Let's see if everybody gets on. I see about 39 participants, so I'll give everybody a few minutes. How's my volume, Fiona? Yeah, it's good. I can hear you good. I'm just going to introduce you guys right before you speak. Okay. I'm holding at 40, so I think we can start. Is that good? All right. Good evening, everyone. Thank you for joining this webinar on visibility and accessibility for vaginal surgeons. A few housekeeping slides. This session is being recorded. The chat function has been disabled, but I'm going to be monitoring, as your moderator, the Q&A. So feel free to put that in, and we really would love you to interact with us. We've got some high-volume V-note surgeons here, all of whom are urogynecologists as well. So I think that this is a timely topic. I think this is an important new tool that we can add to our armamentarium as pelvic reconstructive surgeons in our new specialty of urogynecology. So everyone here is going to be talking about the visualization. I'm going to be talking about ergonomics, and we're going to tell you why this makes sense in our practices. The first speaker will be Dr. Fiona Lindo, and, Alec, if you can go to the next slide. And she is a double-board certified urogynecologist from Houston Methodist. It's a beautiful hospital in Houston, and she's going to be talking about V-notes for hysterectomy. Want to take it away, Fiona? Yes, thank you so much, and it's a pleasure to be with all of you here this evening. Thank you so much for joining. And as they're getting the slides up, vaginal natural orifice surgery is one of the procedures that, as Dr. Iglesias said, is really something that you can use as a toolkit, really place it in your tool kit to use for specific procedures. Some of the advantages of this procedure is that it's minimally invasive laparoscopy surgery through the vagina, and it allows improved visualization, ergonomics, as well for complex procedures. Now, common procedures that this is used for is vaginal hysterectomy, adnexal surgery, apical prolapse repair, you can use it for hysteroscopy, hysterepexy, I'm sorry, and other like procedures. These are the tools that are necessary in order to perform the procedure. This is the gel point V-path system. You have the gel point, you have your ring that you place in order to perform the laparoscopic portion of the procedure, your ports, as well as your retractors to place the ring. And here on the right side is also one of the newer introducers that we use to place the ring. Now, I'd like to start out with the case, and this is something typical. And, you know, one of the type of patients that I would use this procedure, 63-year-old G4P4, who presented with urinary incontinence, symptomatic, stage two prolapse. She also has a significant past medical history of DES exposure, so needing both her ovaries removed. She had a history of lymphoma, diverticulitis, DVT as a result of chemotherapy for her lymphoma. She also had a past surgical history of laparoscopic sigmoid colectomy with reanastomosis, and then laparoscopic cholecystectomy. So this is a patient where you'd think that there are probably going to be some form of adhesions there in her pelvis. You know you need to get her, both of her adnexa removed. And so you, some of my colleagues would have consented her maybe for a Vag His, TVH, Vag His uterus sacral, and then also consent for a laparoscopic BSO if necessary. But with this procedure, that's not what we have to do. So let's go ahead to the next slide. And one of the things with entry, you start out as you would with a normal vaginal hysterectomy approach. Get into your anterior and posterior copotomy. In the posterior side, you really want to spread to allow for space for that ring. And then you also want to make sure that you secure your peritoneal edges. This is going to be helpful in being able to identify, place the ring, allow the ring to be seated appropriately. And as well as being able to identify your structures. You can go to the next slide. One of the things you want to do is make sure you tag your uterus sacral ligaments. And really re-support them back to that vaginal mucosa. So that when you are pulling on those ligaments, you're able to have good visualization intraperitoneally. Next slide. So here's a video of just how you place the ring. This is with the introducer. And as you can see, we're placing the anterior portion of the ring as well as the posterior. So we're going to feel a hold pressure there on the posterior side. And once you've placed that anterior ring, you're going to place that introducer on the posterior side there. And you can see pulling on that posterior peritoneum and vaginal mucosa that's there. And that allows for the ring to seat well in the peritoneal cavity. Next slide. So here you can see the ports are placed usually in a Y formation on the gel port. And you have both of those ports to use for your instruments. And then the port on the bottom at 6 o'clock is used for your camera. And this is the view that you get. Here you can see the cautery devices go ahead and taking the vessels and your pedicles here. It's important, really, you can see you have good visualization. You have the bowel packed out of the pelvis there with a sponge or a pack. And then once you've started, that was on the patient's left side. Now we're going to the right side. You change sides with your instruments. And you're really, this traction is not pulling, but pushing. And you're able to take the pedicles with good hemostasis. In this patient, you can see here that we need to remove her adnexus or ovaries there. You can see the ureter vesiculating nicely there on the sidewall. And you're able to take her adnexus safely with good visualization and good hemostasis. Attention then was turned back to the patient's left side where the remainder of the hysterectomy was completed. And you typically will leave part of the uterus there so that you can have good orientation of the uterus before you go to that opposite side. And you can see in this patient, she had partial retroperitonealized adnexa. And so in order to have good visualization