I want to welcome you to CooperSurgicalís sponsored breakfast. My name is Bob Auerbach.
Iím the Senior Vice President of CooperSurgical and their Chief Medical Officer.
For years Cooper Surgical has been involved with educational programs trying to
highlight some of the new techniques available to those surgeons that were involved
with advanced laparoscopic surgery. Weíd like to continue in that vein and this
year we decided to bring a number of physicians who are internationally known to
help join in that effort. Weíre going to start this morning with Dr Charles Koh.
As many of you know, Dr Charles Koh is the President of the Society of Laparoendoscopic
Surgeons. He is also the Director of the Milwaukee Institute for Minimally Invasive
Surgery. And heís going to speak to us regarding conventional laparoscopic hysterectomy.
I would like to thank Cooper Surgical for sponsoring this event for the last
few years. Always had a very interesting group of people, some from India, from
China, Japan. And the feedback is always useful in my learning too in doing laparoscopic
hysterectomy. Today itís a privilege to have Dr Advincula to present another aspect
of doing total laparoscopic hysterectomy with a robot and I think the idea is that
we want more and more adoption so that laparotomy becomes a last resort.
So when this was first concepted, the idea was how to simplify laparoscopic hysterectomy
because at that time everybody was struggling in 1990, dissecting the ureter, trying
to keep the pneumoperitoneum in. Thatís the way I did it but I figured that the
moment you didnít have to dissect the ureter, which is what you donít do when you
do a laparotomy then it will give more confidence to the person doing the laparoscopic
hysterectomy. So I hope we have begun to achieve that over the years.
Everybody knows that the area that is of greatest concern in hysterectomy is this
area, which is the ureter below the uterine artery.
Whether it be laparotomy, vaginal hysterectomy or laparoscopic that is the area
that we want to try to minimize complications.
If you look at this green line, this is the line of the ureter and this is the line
where you can see the uterine artery not that far away. When you put a cup in and
elevate it you now have increased the distance away from the ureters. So that is
the element of safety you can achieve.
However, there are certain tips that are important if you look at this line again,
when you put an appropriate size cup and push it up you have this distance, however,
if you put too big a cup the ureter is still around the area, in fact it is close
and you may mislead yourself. So cup size is very important and paramount.
With regard to the tip, make sure that the length of the tip that you choose is
less then the uterine length by ultrasound, sorry by sounding. And that is because
is because if the rib of the cup does not push against the fornix then you have
lost an important landmark. You may be misleaded into cutting the vagina lower than
you need to and therefore, the ureters get desiccated at a more dangerous area.
The balloon it maintains a pneumo occlusion very well. For the easy case we start
with a balloon on. For the difficult case we would inflate it at the end when we
want to do the colpotomy because sometimes the balloon can rupture if itís subjected
to manipulation for a long time. It is important to dilate the cervix to Hegar 8
because what happens is sometimes this tip gets stuck in the endocervix and then
you have a problem. RUMI manipulation, you all are familiar with it now.
The wonderful thing about this is you can see with no other tools. You have perfect
control of the uterus. They use this occluder RUMI cup and as you can see you only
need one instrument if you want to do a hysterectomy you cut and really repair well.
In fact, I had an idea more than 10 years ago of doing total hysterectomy with a
3 mm instrument with a micro laparoscope. And this was a 3 mm, at that time Everest
bipolar. So because of total control, one can actually do a lot without a lot of
ports, it depends on what you want to do.
The colpotomy using the cup is above the level of the uterosacral insertion LAVH
when you put in the sponge this is where you cut, which is why you always find the
uterosacral cut during LAVH and you have to sew it back. So there are these steps
that may maintain support of the uterus but more importantly you donít waste time
having to stop the bleeding.
The degree of manipulation that you can achieve here by anti-version and retroversion
by axilla, which is the uterus then can right.
You can see it can get to the hysterectomy very easily without having any other
instruments in the abdomen, all you need is a bipolar cutter.
So sometimes I find that the degree of freedom is confounding. So the surgeon has
to familiarize himself. Often I move the manipulator for assistant to the next position.
