very close. Another thing, when we operate in Louisville, these labels automatically pop up. So we know where the right anatomy is. So the ureters, I think this has sound. Can you please increase it just to demonstrate the urethralysis? Okay. Ureter is always on the left pelvic side, on the pelvic side wall. It crosses the common iliac artery. And then you just lift up. You open up. CO2 gets in. And it helps you dissect the space. And then you can just follow the ureter all the way down. And in cases like this where the patient has a four-stage endometriosis, it is very helpful. And it's imperative to do urethralysis. And then we do it on both sides. We can do it on the left and right. Ureter is always on the peritoneum here. In this case, on the patient's right, we can peel it off. Underneath is the... In the interest of time, I'm going to skip that. So this is another case of urethralysis. You can be rough on the ureter. It's no problem. I mean, it's pretty much you can... Oh, I lost it. I lost my... Can you guys help me in the back, please? So in this case, I'm trying to show... Hello? I hate presenting without my laptop. It would have been different. Oh, same thing. Excuse me. Can you help me in the back? Good. They're working on it. So the thing is always, as a gynecologist, there are two things, really, that I try to explain to my fellows. The key is anatomy. You need to know anatomy. And I use the, like, good analog. It's like I'm a great car driver. I would be worthless in Chicago because I don't know streets. So you need a, really, to know where you're going and where, how to stay safe from certain structures. So that's the imperative is anatomy. And the more you are comfortable with anatomy... I have no idea. It's toward the back. It doesn't matter. Just like... So the more you get comfortable with anatomy, the more confident you will be as a surgeon. And then the next thing... Okay, great. I can't find my... I can't find my... Oh, good, good. All right. I can't find my mouse. Did you just play the video? Sorry. So the other thing is the suturing. So you need to be comfortable in laparoscopic suturing. And usually I try to avoid any of the suturing devices. No, we got that. Okay, this is the one I was... Forget it. Skip it. That, too. All right. So it works. Okay, so we just like... Again, this patient has endometriosis. It's a great kind of anatomy slide because it shows you first how rough you can be on the ureter. That's one thing. And we're going to find the ureter right there. And then we're going to find the obliterated umbilical artery. So that's the ureter, I believe. And then you will find here the obliterated... No, this is not the ureter. This is the vein. And this is the obliterated umbilical artery. And the ureter is going to be... We are, of course, looking on the patient's left side. So the ureter is going to be right there. But you can see the first vessel that goes off the obliterated umbilical artery is the uterine artery. So you can see here the relationship between the ureter. Now we got our labels. Now we know where we are. And then the artery and then obliterated umbilical artery right there. So we are in the paravesical space. All right. So go to the next slide. All right. So the worst case scenario is really like looking at cases like this. I've got 10 more minutes, right? We're close. We're over. All right. So the worst thing is endometriosis like this. So you've got to restore anatomy, do urethrolysis. I showed that urethrolysis I was in. So we'll skip that. So this here patient had a huge endometriosis right there, right on the uterus acral ligament. And guess what? She didn't tell us that she had two ureters. And so we go inside. We do urethrolysis. And then as we go in, we find the ureter right there. But then we try to kind of dissect it. And then to our surprise, we find another ureter right there. So she had endometriosis nodule that was like basically lodged in the pelvic sidewall with both ureters. And then we had to resect this. But, you know, the key is what identified the ureters. I have to skip this. So this is another very interesting video that shows the patient came up to us with pain. And then we did laparoscopy. We couldn't find anything. She then came back a month later again with pain. We did CT. We found she had an ovarian remnant of this side. I can't speed up the video. So anyway, so we had to go and clean the ovarian remnant. So this here, this is the worst case I ever had in my career. And it was a very bad endometriosis. We did urethrolysis on the patient's right side. So we did urethrolysis. And then this is the ureter. And this is the cervix. So have you ever seen the ureter that goes into the cervix? I have not. So after deliberating for like 10 minutes, we finally, in surgery you have to cut sometimes. And then we just cut it, and then we recognized, realized that we hit the ureter. And then you can just fix it laparoscopically also. So you can do a psoas hitch and re-implant the ureter. How much time do I have? Felicia, how much time do we have? We did start a little late. Five minutes, yeah. Five minutes? Okay. So you can do a psoas hitch. You can just like open the bladder and then get the ureter in. And, again, for that, you need laparoscopic suturing and be able to spatula the ureter and so on. So I have two more films that I probably want to show to you rather than this. So we'll just jump to that. Can we advance to the next slide, please? Next one. All right. So here, I don't know if all of you heard, but in England, starting last month, there is no more mesh. So we're all back to the birch. Can we run the video, please? So here we're doing a cadaveric dissection. And this is the ‑‑ in Louisville, we have these cadaveric labs. So we open the Cooper's ligaments. The Foley is in the bladder. And then the Foley is right here. So look here. This is basically a paravaginal repair. The paravaginal defect, according to Delancey's paper, is a second level of pelvic support failure. It starts from the fascial white line and paravaginal defect. The hand is in vagina. So you bring this laterally. And basically, is there a way to speed this up just a little bit? So we have residents that kind of ‑‑ we teach them how to do