I would like to welcome all of you to our next installment of the AUGS and SUFU Fellows Virtual Forum Web-Based Lecture Series. So, as you know, this is a series of presentations by experts in our subspecialty from across the country developed exclusively for our FPMRS Fellows. The goals are not only to enhance your understanding of the FPMRS learning objectives, but also to allow you the opportunity to interact with experts in our field in real time. This presentation will then be captured and made available for view at any time on the AUGS website. So, for this evening's presentation, we have a live surgical video, and we have one of AUGS' finest speakers and scholars with us and clinicians, Patrick Culligan. He is Professor of Obstetrics, Gynecology, and Reproductive Science at Icahn School of Medicine at Mount Sinai in New York. So, his presentation today will be Robotic-Assisted Laparoscopic Supracervical Hysterectomy and Sacral Copal Plexus. Thank you, Dr. Culligan. Thank you very much. We can go ahead and start the video. As you can see, this patient was 66 years old, stage 3 prolapse with the leading edge to the anterior wall, as usual, and in basically pretty good shape, kind of a young 66-year-old. So, to start out with, I've got the third arm. I've got the single-toothed tenaculum in the third arm, but I'm using it kind of like a blunt instrument. I've got it closed. It's not exactly the way it's designed to be used. Another instrument you could use for this is a double-fenestrated grasper. And once I'm sure that I'm at the sacral promontory, what I'm trying to do is get the peritoneum tight across the promontory by pulling the colon lateral and then just creating this space, just a one-layer opening where the CO2 can get under there. And really, right about now, all I want to do is open up the entire right pericolic gutter and make sure that I've done so in a way that will make it easy to close the peritoneum back over the mesh at the end. So, right now, I'm not even focused on exactly where the ligament is. I just want to get this pericolic gutter opened up. And I think it's best to split the difference between the colon and the ureter. And if you have to cheat to one side or the other, I generally recommend kind of cheating a little bit to the ureter side because the bowel, I think, is a little more scary to us in general as urogynecologists than the ureter. I do this without really any assistance. I think that if you get the arms of the robot working to your advantage, then you can avoid kind of sword fighting with someone who's being your assistant. What I'm doing all along the way is I'm trying to make sure that I've stopped any bleeders as soon as they start, even the tiny little bleeders, because doing so just preserves the look of everything. If you start to get much bleeding going, then it kind of stains all the tissue planes, which then makes it harder to discern where you're headed. So, now, I've already done the supracervical hysterectomy. I figured that wouldn't be of much interest. So, I did that supracervical hysterectomy with nothing in the vagina. I just used the single-toothed tenaculum for my traction and just go ahead and do it and come across the cervix just underneath the fundus. So, now that I've completed the pericolic gutter, I'm going to – so, there's the uterus sitting there. Sometimes you can actually use the uterus as a retractor. So, I'm trying to tuck the bowels away a little bit. Again, the theme of this procedure is how to do this without needing very much assistance at all from your bedside assistant. So, if the uterus is going to cooperate here, then I'll have the bowels out of the way that way, and I'm just tucking the single-toothed tenaculum into this space like a blunt instrument. If this isn't going to work, then I'll just toss it up. I can't remember if it worked or not this case. Let's see. Yeah, we're going to forget about that. I'm just going to try to sweep over with the single-toothed tenaculum, or you could use a double-fenestrated grasper again. And I'm not trying to grab the bowel. I'm just trying to get right next to the descending colon in a way that lets the peritoneum get tight over the sacrum. That's the real important part. I apologize that this video is a little bit pixelated. I think it had to do with the video streaming not being supported if it was complete HD resolution. Now, here where I'm trying to find the middle sacral vessels, I just sort of look for them, but I'm not trying to actually do anything to them. I'm really trying to ignore them and find a free pathway down to the ligament itself. And when doing this, I'm really just looking for safe little moves that let me get from layer to layer, and usually with very little cautery. And once I find what I consider like a little window of opportunity down to the ligament, then I'm really not going to do much except spread it open and do little touch buzzes like this to anything that might bleed. Very important to stop every little bleeder as soon as it starts or do something to maybe not let them start to begin with so you don't stain all the tissue planes because I think that's how people get into trouble. I'm only really trying to expose the right side of the ligament, and I'm really generally leaving the middle sacral vessels intact, and by doing so, probably leaving the hypogastric plexus intact as well, which can potentially theoretically help with bowel function. So I'm showing all this real time because, you know, it's sort of like this every case. You just find that little window, and once I've exposed enough of the ligament where I feel like I can safely put sutures in, then avoid the disc, then I'll move on. A little bit of a bleeder there. I'm going to get that vessel and then just leave that alone. I find that if you get the sacral dissection to look pretty good, then generally if you come back to it to do your suturing at the end of the case, it will