Welcome to our live webcast, Robotic Saccharomyces Relevant Anatomy and Complications Management. Thank you for joining us. My name is Jacob, and I'll be the operator for the presentation today. Before we get started, I would like to take a moment to acquaint you with a few features of the WebEvent technology. On the right-hand side of your screen, you will see the Q&A window. To send a question, click on the text box and type your text. And when finished, click the Send button. Or push all questions. All questions you submit are only seen by today's presenter. And your questions will be responded to in the order in which they were received. And we'll be addressed at the end of the presentation. At the conclusion of today's program, we ask that you complete a brief post-event survey. Please take a moment to complete this survey, as it will help plan future WebEvents. We are joined today by our moderator, Leslie Rickey, and our speaker, Lennox Hoyt. At this time, I would like to turn the microphone over to Leslie Rickey to go ahead and begin with opening remarks. Leslie? Thank you so much for the introduction. I would like to welcome all of you to our next installment of our virtual forum web-based lecture series. This is a series of presentations by experts in our subspecialty from across the country. The goals are not only to enhance your understanding of the SPNRS 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 OGG website. We would also like to extend our thanks to Intuitive for supporting this webinar. And upon completion of this program, you will be given the opportunity to provide some feedback, which we value greatly. For this evening's presentation, it is my pleasure to introduce Lennox Hoyt. He is a professor of obstetrics and gynecology at the University of South Florida, and is also the division chief and fellowship director of female pelvic medicine and reconstructive surgery. His presentation today will be Robotic Sacral Copal Plexi, Relevant Anatomy, Complications, and Management. Thank you, Dr. Hoyt. Hi, thank you so much, Leslie, and thanks for the invitation and opportunity to present. Just going to go through quickly my disclosures and talk briefly about the learning objectives. So I want to show you the detailed anatomy relevant to sacral copal plexi, learn how to determine the appropriate length of anterior and posterior dissection, learn the landmarks for locating the middle of the sacral promontory, and learn some tips for navigating the desiccal promontory. We'll also try to learn to overcome the lack of haptic feedback with robotic sacral copal plexi. So in order to get there, I think we should start by looking at what actually is prolapse. It's, you know, and I'm sure you're all aware and have learned this so far in your training, but it's partial or complete aversion of the vagina. So this is complete loss of support. This would be stage four uterovaginal prolapse. So prolapse occurs when the support, the internal support is lost. So here I have a ring forceps in the vagina holding up the vagina, and as I let the ring forceps out, you can see the prolapse develop, and ultimately a complete prolapse, stage four prolapse would look like this. So how do we treat it? What we're really trying to do when we treat prolapse is we've got to take the vagina that's everted and basically replace it back inside the pelvis and hold it in place inside the pelvis. So a number of different approaches to do that, I'm sure you're well aware of this, transvaginal, transabdominal approaches, native tissue repairs, transvaginal mesh approaches, and also sacral copal plexi. Today's focus is on the sacral copal plexi procedure, which came along as a procedure that was designed initially to address the apical loss of support. Over the years, it actually evolved into a procedure that also can address any anterior defects and posterior defects that may be present as well as the apical support. What it does not address is the paravaginal defect issue, but I think most of us, many of us have found over the years with sacral copal plexi, we can get by just by addressing the apex and the anterior and posterior defect. So what I'd like to start with is our first video showing from a laparoscopic view what we're trying to do. Here we are, I have a stent in the vagina, and if I run the video, what I'm gonna show you here is anteriorly, you can see the bladder flap, if you will, the vaginal apex, the posterior aspect, and you can see the stent is actually supporting the vagina. If we let the stent slowly fall out, what we will see here is the loss of support at the apex as the vagina turns inside out. Should be seeing that in just a moment here. All right, so here's the stent coming out. You can see the loss of apical support from inside the pelvis as the prolapse is manifest, and you can imagine on the outside, you would be seeing the vaginal bulge back to labia. So this is the stent coming back in, and what we're trying to do when we do sacral copal plexi is we're trying to replicate this kind of support. It's not considered normal support, but it is a way to resuspend the vagina and anchor it to the anterior longitudinal ligament, which I'll show you next. So let's go back to the next slide, and what we will show is the anatomy of the area that we're dealing in. Since the sacral copal plexi is primarily a midline procedure, I wanna acquaint you again with the support and ligaments that are involved in supporting the vagina. Here is a frank netter picture, obviously a categoric generic picture designed to show you the vagina, urethra, rectum, and we can see here pubogysoralis muscle, pubococcygeus muscle, iliococcygeus attached to the pelvic sidewall via the archostendony of levator ani. Here's the atrial spine here on the left. Here is the coccygeus sacrospinous complex here. Here's the sacrum here. With a little more tissue in place, you can see the cervix, the uterine