laparoscopic surgeries on cadavers and same with fellows. So on the left side, we have not ‑‑ we have created the defect. She did not have a defect on the left. So we're just teaching them how to fix the paravaginal repair. But the key here and the next thing is they're having a lot of fun, as you can see. I just want to go over the birch, because there are a lot of, really, fellows that may not know how to do it. So you put the catheter. The mid-urethra stitch goes like one centimeter in the middle of urethra and attached to the Cooper's ligament. The UV junction stitch goes about two centimeters lateral. And you attach it also to the Cooper's ligament. So basically, we are putting this on ‑‑ we're putting a heel. In this case, just a simple suture. And then we're attaching it to the Cooper's. And this is UV junction stitch that we also attach to the Cooper's ligament. And the key is to make a hammock, not to really strangle these sutures all the way and tie them up to the side. So I just want to see you ‑‑ show you at the very end of this how it looks like to ‑‑ because you may be doing birches more and more if we are not able to use any mesh in U.S. anymore. So this is the side that is completely fixed. And this is the side with the defect on the other side. So this is the basics of the, like, birch. Again, for that, you need ‑‑ And then this video was done by my first fellow 18 years ago. We go in a pair of vaginal. Can you increase sound, please? Hello? Can we get sound? All right. So you open the ‑‑ this is on a live patient. And in surgery, you open the space of retios. You identify fascial. Did they turn off my mic? Is that the sign that I'm done? All right. So we identify ‑‑ So you see ‑‑ So this is really best repair for patients that have sister cells. So basically we put the stitches, and then you have to use, obviously, a permanent suture. And then there is nothing ‑‑ You have to be careful on the first stitch, on the high stitch. You may back the ureter on this side. But laterally, there is pretty much, you know, safe to dissect. Incisional hernia, we'll skip about that. And then overall, this, I'm done with my presentation. The basic, the contraindication for laparoscopy, like, absolute, patients that cannot tolerate laparoscopy, do the cardiovascular. And then everything else is relative, basically. For me, permanent, you know, personally, it's much easier to do laparoscopic treatment of ectopic than opening up the patient, even if they're in shock. And I would like to thank ‑‑ These are all my fellows that I owe gratitude for majority of these videos, especially these two that are now working while I'm uncovering the service while I'm teaching here. And these are textbooks that I've published. I'm not selling textbooks. You can steal them from the library. But this is my website. It's called GYNLaparoscopy.com. And you can find a lot of these videos. All of these videos are on that site. And a lot of these videos are also narrated. If you cannot remember GYNLaparoscopy.com, you can Google best doctor in laparoscopy. Not surgeon, best doctor in laparoscopy. Which means I have a best web design. Thank you. Thank you. Dr. Pasek, I just have one question for you or ask you to comment, remind people. I saw a video recently Peter Rosenblatt shared at a master course, and it was of a colleague who had done a supracervical hysterectomy. The uterus was in isolation. And they started trying to morsel it using the monopolar scissors and ended up with a lot of, every time the, wouldn't carry the current. A lot of smoke. They wouldn't carry the current except when they were touching the bowel. They didn't recognize that they were closing that circuit through the bowel. It might be a minor point but kind of a good reminder for people about the energy sources with the monopolar scissors. Well, the key, again, is just like we as gynecologists are totally oblivious how the surgery, how the electricity works. And it's very important to know the distinction between monopolar or bipolar mode as well as your settings. And, of course, again, anatomy to make sure that you're far away from the structures that you're supposed to, that you could theoretically injure during whatever you do. I personally don't do any supracervical hysterectomies anymore. Okay, thank you. The main teaching point around that is with the monopolar scissors, it will close the circuit. And so if you have it detached from the body, wherever the other end of that uterus is, maybe laying low on the bowel, you feel like you're cauterizing it up atop. But what you're causing is a bowel injury as that circuit is going for its grounding source. Things that are not attached to the body, you have to remember with the monopolar scissors. Do you follow me? It's something we forget about. And that's not the worst example because I've seen the video where the current jumped from the ovary. They were trying to work on the ovary, hit the external iliac vein, and then started bleeding. So that's even worse. Yeah, you're right. That's even worse. Agreed. You have a question? Donna Messinger is from Maryland. For those of us born and raised in Kentucky, thank you for showing that good things do actually come out of the state despite current environments. Quint, thank you for a terrifying presentation. Can you comment just briefly on how you stabilized the patient from a surgery center with that vascular injury to get transported to a hospital? Well, we called the hospital right away. At that time, I made a mistake. I should have opened up the patient and held my hand on her aorta. They told us the surgery center was very close. It took literally like 10 minutes really to bring her in. We did not open that hematoma. And then when we came to the surgery, they were already ready and ready to fix it. But I would definitely encourage all of you. This was an injury that happened maybe like 17 years ago. And I would definitely encourage all of you to open up. Never do fan and steel. Always up and down incision laparotomy and just hold pressure on aorta. Thank you very much. It was great. Thank you.

laparoscopic surgery

complications

vascular injuries

bowel injuries

urinary tract injuries

anatomy

ureter

bladder

surgical techniques