to remove this, you can see that having that added benefit, the laparoscopic approach was really helpful. You're able to dissect using electrocautery and also sharp dissection and able to dissect the adnexa away from the sidewall as well as her ovary there. And we suspect that these adhesions were as a result from her previous colectomy and previous surgeries. So utilizing this laparoscopic approach, we're able to successfully perform this procedure through the vagina. So one of the best minimally invasive ways to do this hysterectomy. Now you can see here the uterus sacral ligament there on the left side. You're able to really see the structures clearly. There's her ureter anteriorly on the sidewall and the right uterus sacral ligament. And in order to visualize that, you can see that the pelvic sutures are placed, but you're basically being able to really lateralize, medialize the rectum. And you're able to see that ligament very clearly while pulling on those uterus sacrals that you have previously tagged. And so we can fast forward a little bit because we're going to talk a lot about the uterus sacral ligament here. But I wanted to just kind of show you how this patient had really good support and had a really good outcome after this procedure that was able to be done vaginally. And so this procedure really is an added benefit, especially with patients who may have had a significant surgical history where you're suspecting adhesions. Patients who've had multiple C-sections, you're able to still perform this procedure safely through the vagina. Dr. Linder, there's a couple questions. Can you hear me? Yes, I can hear you. I just wanted to know for the insufflator, what pressure are you putting in? And the second one was what stage POPQ prolapse was that patient? Yes, it was a stage two prolapse and anterior and apical. And that's a very good question about the insufflation. And we talk about that later, but really it's low pressure. It's at 10. And so this is, you know, you can do this procedure really, you don't have, you don't need a lot of steep Chen-Dellenberg. So, you know, and low pressure. So it's quite safe for the patients. Wonderful. Well, we'll keep chatting people. I'm going to introduce our next speaker, who's Dr. Thomas Clifton-Pittman from the Baptist Medical System down in South Haven, Mississippi. He is also a board certified OB-GYN and urogynecology. And his claim to fame probably for all of us, he's done the most, has the highest volume of V-notes experience, having done his 300th case this past week, right, Thomas? Okay, well, take it away. So he's going to give us some tips and tricks after having done 300 V-notes. Good evening. Thank you all for joining. Let me get this all set up here. I'm not very tech savvy. You're doing great. There we go. Yeah. You know, we all went into this, this line of work for the same reason. That's to improve the quality of life of our patients in the least invasive manner. You know, get them their life back with an incredible ability to enjoy their life. You know, I thank the Lord every day made me a man because no man could do any of the things that you women have to go through. But being able to provide some support and help is, I think, the most rewarding thing for all of us. And, you know, having this extra tool in your toolbox, I think is, you know, probably the best thing and most exciting thing I've seen since residency. When I came out of residency, LAVH was brand new. And of course, we were all trained to be vaginal surgeons, but unfortunately, we've gotten away from vaginal surgery. You know, in this country, you know, if you look at different sources on the Brigham and Women's website, it says that nearly 60% of hysterectomies in this country are still done abdominally. ACOG Committee Opinion 701 says 54% are still done abdominally. But we have all this evidence that shows the improved safety and improved outcomes of vaginal hysterectomy, which makes vaginal approach the most desirable approach. But yet, right now, vaginal hysterectomies only count for about 12 to 13% of all hysterectomies. I think those numbers to be obviously be switched. And I think VENOS is a renaissance for vaginal surgery. I'm really, really excited. You know, with the introduction of laparoscopy, we had the alternative to the vaginal approach and abdominal approach. You know, when I was training in vaginal surgery, I had an attending tell me that vaginal surgery is kind of like surgery by Braille. It's feel and repetition, but the visibility is limited and there are limitations to your choices for patients because of size of the uterus or mobility of the uterus. And VENOS allows you to get around that. You know, about 30 to 40% of hysterectomies are done laparoscopically, with or without the robot. But I think we need to convince all the surgeons around the world that the vaginal approach is the approach that we need to investigate first. And VENOS gives us improved accessibility through the vagina and with the same visibility of laparoscopy. And I just wanted to briefly discuss my series that, you know, I've done 301 as of yesterday, but this is data on the first 280 cases. 260 of those were hysterectomies with or without an adenectectomy. 