cardinal ligaments here, the uterine sacral ligaments on the left and right, and what I wanna get your focus on is the sacral promontory, which is this area up here near the bottom of your picture, but the more apical aspect. So what we're trying to do is support the anterior-posterior walls of the vagina and then take the tail of that Y-graph and anchor it to the sacral promontory. That's the goal of the sacral coccygeus. As we can see here, the important structures on the patient's left side, you can see the common iliac vein and artery. Common iliac vein is more prominent on the patient's left side and an important structure to remember, to be mindful of when you're placing your needles in the sacral promontory. On the patient's left, it's less prominent and it's more prominent best with the iliac artery here, which is harder to hurt with a needle. Lateral to the midline, it's gonna be the ureters. Here, important structures for us not to injure when we place sacral needles and sutures. Most of the important nerve anatomy for the pelvis is lateral to the midline, with the exception of the hypogastric plexus, which is centered around the sacral promontory and is important to be mindful of and avoid when suture placement is involved. The bony pelvic anatomy is gonna be important here because if we look at the sacrum and the sacral promontory and the sacral vertebra, you'll see this structure, this ligament, which is the anterior longitudinal ligament of the sacrum, which is the place that we place our needles, our sutures, when we're looking to anchor the tail of the sacral copepaxi mesh. Primarily, when this procedure was invented and discussed by Dr. Addison of Duke University in the 70s, suture placement was primarily in the sacral curve, S2, S3 area, which is still the area that you strive for when you're doing the procedure as an open procedure. As we've evolved more towards laparoscopic and robotic procedures, the tendency was to bring the suture further up and nearer to the promontory because it's easier to do so with the placement of the robotic and laparoscopic cameras, although there is some discussion about trying to move those sutures back down the sacrum again. The sacral anterior longitudinal ligament of the sacrum becomes more attenuated the further distally you go, and so you wanna be mindful of being in an area where you can get a good purchase of the anterior longitudinal ligament sutures. There's a side view here of the sacral promontory here. Important effort is made not to go too deeply when you place your sutures because of this structure here right at the promontory, you wanna try to avoid a disguided type result. And so the attempt is made at the sacral promontory to stay in the anterior longitudinal ligament and avoid this structure. All right, so if we take a look, a cartoon look at normal support, here's a vagina with paravaginal support here. No anterior defects and also apical support with the uterus sacral cardinal system here. Prolapse basically occurs when the apical and paravaginal support is lost, and you can see here the E version of the vagina. Here it's primarily anterior and apical prolapse here, although there's some posterior wall prolapse as well. What we're seeking to do is to take this vagina, prolapse vagina here and re-invert it back inside the pelvis and keep it there. And so in fact, what we try to do with the sacral copal pexy is to support the anterior leaf of the vagina and the posterior and then anchor the tail to the sacral promontory. All right, so here's a side view of this. Again, the procedure evolved as an apical support procedure where primarily the apex of the vagina was supported. And as it evolved, more and more people will try to address anterior wall defects by extending the anterior and posterior leaflets of the graft to support the anterior vaginal wall and the posterior vaginal wall. So having done that, we'll now start with the next video, which will show the anterior defection here. And what this procedure is designed to show you is with the robot, how we would approach the anterior defection. So the first part of the procedure involves defecting the bladder off of the vaginal apex. And the goal here, you'll see with the arm three, and I'm left-handed surgeon. If you're right-handed, you would flip the scissor and the bipolar mirror. Here, what I'm trying to do is to find the most apical attachment of the bladder peritoneum at the anterior leaflet. You wanna basically go ahead and defect the peritoneum so that you can begin your defection of the bladder flap. This is a really important defection here because if you proceed too distally with this defection, you can end up more readily in the bladder. So you wanna be as apical as you can, still identifying the bladder peritoneum here, which is the first part, the first step is to actually lift the peritoneum. Now, many of us, when we were trained, and I know Dr. Ricci and those of us trained on the open procedure, were taught to first address the sacral promontory. And the reason behind that teaching back then really involved, if you couldn't find the anterior longitudinal ligament at the sacral promontory, you didn't have a procedure. So the intent is to go first to the sacral promontory in the open procedure, make sure that you can locate the anterior longitudinal ligament, defect that, place your needle there first, and then go approach the anterior and posterior dissection. What we found in doing that procedure, that approach robotically, is by the time you come back after your anterior and posterior dissection, back to the sacral promontory, it's actually a bloody mess because there's been some bleeding during the 30 minutes or so, 30 to 45 minutes of the anterior and posterior dissection that makes it now difficult to locate the sacral promontory again. Also, with the retraction allowed by the robot and the assistant, you often, for a difficult