Well this is an example of a simple hysterectomy. Everybody who has done a salpingectomy
can do this part of the operation using whatever energy source. The surprising thing
I found was that the uterovesical peritoneum is loose over the cup over the rim.
So it provides you with the first landmark, you know where to go for the uterovesical
peritoneum. You cut it somewhere at the bulge and you will find the peritoneum was
loose. So as we start to go now, now in this case I decided to dissect the ureters
so that one can see the relationship. We being to see that the area of desiccation,
this is the uterine artery, this is the ureter, this is the ureter and this is the
area of desiccation. It is not that far away but you do get about 2 cm. Now the
moment you have cut the colpotomy the angle, the vagina retracts. If you need to
obtain hemostasis laterally here we have it again you can see that the uterine artery
ureter and the cup. Itís quite a big distance but if you cut it retracts. And what
that means is if you have bleeding pick up the angle again if you want to bipolar.
Donít keep pushing against the angle. And here we see the uterine artery being divided
at, and the distance of the ureter from that area. So the cup, when properly planned
and positioned does allow a good separation off of the angle and uterine arteries
from the uretus. Weíd like to close the vagina in two layers, which reconstructs
the pericervical fascial ring. Thatís the ureter being highlighted again lateral
and inferior to the area that was operated on for a simple total laparoscopic hysterectomy.
To teach my residents I often start off by entering the vagina before any part of
the operation begins. This sort of takes over psychological fear you suddenly see
thereís nothing more to do, youíve reached the end of the operation as it were.
I use various instruments to open the uterosacral peritoneum from electric scissors
to specula to hooks. And the area under the bladder in the right plane is really
quite avascular. You can see push it down and the pneumoperitoneum takes over. So
here it is. We try to get 2-cm clearance from where the bladder begins. Itís not
necessary to occlude the uterines or ovarians if you want to do this. There may
be vaginal bleeders and vaginal bleeders are never going to be stopped by getting
the uterines anyway. And hereís a posterior colpotomy. So, again, in case it is
not obvious because it only became obvious to me when I watched live telesurgeries
in other countries, this is the only device with a cup that inverts when you invert
the uterus other devices the uterus inverts when the cup is still posterior. And
so it doesnít lend itself to such an easy, elegant operation. Now you can turn the
operation over to the resident while you sit down and say join point A to point
B, which is all that youíre doing. You just are going with a cutter until you get
to the blue and then this stage obviously there are many many tools available, the
LigaSure, the end seal. So itís a matter of personal preference. So when we get
to this stage before uterine artery is desiccated, thatís time to wake up the medical
student and ask him to push harder so that we distance the lateral vagina. Now Cooper
has a product that doesnít fall asleep or is asleep all the time, depending on which
way you look at it, so itís able to maintain the manipulator in a position, any
position you like during the operation with changing position. So here is, it gives
a great deal of confidence to novices starting out to see that the problem is over,
youíre in the vagina and if you can just desiccate the uterine artery hemostatically
you are fairly safe in safe area. The same thing is done here. I like this view
of the blue interior and posterior. It tells you really clearly where you are at.
And so the rest of the operation follows. I put a stitch in the cervix now. Somebody
asked me yesterday, I donít stitch the cup to the cervix. I put a stitch in the
cervix in order to pull on the uterus in case sometimes the intrauterine balloon
Well hereís a nice example of what to do, actually. If the uterus is very short,
we donít have any tips that are shorter. So I intentionally perforate the fundus
so that the cup is well positioned. And this is a very difficult case, tiny uterus,
wouldnít break any records, but with severe cul-de-sac, frozen pelvis from severe
endometriosis. So this is the kind of case where you dissect the ureter for safety
and also because you may often find periurethral endometriosis. With severe endometriosis
with rectovaginal infiltration, the ureter is often pulled immediately. So this
is one time where you cannot just count on the cuff to help you, you have to dissect
and free the ureter, which is what weíre seeing here. On the left side the sigmoid
should be brought down. And here you see the ureter behind the sigmoid. This patient
has had a few operations before this hysterectomy. She underwent, sheís an Indian
physician from New Jersey. She underwent IVF, had the embryos put in surrogate uterus
and she said now I'm ready for the hysterectomy. So in this case, at some point
of the dissection you have to clear the rectum. So weíve gone into the normal rectovaginal
space. So this is very essential and now the ureter is stuck in this very solid
area, which also need dissection. So these are not cases for sub total hysterectomy
where you leave the endometriosis behind because you want to remove the uterus.