37 had a concomitant high uterine circle suspension and then 20 sterilizations. So there's not much adnexal surgery, but mainly hysterectomies. And the nice thing about this is that we're all trained vaginal surgeons. We're all trained laparoscopic surgeons. So the learning curve is very, very quick. If you look at my first 10 cases, I was down to about 40 to 45 minutes within 10 cases. And I timed my cases from fully in to fully out. So I finished my case fully out. Once they board, when they get to the holding area, they can go home. The blood loss is low. If you look at the median blood loss of 50 milliliters. And my conversion rate's only been 2%. So only 2% of the cases I've had to switch from a vaginal approach to either a single site laparoscopic or an open technique. And, you know, the OR time I mentioned earlier is really important because obviously the biggest cost of surgery is the operative time and the time that we have to pay for being in the OR. But, you know, V-Notes has the quick learning curve with reduced operative times. This is really great because, you know, in the South where I'm from, biscuit toxicity is very common and my biscuit titer is pretty high. So patients with high BMIs, this is perfect because you can access your target organ in the easiest fashion without worrying about wound complications. Without having to worry about steeped in Trendelenburg. You know, the question was about the pressures. You don't have to insufflate to raise the abdomen off of the bowel like you do with an abdominal approach or laparoscopic approach. You just have to insufflate the pelvis. And I think that's key as far as them tolerating surgery, these large patients. You look at my numbers, 58% of my patients had a BMI over 30, 16% had a BMI over 40, and my largest was 59.6. So we've done quite large patients and, you know, you get great exposure and the complication rate is low, which is what this is all about. As far as uterine weights, you can remove quite large uteri. This picture is a 500 gram uterus. Over that, you usually have to morcellate, but 27% of my specimens have been over 250 grams, 10% over 500 grams, and my largest 876 grams. I haven't reached the one kilogram club yet, but that'll happen one day. Another really exciting thing is the previous cesarean sections and abdominal surgeries. You know, when people talk about vaginal surgery, they worry about previous C-section patients. And Dr. Zirob's going to show a video in just a little bit that shows a great technique with the V-notes that's possible for C-section patients. It allows you to enter safely and opens the door for a lot more patients. 32% of my cases had at least one cesarean section, 18% had more than one, and I had one patient with six previous cesarean sections. I've had patients who had multiple abdominal surgeries, ileocecal resections, colostomies, previous Whipple. All these things you think about would have horrible adhesions. You wouldn't want to approach abdominally, and you can approach vaginally. Another point, too, I didn't make before is that, you know, when you're doing an abdominal approach with laparoscopy with a robot, you're reaching around a bulky uterus to get to the dangerous things, the ureters, uterine vessels. When you're doing this approach, you get the uterine vessels immediately. In the entire case, you're pushing the uterus up and away from the pelvic sidewall, so there's a lot less risk to injuring the ureters, and you get blood loss control almost immediately, which is optimal, particularly in these large patients. As far as complications, you know, the United States, looking at the Green Journal's complication rates, infection rates, abdominal hysterectomy 10.5, vaginal 13, TLH without the robot about 9%. In my data, there was a trend that infection rate was a lot lower. I don't know exactly why, but overall, only 15 patients had a complication, 5.7% complication rate. 3% had infections, and I think the lower infection rate may be related to not clamping and crushing tissues, using a bipolar energy source from below, and not using retractors to traumatize the tissue while you're trying to get exposure, because the ring opens things up, and you can use the scope and see so well. The other complications are similar to what's quoted with the other techniques. Just to repeat basically what I just said. Again, I got ahead of myself, I'm sorry. Operative times are reduced. If you look at the average operative time in my series, 45 to 50 minutes for a uterus less than 250, 60 to 65 minutes for a uterus over 250, and a lot of that's morcellation. If you add in the uterine cycle suspension, it only adds about 15 to 20 minutes to the procedure. And 88% of my first 200 cases went home, they have surgery. So once they get more, they can go home, and they feel like they didn't have surgery, which is kind of exciting. Post-operative pain is reduced. If you look at the European data, post-op narcotic use was only three tablets. In this country, with the problem we have with narcotic abuse, I think that's really exciting. So as far as the trends seen in my series, again, I think the lower infection rates because of the shorter operative time, less tissue trauma, lower blood loss. I think the data suggests that this allows improved safety because of the accessibility of the vaginal approach with the visualization of laparoscopy. And reduced complications, particularly infectious complications, since there's no abdominal wound. Patients have less post-op pain. But we need many more studies, but we're in our infancy here, I guess, in this country with this technique, and it encourages all to start gathering data and we can start comparing particularly pain management and patients' post-operative pain results. But that's my experience in the first 280 cases. Again, I hope you can tell I'm excited about this. This has changed the life of so many of my patients. And right now, it's not, you know, could this be a venose? It's why would it not be a venose? Because this is my number one go-to. Because, you know, I don't think you can argue with the outcomes. And it's just a tool that I'm using primarily, but all the other tools in my toolbox can still be used. If you convert it to a single-site laparoscopy, it's still minimally invasive surgery. So I'm excited and I appreciate y'all joining us tonight. If you have any questions, just- There's a couple. Okay. Thank you, Dr. Pittman. One is, what do you use to pack? Maybe Fiona can answer this as well. I mean, I actually just take three moistened lab packs, two, tie the blue strings together, and if I need to tie another one for three, I'll throw another one in there. But I wouldn't tie them together because I don't want to have one up there and then try and be looking for it. But what do you guys use for packing? I'll put a lap sponge in, particularly when I do my utricle suspension. I find it helpful to push up on the lap and pull down on my tag at the same time to get that tension