promontory, end up having to move your instruments so that coming back to find the suture placement in the promontory can be difficult. For that reason, I use the first part of the procedure to basically identify the sacral promontory, demonstrate that we can find it, and then once we show that we can find the promontory, to proceed then with the anterior and posterior dissection, which is what you're seeing here. Here's a careful dissection with the bipolar myelin and the scissors. Why do I use this combination? Bipolar myelin allows you to be able to cauterize any bleeders that may show up that threaten the procedure, and the monopolar scissors also allows you to be able to go ahead and do dissection and limited cautery in order to create your bladder flap. We're right here at the apex taking care to get the bladder off the anterior vaginal wall. I'm going to move things along a little bit and show you how we continue that dissection. And you can see now we've come to the vaginal wall serosa. Here. And once we've gotten to this part of the dissection, it's primarily blood dissection with a little bit of scissor work and cautery to move further down the anterior vaginal wall. Once we've developed the anterior vaginal wall, the question becomes how much dissection do you have to do? Now, we talked earlier about having an anterior and posterior component to the sacral copopexy mesh in order to take care of any anterior and posterior defects that either are present or may develop as a result of resuspending the apex. And so one rule of thumb that we've developed is that we've noticed that the actual length of the urethra is about 3 centimeters, 3 to 4 centimeters, and the distance from the bladder neck to the trigone ends up being about 2 centimeters. So if we look at the total vaginal length and subtract 5 centimeters, we're at the level of the bladder neck. And so what you will find is that this bipolar marrowland instrument, if you open it completely, you can actually see that it's about 2 centimeters wide. So you can take total vaginal length, which you've measured presumably in the office during your POPQ, subtract 5 centimeters, and that tells you how much anterior dissection you need to go through. In this case, what we're seeing is this section got a little bit thick here, and, you know, because this is a complications talk, I want to show you what can happen if you've basically entered into the vaginal muscularis itself. Sometimes you end up having to go back to recreate this really neat, easily dissected space here between the bladder and the anterior vaginal wall. So what happened to us in this dissection earlier is that we split the actual vaginal muscularis, and we needed to come back here and basically develop the true space between the bladder and the anterior vaginal wall. And you can see now this is going a whole lot more easily with less difficulty than it was before. Once we've developed the anterior flap for the bladder, you can see there's some limited cautery being used with the scissor in order to develop the space. Once you're in the right space, you can use this snipping and pushing technique to further develop the anterior vaginal wall all the way down to the actual level of the trigon. We have a rule of thumb that basically says if you're having lots of bleeding during the anterior vaginal dissection, that usually means that you're either in the vagina, you're in the bladder, or you're at the level of the trigon. Because the space between the vagina and the bladder is actually a potential space, until you get to the trigon, there's usually not that many significant blood vessels that bleed if you're doing the dissection right and you're in the right plane. So you can see here that we've developed the anterior wall all the way down to the level of the trigon. Tricks here for a difficult anterior wall dissection involve bringing in a Ray-Tac, which you can then use to actually help. You can use it kind of like a peanut, like you would use a peanut laparoscopically to help show you where that plane actually is. And it can actually do a pretty good job of actually keeping the bleeding down. So there's our anterior development there. The next part of the video I want to show you is actually bringing the mesh in. We actually use a lightweight macroporous polypropylene Y-graph, 23 grams per meter squared with one plus millimeter pores that we use for the actual mesh. So if I can go to the next video, I'll show you how we do that. Okay, so here we are. We've developed the anterior vaginal wall, and we're going to go ahead now and measure. We're at the level of the trigon there. Here is a bipolar marrow in this 2 centimeters, 4, 6, 7 centimeters or so. We asked our assistant to cut the anterior leaflet of the Y-graph to 7 centimeters. We've just measured it. We think we have the trigon here with TVL, total vaginal length minus 5. We'll have our anterior leaflet come in and be placed on the anterior vaginal wall. Okay. And what we've learned over the years is that when we place, we've all learned to do this procedure using Gore-Tex interrupted sutures. Other people have used other sutures, but most of us have learned on Gore-Tex sutures. What I've found over the years is that whenever I had a mesh erosion or a mesh exposure, there's usually a Gore-Tex suture involved in that mishap. And so what we've evolved to over the years is the use of the delayed absorbable barbed suture. This particular suture is the Quill suture. I use a PD0 Quill or the Strata-Tex 0 barbed suture. And you can see that it places very nicely. We put it in the form of a box stitch. Oh, it's backed up here. Let's see if we can box stitch like this. Taking a good, generous bite of the vaginal wall and sewing the mesh in place. What we've found is that at three months, if you come back to the sacral copepaxi, to the sacral copepaxi procedure, for whatever reason, you will find that