The aim of the operation is to remove the endometriosis and you really have to get
to it. These are very challenging, taxing cases which require a lot of experience
with advanced endometriosis. So the conversion, if you convert is because youíre
not an expert in advanced endometriosis certainly not because youíre not expert
in hysterectomy. These cases you can do a thousand easy hysterectomies and you still
cannot do it. So you have to extend your repertoire. Here the interior fornix is
entered and the anterior rectum will be partially resected. Itís not full thickness
and then in the end the ureters, this is one important step because often you find
at the end of hysterectomy here we have the posterior vagina being very thickly
infiltrated and it has to be tailored to remove the excess endometriosis from the
vagina. So hysterectomy is not the only thing. So hereís the ureter on the left
dissected, the bladder. This is the rectal partial thickness resection using monopolar.
If you ever do this use a cutting curette because it will of the size and doesnít
give any further thermal damage. And you see the vagina is now thin because the
fibrotic endometriosis has been resected. After over sewing the rectum, this is
the end result of such a case. So weíve done many such cases. The cup really helps
you because youíre really lost in the jungle here. You dissect the ureters and then
the cup tells you where to stop the dissection.
Now the next challenge is the large uterus where the ports may need to be higher.
Most of the time I still use the umbilical port and you can look up through the
umbilical pelvic is lower than the fundus and the uterus even in a large uterus.
That part doesnít molt. So you can access through the same lateral ports. You donít
have to make a higher port. I like a 10-mm cutter because there is no space, no
room when I cut. I want it not to bleed and I want to be able to carry on. I get
questions every time which manipulator is best when you have a large uterus? Well
theyíre no manipulator for a large uterus. What you need is a tenaculum that can
grab the uterus and rotate it. No manipulator can rotate the uterus.
Weíll show how this is done and then you a 30 to 45 degree laparoscope to be able
to see beyond the fibroid. Sometimes you need to morcellate the operation is complete.
So the user angles cup allows you to see the cervix. And when you look at the cervix
you forget about the uterus. To you it looks like 50-gram uterus that you removed
just a few weeks ago. So itís less intimidating. But more important than that is
the fact that that part of the surgery is just choreographed like a previous surgery.
And also if you move the scope laterally you can have access to the vaginal angles.
So here we see you can create space, not by manipulating but by using a tenaculum
to pull. This way, there is space between the sidewall and the uterus that increases
the margin of safety.
Ureterolysis may be necessary in this big cases because this is the common extended
iliac. You want to know where it is before you start putting your bipolar cutter.
So thatís part of the armamentaria that may be necessary unless the ureterolysis
before one can safely get at this parametrial tissue.
Sometimes, even with the 30 degrees colpopexy you may need to do a preliminary myomectomy
and we used to Petrescyn on the myoma before myomectomy, let me see where is that
myomectomy. This is where a myomectomy had been done to create space. It mostly
is not necessary so you can continue doing the operation. It creates lateral space.
This is where the cervical lateral fibroid was removed before we could have full
access to the vaginal wall.
This is an example of a hysterectomy showing you a little more slowly the use of
the various tools. The 30-mm laparoscope, your assistant has to be very familiar
with it. I would suggest you call in a general surgeon, they are really good at
this angle laparoscope for your first few cases if you donít have a good assistant.