on the ligament, to get a good visualization of the ligament. My hysterectomy patients, unless they're really obese, I don't typically pack them. But when they're really obese, I pack them because you can use a lower pressure and less dandrung burden. You do have to pack to tie your utricle. So what do you use, Fiona, and what T-burg do you use? And do you guys use like a pad, one of the blue ones or the pink ones? Let's not get proprietary here. So for me, I actually use what's called a surgery wall pack. It's about six inches in width and about 62 inches in length. So it's pretty long. I actually have a video later on in this talk of how I put it in, how I pack the bowel out of the way. But that way, everything's really out of the pelvis. There's nothing in the pelvis and I'm able to do my hysterectomy and my utricle without having to fight with the bowel. Yeah. And you, yeah, you want to pack this and then you put your ring in, go ahead and, you know, roll it down, pack it, then put the gel port on. That was a question, which is good. And yeah, you definitely need less than 30 degrees, Jen Dunbar, much less than with like a robotic procedure. Okay. So far so good. And you know, we are going to eight. Are we going to an 8.30, right? Let me know, because I can keep talking forever, but I'm going to- We're going to eight. Okay. Danny, then take it away. Dr. Danny Zurab is double board certified and he's got a double master's in MBA and a master's of health and physician. I bet you have the longest alphabet after your name. And he is a professor and chair down in New Orleans, in Louisiana. Sorry, Oshner, right? So I'm actually at LSU in Shreveport. It's Oshner LSU. It's a combined health system. Yes. Okay. We're in the South, it's well-represented. Yes, it is. Take it away, Danny. He's got to talk to us about uterus staples. This is, I know the reason why many of you are here. Absolutely. First of all, thank you very much and good evening and good afternoon, actually, for everybody for attending this webinar. And thank you for being invested in optimizing your patient's care and the potential of expanding your repertoire of surgical offerings and procedures. As Dr. Pittman talked about his case series, we're going to transition based on what he had talked about into going over some data and some publications and see what are the potentials of utilization of B-notes in our practice. Let me just make sure that this is easy to see, correct? You got it. Perfect. All right, so let's talk a little bit about the clinical evidence. There's not a lot of data that is higher quality publications at the time being. There's a lot of retrospective chart reviews. There's a lot of retrospective, there are case series. There are very few RCTs. There's actually one that's very well-known and there's one meta-analysis systematic review. It's quoted as a systematic review and meta-analysis at the same time. But let's talk a little bit about the RCT that is out there. It's called the HALON trial. It's the study that is quoted a lot for the utilization of this procedure. And it was actually more of a feasibility study. It focused on whether B-notes was a non-inferior option for TLH and their hypothesis specifically was the actual completion of the procedure without converting. So that was their main outcome. And the study showed based on their findings that it was non-inferior as a potential option for performing a vaginal hysterectomy compared to... So through B-notes compared to a TLH. Now, if we look at higher quality data, the systematic review, which was performed and completed by Dr. Hausman and her colleagues took into account one RCT, which is the RCT that I just mentioned. And at the time that this was performed back in 2020, there was only a handful of studies and there were five retrospective cohort trials. So there were cohorts. Their main finding was obviously that B-notes was equally effective to successfully remove the uterus. And that's because obviously they use the RCT. But they did show also that there was a lower value of a lower operative time, lower length of stay and lower estimated blood loss. So this kind of correlates with what Dr. Pittman showed in his three patient series earlier on. Now, any procedure that we're gonna do, we're gonna have a learning curve. So how difficult or how easy is it gonna be? I can tell you the first time I did it, I was like, why am I doing this procedure? As a urogyne, we're trained to be very proficient vaginally. We can do a lot vaginally. But once you're gonna see when Dr. Iglesias starts talking a little bit further, there are certain things that she's gonna discuss, which in my mind as a physician and as I'm aging, I do not like to use that word, I don't like to use the word aging. It starts making more and more sense why I would be wanting to incorporate this procedure as well as what the benefits of the patients are from a pain and outcome standpoint. So let's talk about the learning curve. So from a learning curve standpoint, this study, which was a cohort study, demonstrated that it takes five cases, this was a French study, five cases to become competent, whereas 25 to become proficient in completing the procedure. And this specifically focused on a vaginal hysterectomy, so a venous hysterectomy. It was not focused on a utricicle ligament suspension. If we transition to patients, Dr. Pittman talked about some of his patients who have a higher BMI. We all have patients who are higher BMI in our practice. So does this help? When we're trying to do a TLH, a big fight is fighting and trying to, being able to manipulate the scope and the instruments when a patient has a higher BMI. So what about transitioning vaginally? Doing this vaginally, it is the same as you're doing a vag hyst. So the access is there. You're not fighting with extra skin or extra weight from that standpoint. And access into the pelvis is not hindered. So this option actually, based on this study, suggested that the patients have similar similar outcomes for obese patients compared to TLH, but at the same time, not at the expense of fighting