the mesh is pretty much fused to the anterior vaginal wall and you no longer have need of the delayed absorbable suture. So 180 days is about the time frame that it takes to have this suture be fully reabsorbed. I'm going to show you the other side of the box suture here. This particular Y-graph, I think, is a coloplast, macroporous, lightweight graft. It's a Restoril. Other similar weight grafts are the Boston Scientific carry one. I think the BARD-A-Lite is one such. And also the Bratislava graft. I think the BARD-A-Lite is one such. And also the Bratislava light from Caldera is also one. There may be others. They don't actually all just come to mind right now. This is Leslie. Can I ask you a question real quick? Sure. So you started, like, it looked like in the lower right hand. I haven't used this suture before, but you started in the lower right-hand corner and ran it across the edge towards the left and then came up the left side? Yes. And so the barbed suture, actually the center of the suture, if you notice there are two needles to the suture, one on the left and one on the right. In the center of the suture, the barbs go in opposite directions. So when you sew to the left like I did earlier, those barbs hook in that direction. When you sew to the right like this, the barbs on this side hook in the opposite direction, so you can't actually pull it through once you've sutured it in place. That's a really good point. That's different from the other. And I forget the one. There's one with a loop that you actually, it also is just one way of single needle type suture. This one's a little bit better because it's harder to push string this suture than the other variety. Great. Thank you. Does that answer your question? It does. It does. I was just trying to follow the suture path. Okay. Yeah. So one path, you'll see the one on the left right here. This one is going off to the left and then coming up on the left side of the vagina, and it'll come around the front as well. Okay. And by the way, the other thing that I have available to you, Leslie, is I have a full 80-minute version of a sacral copepaxi that I've done as a full video. And if you'd like that, I'm happy to send that to the team as well so you guys can put that up on the site. Oh, that's great. You can actually see the full thing. It's hard to give it all in a one-hour presentation as you well imagine. Sure. So I'll send that over to Will so that you guys can have that as well. So what we've done is we've created, in effect, a box with the suture. Started distally, going to the left, coming around on the left side and then also bringing it up along the right side. An important thing to know is that when you use a barbed suture like this, do not ever, under any circumstances, put any knots in it. The knots in the suture tend to be very sticky and attract small bowel, for example, and could create difficulties. So you never, ever want to put knots in these sutures. The barbs themselves will hold. And I have proof. I've come back and I've seen them actually hold in place. So knots are not required and are actually a bad idea in this barbed suture situation. And the single barbed suture I was thinking of was the V-lock, and I think people are familiar with that. This is actually a double-needle approach, and that's the PD0 core and stratus. V-lock is also usable, but you have to be a little more careful when you put the V-lock into place because when you pull on the end of the suture, you tend to purse-string things, and that's not good for the repair because it tends to scrunch the mesh up in a circle, and you don't want that. So what we've done here is actually, you can see you can pull on one side and you can pull the whole suture through until it's settled down. What I've found is the combination of the lightweight Y-graph and this suture without the knots basically has reduced the erosion risk to practically zero because there's little to no erosion. Because there's literally no ischemic areas that put the patient at risk for mesh erosion. It doesn't protect you from lacerations that you make in the vagina. You do have to repair those before you try to put the mesh down, but the de novo erosion risk is practically banished since I've been using this barbed suture technique. Okay, can we have the next video, please? Okay, this video actually shows how we go now after the posterior wall. And again, it's one of those situations where when we learn this procedure, it's an open procedure, we started following the promontory, we started with the posterior dissection first. And it turns out that when you do that posterior dissection first with the laparoscopal robot, you basically don't have anything to hold on to to help with the anterior dissection. So by doing the anterior dissection first, what it's allowed us to do is to be able to use our third arm or the assistant, if you will, to hold up the anterior vaginal wall. That makes the dissection go by a whole lot easier. Important and key points here in this posterior dissection is to make sure that you're not too high up near the apex. The further up you go posteriorly near to the apex, the more fused the peritoneum becomes with the vaginal wall itself. And so it's much more difficult the higher up you are apically to try and take the peritoneum off of the posterior vaginal wall. What we've learned when we were doing this open procedure is once we encountered yellow, we used to say your dissection is over from the open perspective. But what we've discovered is the laparoscopic and robotic approach allows us to be able to go much lower posteriorly because you can actually get a better view of the tissues. And often for those patients in whom it matters, you can literally get down to the perineal body. This is obviously a different procedure compared to what we were looking at with the anterior dissection. But what I want to be able to show is how you can