look even better because something about the CO2 kind of percolating in there makes a difference. So now I've got the cervix unstretched. I don't have anything in the vagina, and my assistant is going to do one of the only jobs, which is to hold the peritoneum. So we use a three millimeter assistant port and a little three millimeter needle holder to grasp the peritoneum and create the proper traction and counter traction so that I can get the camera right on top of the action and do the anterior dissection all the way down to the level of the trigone. So the first order of business is almost always to take down the bladder pillars, and so that's what I'm going to be doing here. In order to get a nice wide dissection anteriorly, it's important to do a very wide dissection right from the start, and that almost always involves taking down the bladder pillars and making it a little wider than maybe even you think you need to. The patient's leading edge of her prolapse was five centimeters. She's got stage three prolapse, and it was a pretty big systocele. And so I want to be able to treat the entire prolapse with the sacrocolopexy and not have to leave anything to do vaginally. And so I'm going to complete the dissection all the way down until I can see the imprint of the Foley bulb on the other side of the bladder, and I want to make sure that I've gotten lateral enough to where if there is anything resembling a paravaginal defect laterally that I can sort of gather up that excess tissue towards my mesh. My mesh is four centimeters wide. It's the Coloplast Restorel Y-Mesh that I use. So here as I'm finding this surgical plane, I'm really just trying to make sure that everything's on proper tension, and when you're doing it correctly, it sort of looks like this right here where it kind of explodes open. Like if you're pulling on it just enough, you can maybe touch those, anything that looks might be a little bleeder, and then just use the cold scissors most of the time, which makes the tissue plane just kind of sort of explode open. And my assistant is really only holding the anterior peritoneum to help me with the counter traction. So every now and then I'm going to pull the tenaculum, which is on the cervix, and you can imagine when you're sitting at the console that it's really sort of like tucking the cervix up under your chin. So now to get a little more lateral, I'm going to get even more of the tissue that I would call the bladder pillars, and this will let me have a much wider dissection plane going all the way down. I'm using the PK Dissector. There's lots of different options that are good. I like the PK as a dissector and as a cautery device, and I'm using the monopolar scissors. And again, nothing in the vagina. So I'm looking for the little areola tissue every time I'm going to make a move in order to get me into the right plane. The ureter is way off laterally at this point, well out of the way. And after I do this side, I'm going to go back to the other side and try to create a symmetric situation. So I'm getting the bladder pillars the same way here. And then I'll go back to the dissection plane and keep going all the way down. So I'm going to skip ahead a little bit. For the interest of time, the video is a real-time video. I didn't edit it at all, so it's a little more than an hour, and I want to be able to show all the steps. So I'm just going to skip just ahead so we can see sort of the final product of the anterior dissection. So I'm going to skip ahead a little bit, and I'm going to go back to the other side. So I'm just going to skip just ahead so we can see sort of the final product of the anterior dissection. So I'm now getting to pretty low down. It'll wind up being a dissection plane. My anterior dissection plane here is going to wind up being about 10 or 12 centimeters. Usually it's just like this. There's two sections, one on either side that's kind of the easy part. And in the middle section, the tissue is just a little more robust and like this. If you ever are doing one and you think it's super easy and there's no robust tissue like this in the midline, it probably means that you've only dissected one side and you have a whole other side to do because you almost always see that midline tissue plane that looks like that. So now I'm just kind of stretching. You can see that at the top of that picture, that's the Foley bulb on the other side of the bladder, so I'm getting way low down. I'm not necessarily going to put sutures all the way down here, but I want to have this fully cleared away so that it's very obvious to me that I'm not going to place any sutures in the bladder. And I want it to be nice and wide with the limits laterally really kind of being what I believe to be the tissue right around the ureter coming back towards the bladder. Now I'm going to use the PK Dissector as a caliper and measure the distance of my plane. So that's 2.5 centimeters when you open it up all the way. So 2.5, 5, 7.5, 10. So that's about a 10-centimeter dissection. And at the end of the case, I'll tell you how you turn that 10-centimeter dissection into a normal anterior vaginal segment. So now I think I'll – I'm going to clean this up and do a little more dissection, but not a whole lot. So I'm going to go ahead and skip to the posterior dissection. This is just me touching up and finishing a little more of the anterior. You know what? I need to – I'm sorry. Excuse me. I haven't shown the posterior dissection just yet. Oh, no. You need to go back? Well, I'd like – yeah, I'd like to go back a little bit. I'm trying to go back a little bit. And maybe I'll just – let's see. You know what? I think we'll just have to see the – oh, goodness. What I'm doing here is I'm doing the posterior suturing. So I think it must have been saved a little bit out of order. This is the first couple of stitches of the posterior suturing. So I've taken the posterior dissection down basically to