So this is a fairly large uterus which obscures the sidewall. There is no space
to go. And these are the ports. I have the umbilical and paraumbilical port. The
Petresyn is for potential myomectomy but also just to minimize bleeding when weíre
using this tenaculum to pull things from one side to the other. So this was one
time when I was trying out the 10-mm LigaSure. We want one cut to be completely
hemostatic because when the bleeding retracts itself the tight space is difficult
to get to. This is a new tenaculum that I designed. You cannot use a corkscrew for
this kind of operation. You want to grab the uterus, rotate it, move it and so on.
To screw in and screw out takes too long a time. Now this is a little gimmicky thing
that I was trying out so that you can cut the whole vaginal cuff from one side without
having to give it to your assistant. I think the instrument disappeared after that.
But normally I stand on the side throughout the whole operation and the resident
or fellows on the left, if they are not operating. The left desiccation and division
is done by the person on the left. So finally, the anterior colpotomy is available
and we get a concern t is the cup a bit loose or not, which is why the person down
below or better still the new handle can maintain it all the time throughout surgery.
It will not show fatigue.
The UPS, uterine positioning system. Now with the uterine positioning system and
the blue of the cuff, which I call the GPS of hysterectomy, you have all the positioning
you need. So after the uterines are treated now the colpotomy is performed. Useful
to have a little curve for you to approach all around, not a vital thing. So, again,
a lot of movement in order for you to be able to see. Sometimes we go posterior.
You would need to oscillate but in this case you just pull all the fibroids to one
side anteverts so your view is vignettes of the pelvis that you are trying to treat.
And thatís very important. With a tenaculum you create the view that you need for
the next five minutes of surgery and then you move on. So you donít have to see
the whole thing panoramically just like with a small uterus when you can. We use
various oscillators, a strong machine. Usually with big uteri I use two or three
Gynecare oscillators. Maybe the motor is improving but you find that you really
need a lot, the motor burns out after a while and this is unfortunate.
The largest fibroid that was done, before I go to that, those of you who are first
doing this, do this cystoscopy for your first 20 cases. I donít do this anymore
because I dissect the ureters. But as I was saying, when you have a fibroid like
this thatís 3 kilogram, in this case we use four Gynecare oscillators and two oscillators.
Even the permanent oscillator motors break down. And itís just a matter of digesting
the tissue one at a time. The operation is still the same. You know what you do
is you ignore the fibroid and just go to areas that are familiar, the ligament,
here incinerate the laparoscope. You can see where, which is why I say you donít
need a high port position the pelvic is still where it is and you can access it
from the same lateral ports.
So the same thing is done here. In the end this was a mocellation-fest which is
not really fun. The elegance of the system which allows you to access the vaginal
fornix is a real advantage. Some fibroids are not big but really more challenging
than the big one. And this one where morcellation in situ was needed in order to
get access to the lateral pelvic wall. So what skills do you need to have? You just
need to have myomectomy skills. So these are all the supplementary things to do
a difficult operation, there may be a big fibroid. You may need to know myomectomy
for frozen pelvis. You need to have practice with severe endometriosis and other
than that well with prolapse for example we also do concomitant sacral colpopexy
when you need to have experience with dissection and with doing sacral colpopexy.
Here after a while the angle scope goes in and look at the view. Looking at the
view you donít know that this is a large uterus and this what happens, it just gives
you great ability to have confidence. But remember this confidence must not be misplaced.
The person down below or your position system must be rechecked time and time again.
With a big uterus we often look at the dissecting ureter. So I hope I have been
able to show you some vignettes of tips and tricks for the easy hysterectomy as
well as the difficult hysterectomy. And I will conclude my presentation. Thank you.
Thank you Dr Koh. As we continue with the theme of minimally invasive hysterectomy,
the words visualization and control keeping coming to mind. And with some of the
new tools that are available for the gynecologist, we have the distinct pleasure
of welcoming Dr Arnie Advicula from the University of Michigan to continue the conversation
targeted towards the new robotic procedure for hysterectomy. As many of you know,
Dr Advicula is the Associate Clinical Professor as well as the Director of Minimally
Invasive Surgery at the University of Michigan and we welcome to the podium.