use that robot arm to help elevate the anterior vaginal wall and show you better what the posterior vaginal wall deception needs to look like. What I have in the vagina here, and you can see it's like a spoon-shaped scent, which allows us to define the vaginal apex and posterior wall. The curved part of the scent is actually posterior, and it allows you to see more of the posterior vaginal wall to facilitate deception. And you can see this nice plane developing here as we go posteriorly. You really want to do your best to get into this avascular plane posteriorly. You only require minimal amounts of cautery here to just start the development of a plane, and then it's pretty much blunt, scissor-type snip and push, if you will, the section to develop the space posteriorly. And you can go as far posteriorly as you need to go. One of the things that we teach our fellows is that if you have a distal transverse posterior wall defect, you want to try and get as far down as you can past what we like to call the rectovaginal septum towards the perineal body. If you're going to demonstrate a defect distally at the perineum posteriorly, then you want to follow the dissection as far down as you can. If you've had a prior posterior wall repair and you feel like the posterior rectovaginal septum is intact and well-attached to the perineal body, then you probably will do fine just getting down to the level of the rectovaginal septum as well before you attach your mesh. Okay? So, I'd like to get the next video up so that we can show actually bringing in the—doing the posterior attachment. And here we are back with the rest of the suture. We have the anterior attachment. It's going to be really important here where the joint between the anterior and posterior leaflet is. If you're preferentially an anterior wall defect, you want to leave that joint between the anterior and posterior arms of the mesh up in a way that it doesn't preferentially attach to the posterior wall. If you bring the joint around the apex, then when you pull up on the tail of the mesh, you'll preferentially pull up on the posterior wall. And so you want to be careful and mindful of what it is—where the defect—the primary defect is so you can address it by proper placement of the arms of the Y-branch. Here we are again. We're getting the posterior aspect of the mesh down to the level of the dissection. And then what we'll do is we'll cut right where we think the extent is there. I'm going to have to cut that all the way back, I apologize. So, yeah. So we'll cut across with the scissor, line that off the field, and we'll lay the posterior leaflet down. One of the advantages of a lightweight polypropylene mesh, macroporous, is that it lays down nicely. And here we are coming in again with this double needle barbed suture. We're going to start by placing the first bite distally to the furthest distal extent. And again, remember, this is a quill suture, it's a double barbed suture, it's a two-needle system. The barbs on the left go in one direction, the barbs on the right go in another direction. And so if you bring it around as a box stitch, you can actually get the graft nicely attached without purse-stringing. Clearly, the advantage endoscopically, and in my case, using the robot, we're able to get down to a deeper, much more deeper than we ever could open. And I know this is also the case with my colleagues who do this laparoscopically as well. One of the things we haven't talked about yet is what do we do in terms of repersonalizing the graft. And I don't think we'll be able to get to it today, but what you will see in the full video that I give you is that when we're done with the posterior leaflet, attaching the posterior leaflet of the graft, what we'll be able to do is to bring the peritoneum edge up and use the same quill suture to reattach the peritoneum posteriorly and basically repersonalize the posterior aspect of the graft. So we're now doing the right side. Does this come through better, Leslie? Yes. Yeah, yeah. I think I missed, because I don't think I missed that it was the bidirectional one. Okay. Sorry. No, no, no. No, it's my fault. So now that makes more sense. Okay. All right. I think because of our time situation, I want to show you actually dealing with some complications and avoiding them. So I'll see about getting to the end of this video here, showing you again how we, let's see if I can bring this up. We've got both arms taken care of here. Once you turn the corner with the barbed suture, you're advised to make a couple of turns to lock it in place, as it were. Again, no knots with barbed sutures under any circumstances. They tend to be sticky. I know this from personal experience, bad idea. Lennox, if you are doing a supra-cervical hysterectomy, do you do basically the same approach? You attach the anterior leaf first? Yes. And you would take little bites of the cervix at the edge of the cervix, obviously, to include the cervix in the pulling up, if you will. All right. So you see the whip stitching here. Again, the important thing with the supra-cervical, it's much more important on the posterior side when you do a supra-cervical hysterectomy to remember that the peritoneum and the vaginal wall is fused near the apex in the area of the posterior fornix. So you want to move down posteriorly quite a bit before you start trying to do your dissection. And at this point, what's not shown here is we would bring the peritoneum posteriorly up and incorporate it in this spiral suture in order to reperitonealize the posterior aspect of the graft. Let's go to the promontory next. We're going to skip over number six. We'll go to number seven here. One of the things that we always wonder about is this is a nice promontory here, but in cases where this is very thick, overlying the safer promontory, you have difficulty locating where the middle of the promontory is. What we've been able to show is that