the perineal body. These are CV4 Gore-Tex sutures. And I imagine the way this must have saved is we'll see the posterior dissection in some other little segment. So I apologize for that. But this is – I always do the posterior arm of the mesh first. I take the dissection plane down to the perineum. And the first few stitches are the hardest ones to do. The reason I do the posterior suturing first is because it lets me get into that space like it's a big room. And I'm attaching the distal end of the mesh to right around the perineum. And then I'm kind of working my way out of the room so that the sutures are actually in between the mesh and the vagina. And it's the very narrow gauge of the sutures along with the large pore size of the mesh that makes that, you know, not matter. So you never really feel the knots at all when you do a vaginal exam down the road. I like Gore-Tex suture. I have not experienced any problems with Gore-Tex suture at all. I know that there's some literature to suggest that it may increase the chance of mesh erosion or suture erosion because it's permanent. I find that the way that I avoid that is by always doing split thickness bites of the vagina. So I'm trying to get literally the wimpiest little bite in the vagina that will hold the stitch down when I tie. So if it pulls through the tissue, then it's not enough. But if it holds up while I'm suturing and tying like this, then it's a good enough bite. And because none of my bites on the vagina are particularly deep, I like to put in a lot of sutures. So I'm getting a nice broad base of attachment. Hey, Dr. Colgan, this is Dr. Rickey. I have a question that came up. It's about the anterior dissection. Can I go ahead and ask it real quick? Oh, please. Go ahead. What exactly are bladder pillars? How do I know that I'm not clamping the ureters when doing the anterior dissection? You can follow the ureters over. And after you do your hysterectomy and you begin your dissection, the ureters are always falling off to the side. And so, you know, what exactly are the bladder pillars? I'm not sure exactly how to answer that except that's the tissue just lateral to the cervix, that it contains more of the blood supply. And, you know, it's more of a term we use during vaginal surgery. But, you know, that's kind of what it is. It's sort of taking the blood supply further down off of the tissue just adjacent to the vagina. And it's fairly easy to identify the ureters at any point in time during that dissection process. So you don't really start encountering the ureters until you get way down low around the trigone. Then they're back in play. But the cervix and the top third of the vagina, they're really not in play. And I keep saying this, but, you know, people kind of come and go maybe from the webinar. So I don't have anything in the vagina when I'm doing this. I'm judging the depth of the sutures that I'm placing in the vagina just by how small of a bite I can take that will still kind of stay in. And I'm trying to preserve as much or get as many sutures as I can out of these cortex, as you can see. I'm working my way out. I do rows of like two and then sometimes just another row where it's not even a row. It's just a single suture and then go up and do two more. So it's kind of like hopscotch. If you know what hopscotch is, put one foot down and two and then one. It's kind of what I'm doing. I like to use what they call the large needle holders, which are actually the small ones. For some reason, they call them the large ones. And that makes me be able to do this instrument tie in this confined space. So just working my way out. After literally over a thousand of these cases, I can simply promise that the cortex suture and placing the knots in between the mesh and the vagina is not problematic at all, as long as you're doing a thickness suturing technique like this. Again, so that's the posterior mesh. I'm going to fast forward just a little bit. This is a device that I use, and by way of disclosure, I invented. It contains all the sutures you need for the surgery and a little sharps container. So you don't need an assistant to hand you the sutures. You just have them here. It comes fully loaded. And you serve yourself the sutures as you need them and then place the used needles into the disposal. I'm going to skip ahead. It's just going to be more of the same suturing of the posterior mesh. And then I'll just show you on the cervix, you really want to get nice, thick bites. There's no harm in getting very robust bites at the cervix. And I plan my mesh length so that the cervix winds up being right at what I call the crotch of the Y mesh. So here's the anterior segment just above. I don't know if you can see this pointer that I'm using. Can you see what I'm doing or not? As a pointer, no? I don't see the pointer. Oh, yeah, now we can see it, the little green arrow. We can see it now. Let me see if I can move that. Yeah, so the anterior mesh is here. And that's the cervix, of course, and there's the crotch of the mesh. And I'm just trying to make sure that I've really got a nice, robust attachment at the cervix. When we place the mesh into the abdomen, it's not necessary to roll it up or anything like that. Just kind of lay it in long ways. And this anterior part of the mesh, I suture back to the proximal arm so it's always out of the way until I need it. And then I just cut that little stay suture and start working down. So now here I am. There's the anterior mesh. And, again, it's going to be more of a seam. I do want to explain one thing, though. This anterior segment of the mesh is only around six centimeters long. So I'm going to take the six-centimeter segment, and that's going to be my anterior vaginal length. So the way that I'm going to do that, I'm going to skip ahead. The way that I'm going to make that happen is I'm going to do what I call gathering up the vaginal epithelium. So remember I said that the length