with the patient's weight and the patient's extra skin that potentially may be there. This does not want to proceed. There we go. What about if we have a patient whose uterus is more than 500 grams? So actually some of our colleagues have completed venotes hysterectomies where the weight of the uterus itself was more than 1200 grams. Now, when we're doing a TLH, if someone's doing a TLH, it's like the uterus is sitting in the pelvis and it's like a funnel. So access to the uterines and so on are harder. Dr. Pittman mentioned that you start with the case by actually initially getting the uterines and then accessing the other structures. You go for the infundibular pelvic and so on. So in this study specifically, this study, again, it was a retrospective review. It focused on the accessibility and the feasibility of doing such a procedure. This showed that this was non-inferior to a TLH. And in real life, I've done the cases where the uterus was large. It is way easier. It is way easier to access the vasculature and access the uterus. And because the uterus is honestly floating up in the air closer, like floating closer to the abdomen. So you're not having to fight with retraction and such. Now, granted, I will tell you the only thing, if you're gonna go for a 200, sorry, 1,200 gram uterus, you're gonna spend a good time morselating. So that's the only thing I would remind you that if you're gonna go for the 1,200 gram, but it is definitely feasible. So if you have a patient who's got anterior abdominal mesh, she's had reconstruction and such, accessing the uterus this way is way, way more, way easier. What about patients who have not had like procedures before and such, they have not had prolapsed uteri, so they're nulliparous and so on. This study, again, all of these studies are retrospective chart reviews. This study showed that the accessibility and the feasibility are equivalent to doing a TLH. Again, I keep talking about TLH because there's not much data out there comparing this to just a regular vaginal hysterectomy and such. I'm giving you an overview of what's out there literature-wise. Now, we are urogynes, so we typically, if we're gonna try to do a procedure that is intraperitoneal, we're gonna consider going for a uterus sacral ligament suspension if we're going transvaginally. We can later on talk about the potentials for sacral colpopexy, but we're gonna focus on a uterus sacral ligament suspension at this point. So what is the feasibility and safety of doing a venotes procedure? As a urogynecologist, for me, this is where the money is, in a sense, for us as urogynecologists in performing the uterus sacral. You have the visibility of the ureter, you have visibility of the uterus sacral, and it's very prominent. So is it easy to do? Honestly, I have in my practice, I'm in a program that we have residents, so I sometimes actually have them assisting me with the procedure, and with the venotes, they actually visualize it, and I've had a couple of them actually do the procedure with me, complete the uterus sacral ligament suspension. I'm not saying as urogynecologists we should be giving it to the residents, but I'm just saying that it becomes even easier to do the procedure this way. So let's talk about what studies are out there. So this was one of those studies which demonstrated that performing a uterus sacral ligament suspension by a venotes is a safe and feasible procedure. You see the ureter so well, so you know you're pretty distant away from the, when you're getting your uterus sacral, you're distant away from the ureter. Other studies, this is yet another procedure, which talks about, sorry, study, which talks about the utility of venotes and the feasibility. Again, the key word in these studies is feasibility, and this one targets specifically severe prolapse, and again, this was a retrospective review. So hint, hint for people who are interested in doing studies. So yet another study. This was another study by Dr. Lowenstein, and we're gonna, actually, there's another article that I'm gonna discuss for him as well, where he talks about doing hysterectomies with uterus sacrals at the same time, reducing the incidence of intraoperative complications in a surgical anesthesia time. This is another study as well. I keep going on and on about studies which demonstrate the feasibility. Uterus sacral ligament suspension, you can go significantly high safely, though, obviously, you know, within, so there are lots of options and opportunities for incorporation of venotes in the urogyne world from a uterus sacral ligament suspension standpoint. Now, what about use of venotes for gender-affirming procedures? As I mentioned earlier on, in the cases where patients have not had, have been nulliparous, and this was a successful procedure for them and feasible, it's the same thing for patients who are undergoing gender-affirming hysterectomies. And when I first started doing these, I've done many of these procedures, it took me a while to learn certain techniques, and I came up with some suggestions, which I typically discuss with colleagues of mine if they're doing their first couple of cases. For example, if you're doing your first uterus sacral ligament suspension through the venotes technique, I would suggest shying away from a case where she's had prior resection of the sigmoid or in areas where the pelvis could potentially have a lot of adhesions just for the first couple of procedures. I would also suggest that consenting the patient for a potential traditional vaginal suspension, not just a venotes suspension, in case you need to convert, in case you're unable to access the uterus sacral ligament adequately. And the reason why I mentioned that, in the first couple of cases that I was trying to do, I'm used to putting an Alice clamp on the uterus sacral ligament and close to it, and putting traction in order to see the arc of the uterus sacral. With the cap in place, it makes it a little harder. So what I have been doing since then is when I get my uterus sacrals initially, when I'm starting the hysterectomy, I actually tag the uterus sacrals