Good morning everybody and thank you very much for the invitation to be here this
morningís very early breakfast symposium. To share with you some thoughts on a new
type of technology that I really feel is going to be very impactful and
beneficial to not only conventional laparoscopic surgery but also to robot assisted
surgery. And certainly I just want to say first and foremost that itís very exciting
to be up here standing next to Dr Koh because as a resident in the mid-to-late 1990s
certainly the use of the colpotomy ring was something that certainly revolutionized
my surgical armamentarium, particularly as somebody who was trained in both traditional
laparotomy and vaginal hysterectomy but also at the same time laparoscopic hysterectomy.
So Iím going to do is summarize whatís happened with the application of robotics
to GYN surgery, particularly hysterectomy. Then weíll talk about the current needs
in both conventional laparoscopy and robot assisted surgery and then Iím going to
go into detail regarding tips and tricks involved with the use of uterine positioning
So itís no secret that we have a lot of advantages with the conventional laparoscopic
instruments we have and certainly watching those videos with Dr Koh we see that
you can do quite a wide array of things with the tools that we have. And a lot of
that is made possible by the way that the tools are designed, the energy sources
that were demonstrated, the light sources, all of those things that before we were
only able to just look at.
And of course when we look specifically at hysterectomy where we have large numbers
being done annually and of course the vast majority being for benign reasons, itís
exciting to see that we can have an impact on this particular procedure.
But whatís interesting is despite the fact that we see an evolution in hysterectomy
from traditional methods to the lap assisted vaginal hysterectomy, the supracervical
in a totally laparoscopic hysterectomy, as somebody who was being trained and also
out in practice training others, whatís always baffled me is the fact that we still
see a vast majority of our hysterectomies done by way of laparotomy with only a
small percentage of them done minimally invasively, either vaginally or laparoscopically.
Now this is based on 2003 data that was published in the Green Journal in the fall
When you ask yourself why is the problem, well certainly we have a little obstacles
to deal with and you saw a lot of this in those videos with Dr Koh. Certainly the
surgical field with distorted anatomy, complex biology, the large uterus, these
things can certainly stand in the way of the surgeon completing a less invasive
hysterectomy. Obesity can be an issue. The instrumentation, learning curves and
of course the surgeon experience and comfort level. And Iím sure we can probably
throw in there the way we do our residency training nowadays. Probably all are impacting
how weíre transitioning to less invasive hysterectomy.
When we focus specifically on instrumentation we know that the tools that we use
have limitations and so certainly the fulcrum effect that has to be overcome, itís
a 2-D field, unsteady images, the learning curves for these advanced cases, all
those things are obstacles that can prevent an individual from completing a total
And so for me as somebody who trains residents and fellows all the time, one of
the things that I was looking is what is the next step? And for me, for the past
seven years, itís really been the application of robotics to hysterectomy as a way
to hopefully overcome that, add another tool to our surgical armamentarium.
I utilize a da Vinci ADS surgical system. As you can see these are the components
that are incorporated during the course of a robot assisted case. Weíve got a console,
a patientís side cart and a vision system.
Highlight wise, it is the surgeon that controls this system. Itís not a plug and
play device where you just push a button and it does the work for you. Itís now
3-D and in many instances high definition. Although thereís no haptic feedback,
one of the things that Iíve learned through the years is that you develop a sense
of visual optics. There are seven degrees of movement of your instrumentation. As
you can see in those schematics where you now have a wristed type device. Thereís
terminal filtration, motion scaling and of course the ergonomics of being able to
sit through whatever case that youíre doing.
And of course you can see the tools look very familiar with the tools you saw in
the earlier video, the difference being that theyíre now wristed. So theyíre very
familiar with what youíd use in a conventional laparotomic or laparoscopic case.
Now whatís exciting is Iíve been able to take this technology and marry it with
the things that Iíve been comfortable with that Iíve grown up with my whole life.
Things like uterine manipulator and the RUMI Colpotomizer system.