from the cervix all the way down to the end of my dissection plane is about 10 to 12 centimeters. So it's roughly twice the length of the mesh. And so the way that I'm going to make the vagina actually the size of the mesh is to kind of what I call gather up the excess. So I'll put a stitch in. That's about one centimeter from the crotch of the mesh. And now I'm going to skip down here around maybe two centimeters or more when I put the stitch in the vagina. And then I'm going to go back through the mesh. And when I tie it down, I need to take the mesh off of traction. I should have mentioned this before. But right now I'm actually using the double fenestrated grasper to hold the mesh on stretch to give me my traction. And I will release it when it's time to tie down. And in that way I kind of gather up the vagina to the mesh. And so each one of my sutures that I place is going to be doing that same thing, kind of gathering up the vagina. And if I plan out those proportions correctly in my mind, then when it's time to put the very last row of stitches in, the edge of the mesh will line up right with the end of my dissection plane. Does that make sense, Leslie? Yes. Yes. And we have a few more questions here that have come up. So one is, how do you mark the proposed vaginal apex in a case of vaginal vault prolapse with a large cyst to seal? I don't mark it. What I do is I just decide ahead of time how long I think the anterior vaginal wall should be from the apex to where the bladder neck starts. And that number is usually going to be in the neighborhood of, in a post-hysterectomy case, it's usually going to be in the neighborhood of anywhere from 5 to 7 centimeters. So I will cut the mesh to that length. And I'm not going to worry about marking where the apex is because the other thing I'm going to do is measure the posterior wall during an exam under anesthesia. And that length is usually going to be either 8, 9, or 10 centimeters. And so I'll cut my mesh to those sizes. And when I start working posteriorly, the rest kind of takes care of itself because I do have to have something in the vagina, of course. Maybe that was part of that question. I have to have a brisky retractor or something in the vagina to delineate the vagina. But I don't really worry about where the previous apex or the cuff used to be. I just kind of go with what the patient has and adjust accordingly. So I hope I'm answering that question effectively. It's all about what the patient's anatomy will allow in terms of the length of the vagina. In a post-hysterectomy case, it's also important not to put sutures right at the apex. I usually leave a gap of about a centimeter at the crotch of the mesh and the apex of the vagina to avoid erosion. There's two questions that are sort of similar. They are just regarding the needle-protecting device. What's the name of it and how is it obtained? And then how do you get it in and out of the abdomen? Okay. Yeah. And I'm trying not to make this a sales pitch because by way of disclosure, it's my company, my device. It's called Stitch Kit, all one word, S-T-I-T-C-H-K-I-T. And you get it at stitchkit.com, and it goes in through the camera port. It fits through a 12-millimeter port. And so when it's time to suture, it can be placed blindly through the camera port because once you replace the camera, it'll be right there when you look for it. And so that's that. And then can I ask you one more question real quick? Sure. This one's from me. One of the things that I find a little difficult sometimes, especially with the supracervical hyst, is getting, like measuring accurately. And I think it's really important what you said that the kind of the V or the crotch of that mesh kind of float over the cervix, you know, like kind of leave a little bit of room there. So do you just use the calipers and the two and a half centimeters to kind of get that accurate? I do. I do. Okay. Well, I do two things. The first thing I do is I decide, this is just a little quirk that I have, I decide how long my mesh segments are going to be based on my physical exam of the patient right before we do the scrub and start the surgery in the operating room. So a good rule of thumb is 10 centimeters is probably the most common posterior arm length for me, sometimes 11, rarely it might be 9. And then on the anterior, what I'm feeling for is there's the, you can tell where the bladder neck is and you can tell obviously where the cervix starts. And when that's all stretched out from the prolapse, I'm just trying to do an exam myself and imagine how many centimeters that really should be to make the anatomy normal. And that number usually winds up being, you know, 5, 6 or 7. You know, so probably the most common length that I cut the mesh is 10 centimeters posteriorly and 6 centimeters anteriorly. And if I do that, then the technique kind of takes care of the rest. Okay. Thank you. Sure. So here I'm just going to be continuing down the anterior segment. And again, when it's time to put the sutures in, I'm going to have the mesh, the proximal arm of the mesh on stretch and I'm going to stick with my proportions. So I skip down one centimeter on the mesh and I'm going two centimeters on the vagina. I like to place both ends of the suture through the mesh. I like this particular mesh because it's see-through. You know, it's kind of always transparent. So if you have a very short suture and some of the suture is behind the mesh, it's still easy to see what you're doing and still tie it down. And the other nice thing about this suture material, the Gore-Tex, to me is it's very forgiving. You can do almost any kind of a knot and turn it into a slipknot with the proper technique. These sutures that I use are eight inches each, and so I usually get four to six individual sutures out of each strand. The needles are TH26 needles, so they're similar to SH needles. Pat, I have another question that came up. If I can't morselate