and keep a suture attached to the uterus sacral. And I actually also attach it to the vaginal wall in order so that if I put a lot of traction, I can pull on it safely and it won't detach and the arc will become very visible with the cap in place. One key thing for this procedure to be successful is that the colpotomy, posteriorly and anteriorly, needs to be enlarged. We are used to doing a very small colpotomy and we do the procedure through it. The colpotomy needs to be enlarged. So I typically introduce two fingers in the colpotomy posteriorly and do a smiley, kind of like expand the colpotomy, and the same thing anteriorly, while ensuring that the vessels at three and nine o'clock are safe. The reason why the colpotomy, if it's enlarged, I'm not doing it with the scissors, I'm just introducing one and then a second finger into the colpotomy and enlarging the incision, that allows the ring to stabilize and sit in place better so it doesn't pop out. I've never had it pop out once I started doing the enlargement of the colpotomy anteriorly and posteriorly. And it is safe because the minute you're in posteriorly and you enlarge it like a smiley, there's nothing in the way unless there's significant adhesions posteriorly, same thing anteriorly. If these are your first few cases, I would suggest using a zero degree scope. That's easier to use initially unless you're very comfortable with a 30 degree lens For me, I preferred starting with the zero degrees and then I switched to the 30 degrees later on. I've also noticed that some patients need T-Berg. I rarely go to 29. It's extremely rare that I go to 29 degrees when I'm doing the procedure. I do use a mini lap. I introduced the mini lap just when I put the ring in and I slide it under the uterus if I'm doing it with the uterus still in place. In other words, I'm doing the hysterectomy followed by the utricle. I slide the mini lap under the uterus and I go down and up. That way the bowel is moved through the pelvis and up above the pelvic brim. And I typically go for eight to 10 millimeters HG. So the pressure is pretty low. The nice thing about it, anesthesia is not fighting you. They're not telling you, we're having a hard time oxygenating the patient, especially if someone has a higher BMI. Now, one of the tricks that I've learned over time to be more efficient in the OR specifically with utricle ligament suspensions is when I'm introducing the needle into the pelvis through the port, I'll use the 12 port. So the kit actually comes with the one we're using has three 10 millimeter ports and a 12 millimeter port. So I usually use the 12 millimeter port to introduce the needle. And I typically approximate the needle. If I'm working on the patient's right, I approximate the needle on the right side of the needle holder. And I literally introduce it through the port. And the minute I release the needle holder, it can immediately swing ready for action in a sense. So it's kind of like slides 90 degrees and then you can take the stitch into the utricle. And I always use the four ports. And I tried as much as possible to have all sutures delivered through one port in order to make it easy for suture management. The one other thing that I was, while I was learning, this was my learning. I'm giving you the tips and tricks of what my learning curve was. As urogynes, we have patients who may have very long cervices or very wide cervices. So if the cervix occludes the aperture of the gel port, of the ring, my way around it was to do a trachelectomy. So I would do the trachelectomy before putting the gel port in. And I actually close, I suture the side of the trachelectomy. At that point, you would have already gotten your utricicles and very often your uterine. So there's minimal to no bleeding, if anything. So it's pretty hemostatic. And it just takes a few extra. Since we're only going, we've got 13 minutes. Yes, I'm nearly done. Sorry. Questions. And the other thing is I would suggest tagging the peritoneum anteriorly and posteriorly so that the likelihood of bleeding is less, as well as when you're approximating the anterior and posterior walls, it's very easy to identify the midline. This is a video of the utricicle ligament suspension. So I mentioned the securing of the utricicle ligaments to the vaginal sidewall. I typically suture. So I have the anterior and posterior vaginal walls. This is actually my resident performing part of the procedure. Just the usual utricicle ligament suspension here. And then I typically, I would do the tracheostomy and I typically attach it to the pelvic sidewall. If you are interested in doing the vaginal hysterectomy completely and then switching to doing your utricicle ligament, that's an option. This is the ureter vermiculating and that's the utricicle ligament. So you can visually see it. And as I mentioned, the needle is aligned with the side of the wall that you're going to work on. So if you're going to work on the patient's left side, the needle is hugging the left side of the needle holder. It just makes it easier to swing into place that way. And there, it's ready for action. That's the ligament. What are you using, PDS? I use Vicryl. I was trained by Mickey Coram and Mickey Coram uses Vicryl. So I've taken that up. You have O-Vicryl on a CT1? I have O-Vicryl on a CT1. I also use CT2s depending on the color. Cause I used to, I used to, I use purple and white, so dyed and undyed. And they go through the 12 ports aligned with the needle holder. And this is when we switch to the patient's left side, sorry, right side. And as you noticed, it was aligned with the right side of the needle holder already. And it just was ready for suturing. And typically the needles are the sutures go through the middle port and as I mentioned I use I color code them to align which one's proximal and which one's distal. And then the closure technique is whatever technique you're comfortable with or interested in. Now there is something specific to the V notes specifically that you know as urogynes it may be helpful for us if we want to try to make sure that we can complete a procedure