In particular, Iím such a huge fan of the Colpotomizer system and, again, although
it sounds redundant, I think itís probably one of the most important aspects of
this particular device and that is its advantage that you gain when you perform
a laparoscopic hysterectomy. Again, you can see here that where you would create
your traditional colpotomy after taking your uterine vasculature, itís quite proximal
to the ureter. But with the use of a Colpotomizer ring, with good upward traction,
again thatís the key, is upward traction, and a perfectly placed ring with good,
constant, upward traction. And these are going to come into play when I talk about
the uterine positioning system. But you can see how much that distances the ureter
from where youíre going to take your uterine vasculature and where youíre going
to perform your colpotomy. Now, again, the caveat to that is that youíve done an
appropriate dissection, that you developed the tissue planes the way you would,
analogous to an open surgical technique.
So you can see here this is a robot-assisted case. What Iím doing at the onset is
just doing a generalized survey of the operative field. And this to me my favorite
part of the case because Iím inspecting and I can see that Colpotomizer ring. Itís
been adequate, itís been correctly placed. I can see the bulge and even though I
donít have to keep any haptic feedback, I know visually that when I push there thatís
the location of that colpotomy ring situated around the cervix. And Iím just doing
a generalized survey, looking around the field. This is a four arm technique. Iíve
got an endoscope in and three wristed instruments in the pelvis. And all Iím doing
is planning. Iím just deciding how Iím going to attack this case to get this laparoscopic
hysterectomy completed. Iím going to look anteriorly to make sure I can see the
anterior cul-de-sac and also the outline and the delineation of the colpotomy ring.
Weíre going to get upward traction when you push upwards. Again, thatís the key,
whether youíre doing conventional laparoscopy or robotics, thatís very critical.
Iím visually palpating the vessel location of the ring. Thereís the Foley bulb,
thatís the bladder. Iím good to go.
Next Iím just going to give you a little snippet here of the hysterectomy where
weíre visualizing the ring during the course of the dissection. And you can see
here, this may or may not be the same case, but in this case weíre preserving the
apexia. But you can see the type of reach that I have on the contralateral side
of the pelvis. I have instruments that can come from the left side of the pelvis
and work on the right. The wristed nature allows me to develop the tissue planes
and you can see here I have upward traction, the uterus is being pushed upwards.
Itís pushing the colpotomy ring in to the abdomen. Iím developing my tissue planes
just like I do in open surgery. So the key is Iím going to develop the anterior
and posterior leaf of the broad ligament and as you push upward and you develop
that itís going to allow the ureter to fall more laterally, well out of harms way.
It will allow me to then skeletanize the uterine vasculature and also develop the
best vascular reflection. All, again, the same things we do with open surgery. And
for me, Iím a big stickler of that because thatís how I was trained. The advantage
that you gain with robot assisted surgery is that you can operate like youíre doing
open but youíre really in an endoscopic, closed environment. Iím just showing you
that the ureter is way lateral, but again, you can see the bulge of that colpotomy
ring as we get upward traction and I developed my entire hysterectomy, doesnít matter
whether Iím dealing with a 20 week uterus or an average size uterus, that ring is
a great landmark for being able to delineate where you are in the pelvis, to isolate
your structures, to develop your bladder flap and subsequently create your colpotomy.
And, again, you can see thatís my goal, thatís now working towards, Iím going to
go ahead and create a vesical uterine reflection. All of these things are going
to set me up for the next step of the hysterectomy.