at my institution, then can you comment on concurrent HIST with sacral copal pexi and do you recommend two-layer closure on vault? if you have to do a total HIST? If you have to do a total HIST, I think it's hard to tell people exactly how to do that. I do think there's a couple things that I do recommend. One is however you close the cuff, don't put anything up against the cuff after you've closed it because I think that's what actually causes the problem. So whether you have one or two layers there, the issue at the cuff tends to happen when somebody's got a probe in the vagina pushing against your closure. At least that's my conjecture, that's what I think. So what I do to avoid that is I'll do the posterior dissection as the first step and then the second step of the case will be the posterior mesh placement and then I'll use and then I'll do the finish the hysterectomy after that so that I can use the mesh as my traction rather than something in the vagina. So then I'll do the total hysterectomy, pass the uterus into the vagina to get it out and then do the closure but I've never had to really actually manipulate the apex. So it lets me just kind of leave it alone. I don't really like to do that. It's more cumbersome. So usually what I do is a super cervical anyway even if I can't morselate and because you know obviously this case is where I can't use the morselator and in those cases I just extend the umbilical incision a little bit and I put the extra small Alexis retractor in and I do what amounts to hand morselation just like you would do with a vaginal hysterectomy. So I make sure that I take the adenects off first so they don't get lost and then I'll get the cervix coming through the Alexis retractor that I've got in the umbilical incision and then I just kind of pull it out with a small morselation technique which usually doesn't take much because these are typically very small uteri. What I'm encountering here is that I thought that I was finished with the dissection plane and I thought I was happy with it and then I decided that I wasn't exactly happy with it. The reason is because I was thinking that I might have a situation if I didn't do it a little bit extra here where after the mesh placement there's still a cyst to seal and I'm trying to avoid that. So I did a little more dissection there. I was kind of using the suture cut as a suit as a scissor because it is a scissor and now I think I can pull up what amounts to the very just the part of the cyst to seal that's closest to the urethra. Yeah so I would say that I find an excuse to do a super cervical hysterectomy almost all the time and then the only adjustment I make if I can't morselate is I'll do the retrieval through the umbilicus with a small extension and it's not the end of the world but it just increases the pain of those patients just a little bit. There's more and more data you know in support of us urogynecologists continuing to use the morselator by the way. There was a lot of nice information presented this year's AUGS so I'm having a much easier time on that front with the hospital. So in the interest of time I want to I want to scoot ahead a little bit. I'm going to kind of you know not put you through watching knot after knot after knot. Let's see so this will probably be the last one. I will say that I probably put in too many sutures so the one thing you really wouldn't want to do is put in more than me because um I probably put in too many but sometimes it's hard to stop. So this is the stitch down into the space where I was just dissecting. I don't have any cautery and I didn't feel like putting any more instruments back and forth so I just you know it's not much bleeding it just looks a little more bloody than I'm used to but it's not too bad and when I tie this down it should flatten out that mesh nicely and if you're not used to the idea of suturing without something in the vagina you can kind of take it slowly. You can practice. You can you know stop what you're doing and feel how it feels in the vagina after you put a few stitches in. Again the the way to make sure that you're not going through and through is to just put the sort of the wimpiest bite you can vaginally and then if when you're tying down it doesn't pull through it's good enough. Skipping ahead a little bit more. This is something I do sometimes when I have what I think looks like a kind of a big gap along the side of the mesh for a big prolapse like a big stage 3 or stage 4. I'll close the two edges of the mesh together and catch a little bit of a vagina there and again it sort of just bunches up the vagina which takes a stretched out vagina and makes it basically more anatomic. Another way to think about this bunching up technique or gathering up technique you could think of it as creating rugae almost. Sometimes that makes people understand what I'm doing. All right so a little bit ahead again. Yeah see I'm I just put in a lot of sutures. I do. All right there we go. So what I've got what I'm doing now and this is kind of important I'm just going to pause for one second. After getting the anterior and the posterior mesh attached the very next thing I do is begin my peritoneal closure. So I start closing the peritoneum before I attach the mesh at the sacrum and to me that eliminates the hard part of closing the peritoneum. So I'm going to do a purse string and this is a zero monocryl on an SH needle and I've got a little fisherman's knot tied in the end so it's like a little loop. So I'm going to get myself down into the pericolic gutter dissection posteriorly and I'm just going to do an actual purse string just going along the edges of what I've done. Now I didn't say this but before but when you're doing the hysterectomy if you preserve the peritoneum as much as possible it'll be much easier to close the peritoneum over the mesh at the end. So again I'm just going to go you know just only through the edge of what I what