if you take the crossing over of the ureter over the safer promontory and you measure three centimeters medial to that at the level of the promontory, you always find the anterior longitudinal ligament. And so what that means is that if you're in a situation where you have a really deep promontory and you don't know exactly where it is, if you find the ureter, literally three centimeters medial to the ureter will always be the promontory. And in a thousand-something cases, we've not seen that principle violated. So that's a good tip for you when you're doing a difficulty section. Laparoscopically, you have that advantage. With the haptic feedback, you can poke. With the robot, you tend to not have it. But with that three-centimeter principle, you could do very well in terms of locating the sacral promontory. All right. Next video, we'll look at the promontory dissection. This one will be pretty straightforward for starters. And then I'll show you a case of what happens when the promontory has bleeding issues. All right. So here we are at the promontory. We've identified it. One of the great advantages with the robotic and laparoscopic approaches is that we've had to live with three and four and 500 cc blood losses when we do the procedure open. That was the routine expectation. Now with laparoscopic and robotic approaches, we've come down in blood loss and often end up with 25 to 50 cc blood loss on a stretch. And that's primarily because we get a different view of the sacral promontory. We can identify blood vessels earlier. And we're also elevating the peritoneum to basically try and stay away from the blood vessels that could come to haunt us in the sacral promontory. So it's literally a different procedure when you do it laparoscopically, robotically than it was when we were open. So here we are developing the preperitoneal space, the pre-sacral promontory. You can see here the anterior longitudinal ligament of the sacrum. Up here on the patient's left side would be the common iliac vein. We're far away from it. On the other side to the right would be the iliac artery on the right side. We've clearly stayed away in this particular case from the middle sacral vessels, although sometimes they can be seen pretty prominently and you have to make the decision about whether you want to cauterize them or avoid them. Here we've identified the sacral promontory. We can get as far down here, right at the level of the promontory there, and place our sutures there. For people that want to go further down the promontory, I would advise going with like a 30-degree down scope, which allows you to look a little further down the promontory in the sacral curve and have your sutures placed there. All right? So here's the promontory. The next step is to go ahead and place the sutures. This is a left-hander placing sutures. And what you're going to see is I want to start as far to the patient's left as possible because I'm left-hander. It's a CV2 Gore-Tex suture. You can see the needle coming through. See a little cautery there. Deal with that small bleeder. One of the things that's really important to note is that with the robot and with laparoscopy you need as much retraction as you can. So if you notice what we're using, this first suture here, less of an issue in this patient, but in the case of a deep pre-sacral space, this first suture is actually acting as a retractor bilaterally to keep that space open. So remember that as a tip to use in the setting where you have a really difficult promontory dealing with. So at this point, you make the decision. I've basically evolved to the point in this procedure to where I always re-peritonealize. As my end got larger, I was starting to see a 1% to 2% case of small bowels sneaking under the tail of the wire. So I'm going to go ahead and do that. I see a 1% to 2% case of small bowels sneaking under the tail of the Y-graph. So I solved that problem by completely re-peritonealizing the tail of the Y-graph to obliterate that space and that 1% to 2% potential for having small bowels wrap around the tail of the Y-graph. So at this point, the next step is to pass our suture, cortex suture, under the tail. On the left, we pass the suture through the space in the tail of the Y-graph. And on the right side, because I'm left-handed, I pass the needles on the right and the suture is the tail on the left. And here we are passing the second needle. And then the intent here is a surgeon's knot forward and then a surgeon's knot backwards with cortex. The advantage here is that the suture cinches down very nicely, as you'll see. Right there. And at that point, you can now take and cinch the knot down. I'm going to bypass that second one there. And now we can actually take and pull like this, pull on one end of the suture, use the Maryland to help us cinch the knot down. And there we are pulling in order to cinch the knot down. If you have a really thick promontory here and you have lots of soft tissue and you're using the robot, pay attention to this wrist on the robot here because you'll know that you're on firm tissue when the wrist of the instrument, that Maryland, the wrist on that Maryland starts bending. That's how you'll know you're on hard tissue, you're on the promontory. If you lack that haptic feedback, that's how you manage that. You see a little bit of bending at the wrist there, that's how you know you're in the right, at the right level. All right. Done that again, didn't I? So there we are. First one's down. Next is down. Do the same thing with the second suture. And at this point, what we will do is move into the sacral curve and basically develop that incision on the peritoneum and bring it around the vagina to the left and on the right and sew it back over the tail of the Y-grass. And then go ahead and close the peritoneum over the promontory suture. What I'd like to show next is the management of a—next video, please. It's number