vaginally. Sometimes very rarely though we run into patients where they've had significant adhesions anteriorly from like three or four c-sections where the anterior the bladder is very much adherent to the anterior vaginal wall anterior wall of the the uterus. So there's a technique through the V through V notes where if you open posteriorly your intraperitoneal posteriorly but anteriorly you complete the dissection anteriorly but you can't actually enter. In other words you have a flap of vaginal tissue and then there's the uterus and tissue between it where it could be bladder it could be anterior vaginal wall we're not sure. There's a technique through the V notes that is very helpful for identifying entry easily anteriorly and at the same time potentially reducing the likelihood of performing a cystotomy. It could be used for patients with lack of descensus for previous c-sections. I think the use is very good for previous c-section patients. So if you notice anteriorly we've done a lot of dissection and the ring anteriorly we're pushing it in between the anterior aspect of the uterus and the bottom side of the vagina on the anterior vaginal wall. So it's in posteriorly in the pelvis anteriorly it is not in the pelvis. So what we're going to do is we're going to put the cap we're going to insufflate we're going to fill the pelvis with gas and the abdomen with gas and we're going to let that gas distend the peritoneum and the area where the bladder is anteriorly so that we can try to identify the space anteriorly. So here we're looking we've already started insufflation we're in the pelvis that's you see the pelvis we're interperitoneal posteriorly and let's look anteriorly there we go anteriorly you see the adhesion anteriorly and if you look over here nice yes so this is the advantage of over here it gives us the potential for identifying entry entry sites safely. You notice the the the peritoneum is shaking it's called the sail sign that's from the insufflation and directly with the scissors you can just open the space and we're in anteriorly as this shows. So this is one technique to try to help get in anteriorly as well. So this is my part thank you very much for listening to me. Yeah and I'm just going to take it home and if you don't always pick up my slides can you write in the brand or the name of the the six foot long packing. So I'm Shirley Glazia and I'm up here in Washington D.C. next slide and I got into this I mean lots of vaginal surgery but because really of the ergonomics and the visibility. So the you do not this is actually a case recently where we're doing a hysteropexy you just do not get this view on a traditional with your own eye without the without the scope seeing the relationship of the uterocycle to the ureter and there was a question by Dr. Chen about if you get too high if we get too deep there are there's risks for doing that I mean obviously including the your the rectum and causing a relative bowel obstruction putting the needle too deep into your sacral and getting into your pelvic plexus and getting some nerve injuries I guess is theoretical because you don't have that maybe the same haptics but I think you have better visualization. And so next slide is a summary slide from one of my former fellows Dr. Yotiri Kaplan who's up in Columbia and Dr. Amy Park both of whom wrote this in the Green Journal a couple months ago in March and there is a society that's multi-specialty related to just surgical ergonomics but looking at vaginal surgeons 87 percent have reported work-related musculoskeletal injuries and you know it is very awkward positions but I know people are getting neck surgery hip surgery like 14 percent of missed work 20 percent of modified their work hours they've had surgery for back pain the awkward positions neck deviation being the most common this is because of the attendings and we have fellows and residents we're the ones assisting and this is much more common for the assistant surgeon than for the person in in the middle. Next slide and this is like what the stuff so that's me on the left that's my fellow Fabian Gattani and that's our resident who wants to go into MIGS and she's actually doing a study looking at the ergonomics of vaginal versus V notes but you can see me standing excessive just to be able to look to see what she's doing on my neck the person in the middle can sometimes get excessive trunk flexion and we're doing all these exercises and stuff to to counteract the stuff that we've just spent three hours doing this is very important. Next slide because this is what it looks like with V notes and you know I'm standing straight I'm straight on my camera is not deviant I can see what she sees we actually have dropped it down from you know crowding with two assistants and the primary surgeon in the middle to just the one and someone handing the stuff I can get some more tips and tricks we have a presentation at AGL I use the 30 degree lens we also use self-writing needle drivers but the bottom line is you know it is actually more comfortable. Next slide this is a paper a picture and this is actually from our OR because with the with the red white and blue flag that's Dr. Sokol and Dr. Latere-Pavlin there actually was an app that they used so they could measure the amount of time with tape on our back in these awkward positions and certainly straightforward vaginal surgery is not good. So next slide because I know there's lots of billing questions here we are neutral my back is straight I'm comfortable I this is the question that's like the loaded question how do you code Cherelle the laparoscopic the V the uterocyclic ligament suspension listen guys we don't even have a laparoscopic uterus suspension vaginal copeplexy code you're going to use the same 5 7 2 8 3 I want to caution you not to use the laparoscopic sacral copeplexy that would be dishonest because that code does require a use of a graph placement of a graph so there is no specific laparoscopic code for so you're going to use the same uterocyclic ligament suspension what is different is that if you're doing the hysterectomy with v