I had to do for my dissection or my hysterectomy and work my way all the way around that cut edge of peritoneum and in all of this is before I've attached the mesh at the sacrum. Pat I have one question real quick about the posterior wall. Does the gathering technique work for the posterior wall as well? It's much harder to do on the posterior wall. Fortunately we don't have to do it very much on the posterior wall and the answer is no. It's trickier so I don't usually do it that way. I if I need to if the posterior wall is a big defect actually what I do is I do a technique where you think of it as almost like a posterior coporaphy where I use vicral sutures and I and I um I essentially do a gathering up or a posterior repair and then attach the posterior repair to the mesh. So it's sort of like doing an anterior rectopexy but it doesn't come up that often. If anybody had a specific technique for a large posterior defect and wanted to give me a call or an email I could describe that in detail but it's probably beyond the scope of this but so short answer is no. The gathering up works anteriorly but posteriorly it's trickier. When doing this purse string you know I recommend trying this because it really makes your life easier. The covering the peritoneum can be a finicky kind of a difficult step but if you do it like this where you haven't attached at the sacrum yet it's just easy and you just go close to the edge close together close to the edge close together over and over you know I go clockwise and this is unedited and it's you know I don't really want to skip ahead because you might get lost in what I'm doing so coming around it's possible to get too close to the ureter you have to pay attention to where the ureter is when you especially on on the on the posterior edge I do I do incorporate the round ligament into this because otherwise you have a little gap and so it's also important to incorporate this if you don't get this section then you're going to wind up with a gap where the mesh is exposed and now this is the actual paracollic gutter dissection edge right here and the next step is to jump over the mesh and to catch the other side of that paracollic gutter dissection and then pass the needle through the fisherman's knot and it's just a simple little loop knot if you don't know how to make one of those I have a video instructing that on the again I'm sorry to go back to the company but the stitch kit website has all these steps it's stitch kit calm and it shows how to make that little fisherman's knot so now I've completed the purse string but you know I'm not ready to finish the dissection I mean the covering because I got to fasten the mesh to the sacrum so that's what I'm going to do now so now I've got the double fenestrated grasper in as my as my retractor and I'm just going to open it up like a fan and sweep the colon over until I can see the space that I originally dissected so it's I'm going to find a nice white little area and I'm going to have to this is what we all need to be really mindful and avoid placing a suture into the disc if you think about this as a ski slope then the safe area is just when you've dropped over the edge and you're actually going down the hill if you it's rather skiers out there if you put it on the flat part that's you know right into the disc this is a little bloodier than I would usually like but I think it actually looks more so because of the fact that we don't have the HD picture I'm going to skip ahead because of the because we're running out of time here I'm just deciding on the tension and so my assistant's feeling the vagina for the proper feel and so it can't be too tight the cervix has to be up the anterior wall can't be tight like a drum it needs to have a little give to it and when I decide where that is then I'm going to measure two needle driver widths up from there cut across the mesh and and now when I know that so now I know that when I when it's time to put the sutures in I'm going to go to needle driver width down from there and that's where my mesh needs to be along the sacrum so here I've probably need to back that up so you can well actually we got another one so I'll show you the next suture so I go down through the mesh and then and then through the ligament and then tie a slipknot and I don't tie it down yet because I I just want to get it just like that because it makes it easier to pass the you know get the other ligament suture done so I'm going to get rid of that needle and um let's see like this okay here we go this is another ligament stitch both of these are to the right of the middle cycle and and it's just over the edge heading down the slope of the sacrum and so I can tell that and I'm sort of suturing up towards myself so the curve of the needle keeps me out of trouble with regard to the disc and I'll pass both ends through the mesh and then and then I'll tie both of these down once I'm ready to do so I only ever use two sutures at the sacrum I think two has always been enough I don't think these cases really ever fail at the sacrum so now what I'm going to be doing is tying a slipknot here getting rid of that needle and then just you know tying a bunch of throws to make sure that there's no air knots can't have any air knots I'm going to pull all the space out of there when you're doing that it's really important that you once the suture stops moving you got to stop pulling because if you don't the next thing you can do is break it so right there when I when I see the suture stop moving that's what I know I've done enough and I just keep doing my throws I'm going to do this side now same thing pull pull pull until it stops moving and then don't pull anymore then just tie your knots so lots and lots of knots I kind of overdo it here because my worst fear is that these would somehow come undone so I probably put in eight throws on each of these during this part of the surgery I've got somebody with