This to me is the important part. Itís understanding the relationship of the colpotomy
ring to your uterine vasculature and to your ureter. And one of the things that
Iím a big stickler of when I do cases is Iím always telling my resident or my fellow
if Iím the individual seated at the console and theyíre helping me with bedside
assistance, is that I want them to constantly give me nice upward traction to deflect
the uterus over to the contralateral side that Iím working and to give me good upward
traction. And as you can see here, I did some similar videos you saw with Dr Koh,
this is a somewhat enlarged uterus. I notice that the ureter is quite proximal to
the colpotomy ring and to the area where Iím going to eventually need to ligate
my uterine vasculature and then create the colpotomy. But you can see with upward
traction on that uterus as I develop this dissection plane, itís going to allow
my ureter to fall much more laterally, well out of harms way. But the key here is
that you have to have the upward traction. And Iím going to demonstrate here in
a second when you donít have the upward traction what that does to where you would
eventually seal and ligate your uterine vasculature. Iím going to go ahead and fast
forward this just a little bit. So see you push the ring up you can see how far
that ureter moves. If you donít push it up and youíre relaxing on the uterus, see
how close I just pinched it where the vessels are. But look I push up and there
it is, it goes far away. See that, that to me is tremendous, thatís a huge advantage
of understanding of how to manipulate the uterus and incorporate it with the colpotomy
ring. So to me thatís the advantage and thatís critical. Thatís the other point.
As I talked about upward traction during the course of the dissection, thatís critical,
but also being able to maintain it, thatís the other thing. And thatís where you
can already start to see where some of the potential problems are.
Here to show you the advantages that you gain with the colpotomy ring. I've developed
all of my tissue planes reflection. Iíve ligated already my uterine vasculature.
The ureter has dropped well out of harms way and you can see thereís no broad ligament
left. Itís just the uterus and the colpotomy ring. This is another one of my favorite
parts of the procedure, favorite things to look at, cause I know Iíve done my dissection
correctly, visually palpating where the ring is here and then I can easily come
with my monopolar scissor and, again, because Iím wristed, I can very easily circumferentially
go around this ring and detach the uterus and cervix. Again, Iím just showing that
I visually palpate, make sure Iím on top of the upper beveled edge is where I typically
will cut. And you can see I just work my way all the way around this ring. Iím working
on the opposite side now, just sort of fast forwarding this for the sake of time.
You can see Iím not having to port hop. I have the huge advantage I can leave my
instruments in the same place. Again the ring is a great landmark for doing your
colpotomy. I usually start one half of the ring, usually from 12 to 5, then I go
from 12 to 8 and then I complete the 5 to 8 oíclock position of the clock. And there
you go you have that 5 to 8 oíclock position there that will complete the colpotomy.
And again, hereís another key part of the case, for again you also need upward traction
because itís that counter traction that helps you do the detachment at this point
And so whereís the hang up? It looks like weíve got these great tools, the uterine
manipulator, Colpotomizer, weíve got robotic device. Whereís the hang up? Well in
robotic surgery the big hang up is that we dock between the patientís legs as you
can see here. So as somebody who was trained as fellowship trained conventional
laparoscopist, one of the first things I struggled with was the need to reach between
the patientís legs myself and be able to manipulate the uterus and place it where
I want it.
And you can see here what I mean by docking is the fact that the patientís side
cart is placed strategically between the patientís legs and that can often times
inhibit the ability of your bedside assistant to gain access. And this is just to
show you here in a 45 second clip the location of that. This is an older device.
This is what we call a standard. Itís much bulkier system. And you can see it sits
between the patientís legs. And of course once itís positioned between the patientís
legs, we then bring arms into play and thatís really what provides a large portion
of that obstruction to the vagina. Iím just going to let this play through. Hereís
where we bring the endoscopic arm down. Docking usually takes about one to two minutes.
You can see already weíre starting to include visualization and access to our uterine
manipulator that is placed in the vagina. Here we go, weíre bringing the lateral
arms down and that essentially completes the docking process once we attach that
to the ports.
Then again, this is another point where weíre trying to overcome a solution, you
canít underestimate the importance of your bedside assistant. So you have to be
able to work with them and you have to understand what it is that theyíre dealing
with when theyíre trying to assist you during a robot assisted laparoscopic hysterectomy.
So whatís the solution? Well you know whatís exciting is thereís a solution to this
Thatís the uterine positioning system. And Iíve had the fortune of being able to
evolve with this product as itís come to its fruition.