notes you would use laparoscopic assisted vaginal hysterectomy um codes as opposed to just the straightforward tbh uterus staple honestly it's about the same so what we're what we're gaining is better visualization potential less ureteral injury I feel that in my heart of hearts that I can see this better and you know guys we have anywhere report between six to eleven percent ureteral kinking after this procedure so let's go ahead and answer these questions since we have two minutes left and I thank you for your attention all right so I think I answered but I do I mean my partners are concerned that if we get too high that we could you know kink off the the rectum I think it's theoretically possible I do think you need to have a sense of to the length of your total vaginal length when you're doing these honestly just to make sure that we're not bridging and then the second thing is you know that nerve injury what what do you think um Danny and and Thomas and Fiona on preventing um injury I think the visualization is better absolutely and you can sleep at night not worrying about the ureter I never worry about it but I'm going to tell you I used to be so paranoid I would be like doing my three sistos place do the hysterectomy place the uterus ankles tell them not to the uterus ankles do your sister make sure you didn't tack off finish your anterior pair of the sling tie the uterus ankles do another sister check the ureters no you know I feel very confident I can just see it I just do one sister at the end you know maybe you know even after the sling I just do the one sister at the end and save some time there how do you decide where to take the bite in your staple tips so I'll go ahead Dr. Thomas no no go ahead okay so one of the things is I'm going to answer two of the questions here one was where do you place the bite and how do you take it when you're used to using an alice and to visualize the uterus staple and so the key thing is Dr. Zara mentioned earlier is making sure when you tag those uterus staples you leave a suture on the end of that and you actually re-approximate that suture back through the vascular mucosa that way you're able to really pull and kind of tug on that uterus cycle to visualize it the other thing is that that ring is kind of seated right where the spine is a little bit and so if you know where the ring is anything above that is above that ischial spine and when the the third tip would be every time you're doing a uterus staple you're using your retractor and you're retracting medially the rectum medially away right from that uterus staple well remember that the rectum also is attached to the uterus staples so when you retract that rectum medially it pops that uterus staple very clearly into view and you're able to see exactly where to go so those are going to be those tips I'm going to leave with you in regards to how to visualize the uterus staple without palpating it or putting an alice on it. And Danny you're the one doing um or starting to take a couple pexies you can get too high I I wouldn't say that you don't want to go into the you know um pair of the pre-staple space area no no not at all but you could potentially reach it with a few packets so I just want to caution I think knowing where the where it is in relation to the rectum and having a sense as to what your total vaginal length is or at least the length of the put when you first start um I think is key and you know that's all with experience and I mean I'm going to be honest with you I just like to do the hysterectomies vaginally I just feel like we're fast I mean the the bites with the it's fine uh and but I think if you you know if you're adept to do a little quickie hysterectomy what you are getting better is the visualization and maybe the um you know the ergonomic effect what was the next question here the billing did we answer those they insist on tbh well no I do think you can say labh I think that that's kosher what do you think Danny you're the MBA I cannot speak to coding I'm currently using the tbh code personally but I cannot speak to coding but uh what you mentioned earlier on about that there is no code specific for laparoscopic utero sacral ligament suspension 100% agree and big caution about not using the code for sacral copal pexy thank you for saying that because that requires a graft I think we need to unfortunately we are at time but I think we should do another webinar specific to tips and tricks for hysterectomy there is some definite advantages to that and I think we definitely need some um tips on that but um this I think unfortunately our time is up you want to say a few words on that Danny so I've performed multiple hysterectomy they are um they are doable just like they're doable vaginally nice thing is you're visualizing exactly where you're going um there are certain tips and tricks that you need to make it more efficient and uh easier on you like how to manipulate the uterus how to move uh the uterus out of the way and so on but there is a lot of potential for this technique um it's we currently do it for utero sacrals and vag hyst but there's options for hysterectomy and sacral copal pexy and I like that I like it I like the way it looks anatomically better than sacral spinous hysterectomy so it's a great native tissue hysterectomy repair all right um well thanks everyone it really I love working with you guys um I want to encourage you please if you can take the time um to fill out the survey you just want to improve on improving and um that is going to be sent and there is a way that if you want to join the b-note society you can go to b-notes.com um there are lots of pre-recorded webinars and other information on that probably Dr. Pittman Jan Bacala you guys probably all have it I'm the novice I'm probably the oldest here but the most novice when it comes to a new convert to um to v-notes but I really like want to save my neck as I get up there in age thanks everyone great

V-notes

laparoscopy surgery

hysterectomy

uterine sacral ligament suspension

minimally invasive

visualization

ergonomics

complications

urogynecology