something in the vagina to give me a little slack all right so there's the finished product with the mesh so now what I'm about to do is retrieve that needle where I did the purse string of the peritoneum and I'm going to gather up that tissue and then just begin to sew like this where I'm getting the that edge and then coming over and getting the other edge the hard part is already done so it's just the easiest thing to just get that peritoneum to close over the mesh the mesh so this is why when I said you do the pericollic gutter dissection that you have to do enough of a dissection where the peritoneum can easily stretch over the mesh so there's several throws like this on one side and several on the other and if you're not sure or if your assistant's not sure about the proper tensioning vaginally you can make an estimate and hold the proximal arm of the mesh against the sacrum and then scrub in for just a few minutes and feel it yourself at the end of this I just tie a little loop knot so I'm kind of pulling this and it's almost like a shower curtain I'm just going to push the peritoneum down until there's no gaps and there's some and it's all completely covered and then just tie your knot just like this I use a zero monocryl because it's really tough to break a zero monocryl all right so the finished product right I'll go back just a little bit there I'm just retrieving that needle the finished product is at the top of the screen under this needle here let me see if I've got a good view of it hmm hang on I'm just putting all these needles into the device to retrieve it at the end I'll back up that's that's it I if I can pause it right there you'll see the finished product right here so this is the original part string and then this is going up the Fairchild gutter and the mesh is completely covered if you do this technique be careful that you don't leave any gaps because it's possible if you leave a little gap that you would create a place where there could be an internal herniation of small bowel all right so that's the case the next steps will just be retrieval of the sutures in the stitch kit device and then I morpholate so we did the morpholation of the uterus tubes and ovaries I have one other question Pat another question came up can you reiterate thoughts about why not to cauterize the middle sacral arteries yes you first of all I just don't really ever have to I find that there's plenty of space if I just dissect off to the right side of them the theoretical reason is that when you cauterize the middle sacral vessels you're probably damaging the hypogastric plexus which could produce constipation and I I can't prove that it just sort of makes sense and because I just never really need to well I can't say never but I usually don't need to cauterize those vessels so I just leave them alone and then there's one other one regarding the morpholation I guess you said at your institution sometimes you have to morpholate in the bag and sometimes you have to power morpholate I don't really I don't morpholate in the bag ever okay I so what I do is I'll I'll do power morpholation most of the time and that's after screening and we screen with an ultrasound and endometrial biopsy and if and so if I'm going to if I can't do that let's say they have a little fibroid because even a little fibroid makes makes us have to flip over to non power morpholation I I just put the extra small Alexis retractors through the umbilical incision that I've extended a little bit and then I just bring the firstly adnexa out so they don't fall off and then I take the uterus itself and just kind of hand morpholate it while it comes out of that incision so it's just like doing a coring technique or a bivalve technique if you're doing a vaginal hysterectomy and so there's not fragments left behind so I don't use a bag it's just I don't think it's necessary got it the and I apologize the posterior dissection somehow in this I don't know how the video was manipulated it didn't I don't think it made it into this segment the posterior dissection is I do have good examples of the posterior dissection on that website that I mentioned though I see another question how big is the incision for the Alexis retractor it's the it's a 12 millimeter incision because it's my camera port but then what I'll do is take it take the fascia another centimeter or so and that basically takes care of it you know Pat there's some people at our institution now they're using the that gel port they're using the Alexis retractor and the gel port and so they'll I guess you don't need the gel port but it kind of will hold that incision open at the end that I think makes it probably the morcellation or removing a uterus that's only you know not not too too big through that incision yeah I hadn't really thought to do that well my only concern had been that the hysterectomy is pretty short right like so if you want to crank open that incision the entire time with a hysterectomy but sometimes if you're doing a hyst and a sacral copal plexus and it's a difficult dissection and I haven't used it yet so I don't know but I'm a little concerned about cranking open that fascia the entire time versus just at the end but it looks cool yeah you know I the technique I used works pretty well you have to put in a couple extra fascial closure sutures of course you can't just use one like usual otherwise you might get a hernia but yeah that would make sense too I think I'll start doing that because I do the same thing I make a little bit bigger incision at the umbilicus but I bring it up in a bag and I have not used the Alexis retractor and it can be a sort of torture at the end the only thing I'll say about the Alexis retractor business is you need to grab the the uterus with some instrument I use a needle holder or I'm just through one of your ports and then put it into the pelvis because those uterine are smaller than you think and you can actually have trouble