nine. All right. And this is the case where there's a nice, deep promontory that's about a centimeter thick, the presacral promontory fatty tissue. We've identified the sacral promontory. We're placing needle number one. You get the impression over here that we may have incorporated that middle sacral vessel there. Let's see. We've got our first suture in place. We're going to look to see where it's coming out. There it is. We're going to pull it out—the needle out somewhat, and we'll leave some of it in place. And here's the needle accomplishing, in effect, a little retraction so that we can place our second suture. All right. Here's that vessel there that someone ignored initially, and here we are placing our needle right in it. It became known after the fact. I want you to notice that this first needle is actually acting part of the retractor, and I want you to see what happens here. So, here we are. This, in the open procedure, is—basically gets everyone very excited, but then what we are able to do in the laparoscopic robotic case is, because we understand our anatomy and we understand what's going on, we're able to place our needle right in it. What we are able to do in the laparoscopic robotic case is, because we understand our anatomy of the middle sacral vessels, we can basically cauterize around it. Really important point here. When you use this bipolar, Maryland, or your PK, if you use that for cautery, you notice I did not grab the tissue. I basically straddled around the bleeding vessel and then cauterized with the bipolar. The reason for that is, if you actually grab the vessel, you can never let it go because it's fixed when you cauterize. I wanted you to basically see that. Here is another technique that we use. We would go ahead and basically tunnel under the pre-sacral peritoneum here. You see us tunneling all the way down. We can then bring the tail of the Y graft through the tunnel and pull it back up, and that, in effect, gets us re-peritonealization of the graft. It's really important to take your instrument and pass it just under the peritoneal tissue, tunnel downwards, and then what we will do at the end is go back and pull down distally on this peritoneum in order to basically completely re-peritonealize the tail. The last thing I think we have time for here is the video number 10, if we can go to that one. In cases where you have difficulty accessing the sacral promontory itself, actually seeing the anterior longitudinal ligament, we can feel it here. We think it's right under there. We've gotten our three centimeters medial to the ureter, and I don't know why this is happening. Can you guys help with this? Here we are. I think I keep going back to zero, but let me try here. We're trying to locate the promontory, and we can't quite do it. We think it's under there. Here's a nice little technique that we call wristing at our shop, where you can literally take the wrist of the instrument and actually separate the soft tissue, much as you would with your fingers, and you can see the promontory of the anterior longitudinal ligament developing really nicely with that technique. Now, there's also the middle sacral decimal, but at least we're not injuring it. So that's a nice little technique called wristing that you can use the blunt aspect of the instrument to actually separate the fatty tissue to help identify the sacral promontory. You want to be a little mindful of being too far to the left. I saw a little blue there. That could easily be the common iliac vein, so you want to be careful when you're doing that. But the wristing technique allows you to get really quickly down. So I think I'm going to stop there and see if there are questions. If there are not, then I can show you some more complex procedures at the promontory, especially difficult promontory, but I think I'll stop, Leslie, and see if there are any questions. And just remember, y'all, if you have any questions, just type it in. Lois, I'm just going to ask a question while I see if anybody else has one. What do you use to hold your sigmoid over? Okay, so what you weren't seeing in this section was arm number three, which was actually being used to hold a sigmoid promontory over to the left. And you can do this probably about 60% to 70% of the time. You actually have to move the sigmoid yourself. Probably 30% to 40% of the time the sigmoid is actually flipped over to the left anyway. And so we use arm number three on the robot to do that. I know there are people that actually will take and place a suture in the seroser of the sigmoid and anchor it in the left anterior abdominal wall and use that as their retractor. I've found that I've not had to do that very much, but that's certainly an option as well. Well, I'm not seeing any questions right now, so I'm going to take that as a request for more video. Okay, let's go to the difficult promontory, then, number 11. Did you have that? This is a much longer video, but what I want to basically show you is here are some tricks. This one is actually interesting. So here's a dissection where it looks like it's a pretty straightforward dissection because the promontory is right there. But you'll see as we develop our – okay, so that was arm three, Leslie, which is what we were using to hold the sigmoid. And now we can see that arm three in now and using it to help elevate the opening. One of the things that was a little disturbing about this dissection is that there's some thick tissue here that looked kind of tubular. That was causing some concern during the dissection. And so we basically made sure there was, you know, obviously we still do this procedure with two units of back thread cells in the room. That's already type and cross in case we need it at this point. You can see some tubularity over the promontory. And I'm not able to basically say exactly what that is. Could it be portions of a hypogastric? Is it an aberrant vessel? It's hard