finding it so right before right before I'm about to put the Alexis in I make sure that I've got some instrument on the uterus so that when I've got the Alexis in there it's going to be easy for me to find the uterus okay that's good point if you don't use a bag so sorry about the posterior dissection part I do have videos posted about that Patrick can you say the name of the website is it stitch kit stitch kit calm that's right stitch kit calm I had another question about that oh wait here I have another one thoughts about non-absorbable suture to the anterior and post oh thoughts about absorbable suture to the anterior and posterior compartment I think it makes sense I the only reason I don't use absorbable sutures is out of habit and kind of personal inertia and but all over Europe and more and more people in the US are using absorbable suture and I guess typically that's going to be PDS or I guess it could be monocle but I think most people use PDS when they're going to do that and the I don't think braided suture is a great idea because especially if you're going through and through I think the there's some evidence to suggest that the braided suture would increase your chance of mesh erosion and then when it comes to barbed suture that's something I'm very intrigued by and I know people who are doing that but I haven't made that switch yet because it's it especially in the interior wall it would it would be hard for me to do my technique and I'm kind of waiting for some more data on barbed suture but it would certainly be a time-saver let me see have have you ever seen the technique of retroperitoneal hydro dissection and tunneling of the mesh through the space opposed to opening it completely yes I worked I tried to I tried to work out a technique that was always the same for doing that and what I what I decided is that the for me the soft tissue variables are just too many so sometimes you know there's the shape of the soft tissue there and then there's the vessels and you know that to me it's it's not always the same so I like things that are always the same and if and so the reason I do the way I do it is look after having tried that I think just opening it up all the way it's kind of always the same because you're only trying to get that one layer and what I found is when I was doing the tunneling techniques that I still had areas to close and they were almost as big as the area that I closed anyway and so when it was fast and slick it was great but other times I thought it took me a little longer so but that's just me I know that there's people out there doing a great job with that technique and I got zero problem with it it's just not my choice right does anybody else have any other questions for dr. Cole again is everybody completely satisfied take a couple of hexie experts experts okay well if nobody has any other questions I am just going to give a big thank you to dr. Cole again for that great presentation it's really you know you guys will see if there's a lot of fellows there as you get out of fellowship you don't really get the chance to work with colleagues and see the way other people are operating very much so it's always fun one to see these videos and two to get the great commentary with it and the opportunity to ask questions so I really I really appreciate everybody being on the call wait I have two more questions while I'm in the middle my thank you is that okay got a few more minutes oh yeah do you think PDS would hold up well for gathering technique I do I think PDS would work just fine I think it's a little more difficult to work with because it's got more memory but you know once you get good at suturing yeah I think it would hold up just fine yeah and then the last yeah a PDS is sometimes hard to work with in the peritoneum and then the last question it looks like is there were a lot of thank yous by the way why close peritoneum good yeah good question there seems to be some evidence to suggest that you don't need to close the peritoneum you know what I don't want to argue that one way or the other I just I feel like with that mesh sitting there I'm afraid that somebody's going to get a small bowel obstruction so I closed the peritoneum every time you know I think that's more I think that's the most common way to do it I know there's other people that that feel strongly the other way but oh and I feel I see a question here I'm looking now at the screen of it was zero monocryl on an SH needle it's a you have to order that special it's not usually on the shelf but zero monocryl on an SH needle is what I use for the peritoneal closure while we're waiting for any other final questions I just want to thank everybody and especially you Leslie and thanks everybody for being here no it was my pleasure like I appreciate you taking time out of your schedule put the video together and to be here this is a great opportunity for the fellows and everybody else and thank you also to the fellows for carving out time in your days from coast to coast to be in this virtual form with our speaker it's always more fun to have the interaction and the give-and-take so again thank you everybody I think this was a really great session so as was mentioned the beginning you will at the completion of this program be prompted to provide feedback so please do that helps us plan future sessions I also just want to give everybody a heads up our next program is on February 17th it is the ins and outs of RV used by Cedric Oliveira who is an assistant professor at NYU School of Medicine and again that's February 17th and at seven o'clock so I that's it I think we're done all right perfect thank you all right everybody have a great night

Robotic-Assisted Laparoscopic Supracervical Hysterectomy

Sacral Copal Plexus

Dr. Patrick Culligan

live surgical procedure

specific instruments

dissection and suturing techniques

peritoneum preservation

non-absorbable sutures

post-operative care