to say at this point. And so we slowed our dissection down in an attempt to better define that structure that you'll see develop right around here where the arrow is. You'll see right here. So there it is right there. Whatever it is, it's about five millimeters in diameter. There's a component that's to the right, and then there's another component to the left as well. And so the strategy at this point is how do you manage this, right? So if it's a blood vessel, you can cauterize it. If it's an aberrant and it's a nerve bundle, you don't want to cauterize it. It's unlikely to be a ureter because of the location, but, you know, it's not peristalsing. So since we don't know what it is, the first question really had to do with is it mobile enough and can you get it out of the way such that you could actually place your needles without involving it. And I think what we ended up showing here is that it is actually quite a mobile structure. You can see it moving. It moves to the left and the right, and the intention was to get our needle in there, to the left of it slightly so that it wouldn't get in the way of the needle as you were placing the dormitory suture. So this is an example of a structure that basically just showed up that obviously didn't read the textbook, and you have to manage it. This is not a reason to abandon the procedure. It's just a reason to be much more careful at this point. So what we did here is having identified the structure, we brought our suture in. Oh, I did that again. Okay. The suture is placed there. There's the tip coming out. Here's that structure to the right of the suture. And we can actually use this suture, this needle, as a retractor, if you will, to keep it out of the way. Actually pulled it through. At this point, you can pull it through or use it to keep the structure out of the way. The second suture similarly placed, a little more distally. And then once the tail of the Y-graft is tied down, we would put a biologic barrier between the graft itself and the structure in the event that it might have been a blood vessel to prevent the graft from eroding through the structure following the procedure. Okay. Any questions? So, Lennox, do you traditionally tunnel to repair needle lines or do you make an incision? Yeah. I'm opportunistic about it. If the tunneler looks like it's going to work, like if we lift right there and we see that it's a straight shot with the tunneling, you can go ahead and tunnel. I usually tunnel with the instrument that's on the left. It comes through nicely. If it looks like tunneling is just not going to work, if the peritoneum, if the sacral curve is too deep, then we can go ahead at that point and basically just cut open with the scissor. Cut the pre-sacral peritoneum open. At the distal apex of the incision, we would tie our two-ovicle suture, make a knot there, and then bring the peritoneum over the tail after we've attached the tail to the sacral commentary. You can do it either way. You can do basically whatever is easiest. Okay. All right? It seems what I'll have to be able to do is, Leslie, I think I want to basically send you these videos together with the full 80-minute one, and maybe you guys can put those up on the website. Unfortunately, they're not narrated, so it's going to be up to the user to learn from just looking at the videos, if that's okay. No, I think that would be great. These videos, I'm actually doing one of these tomorrow, and an obese woman who I'm a little concerned about her visceral obesity and a big set of sacral commentary. I had a bear of one a few weeks ago. So these are always great to learn from, and I appreciate also that you shared some of the difficult dissections. Oftentimes on videos, we see the easy ones that take like two seconds. So I think, you know, oh, look at that. I was like, oh, I see. That looks like, yeah, I can do that. So, yeah, I think that the post-hysterectomy ones are really, you never know what you're going to get exactly. So I think they were really valuable. So if nobody has any questions, I just really want to thank Dr. Hoy for that fantastic presentation. I think we learned so much from one of our subspecialties, blindness educators. I want to thank Dr. Hoy for carving time out of his day and also for all of you that have participated here. Again, please provide your feedback, and please look out for Dr. Hoy's videos on the website. We will figure out a way to put them with these other archived videos. And so we are looking forward also. I have you guys on. Our next program is on Wednesday, June 8th. It will be on the Musculoskeletal Mystery, Bridging the Gap Between Physical Therapist and Medical Practitioner by Ingrid Harm-Hernandez, who is a PT and also chair for the APTIS Special Interest Group. And, again, that will be at 7 p.m. Eastern on Wednesday, June 8th. So mark your calendars. Thanks again to everyone, and a special thanks to Lennox. Thanks for all those videos. That was really fantastic. Thank you. And we're still not teaching the fellows to speak up, huh, Leslie? I thought that was part of the mission. I know. You want to hear everybody's voice, right? Yeah. I thought we were over that. But, hey, maybe we're not. That's okay. I think they just really enjoy it. Everybody loves a surgical video, so that was fun. Okay. We'll get with Will and see about getting the videos up. Definitely. All right, great. Thank you, everybody. Thank you so much. Perfect. Thank you. On behalf of OGS, I would like to thank you for your participation in today's event. A post-event survey will appear requesting your feedback. Please take a moment to complete this survey, as it will help OGS plan future web events. This does conclude today's program. Thank you, and everyone have a great day.

Robotic Sacral Copal Plexi

Anatomy

Complications Management

Leslie Rickey

Lennox Hoyt

Laparoscopic Approach

Robotic Approach

Prolapse Treatment

Barbed Sutures