And you can see here the concept is simple. Itís basically taking the bedside mountable
device that can easily situate itself along the railing on your operating theater
table. Itís pneumatically controlled and it will attach through an adapter to your
uterine manipulator. Again, you can see some schematic renderings here. This is
being used in a model, attached to the bed. Your fake patient is draped and you
can see the assistant who has to reach through these arms, normally would have to
hold the uterine manipulator in the entire case. But you can see here instead of
holding it the entire case, this individual can adjust it. These are the types of
adapters. This is when we were playing around using it with a ZUMI. But you can
see here can adjust it and then leave it alone and it will hold uterus in place.
The other exciting thing thatís happened at the same time as the uterine positioning
system is the development of the RUMI arch. Itís a bit heavier and beefier, although
Iíve grown up with the traditional RUMI. One of the things I always struggled with,
with my residents is getting them to understand the handle because it gives them
a lot of degrees of freedom and a lot of times they get confused. So for me, Iím
a simpleton, I like things to be simple, particularly when Iím teaching them. And
you can see this evolution of an arch, itís a much beefier, stronger handle. Here
it is with just a traditional tip. And of course the tip integrated with a colpotomy
ring and a vaginal balloon pneumo-occluder.
These are the various adapters. Hereís an adapter for the traditional RUMI. And
hereís a photograph of an adapter with the RUMI arch for the entire system set up.
So letís go into the use of the device. So patient positioning, thatís probably
one of the first and foremost things you need to consider if youíre going to utilize
the uterine positioning system, you need to have adequate access, first of all to
your bed rails and to the vaginal area as youíre placing this particular device.
One of the things that I want to point out is that when you utilize lithotomy stirrups,
whether they be Allen for example or Yellofins as in this case, you want to make
sure you use them correctly because normally they should be placed, the articulating
joint of those devices should be placed at the same location as the ball and socket
joint of the patientís hip. If itís done correctly theyíll function correctly but
also it gives you an adequate amount of rail space at the end of your table. If
you put those things, the brackets, all the way to the end you wonít be able to
place the bracket of your uterine positioning system onto your table. So as you
can see Iíve perfectly positioned my patient and I have room to place on the bed
rails the uterine positioning system to get my bracket on.
Just going to play this video here to show you how easy it is to place this. But
you can see how we place this. It takes about 30 seconds, attach it to the bed rail.
Itís placed non-sterile. It will be subsequently draped during the case. Just a
couple of screws that go on there that lock it into position. And thatís it Ė hooked
up. Iíll bring in the pneumatic foot pedal, there it is. And once I step on it I
can adjust it. And thatís all it takes.
Hereís the foot pedal itself just showing you how it works. Key here is anytime
you want to move this thing you definitely want to hold the handle before you step
on the foot peddle because if you donít do that and you step on the foot peddle
itís going to completely release that entire device. And you can see how very easy
it is. A little bit of pressure on the foot, lets that handle go. And of course
itís, again, itís not draped yet and we havenít attached the adapter yet.
Iím going to have this clip play here just to show you how simple it is to attach,
for example, the RUMI arch to the uterine positioning system. You can see here where
Iím going to go ahead and select our tip. In this particular case this wasnít a
hysterectomy but I used this clip just to show you how simple it is to apply this
device to the uterine positioning position. Itís also much easier to put this tip
under this arch. It didnít take very long at all to twist that into place. There
are grooves on the side that will house the tubing. Iíve already grabbed the lip
of the cervix with a tenaculum and Iíve dilated the cervix to about 21 French. Iím
just removing that chromopertubation tubing so it doesnít get in my way because
in this particular case I donít need to chromopertubate. Going ahead and placing
this. And you can see at this point the patient is prepped and draped. So is the
uterine positioning system and Iíve also attached the adapter thatís specific to
this RUMI arch onto that uterine positioning system. Go ahead and inflate the balloon
and once we do that weíll bring in the uterine positioning system. So you can see
that itís pretty straightforward. Weíre not reinventing the wheel here. Essentially
doing the same things that would you in any type of laparoscopic procedure that
youíre going to perform. But I want to show you how very easy it is to bring that
positioning system into place and actually lock it onto this handle here. And you
can see Iíve got nice range of motion here. Iíve got good maneuverability. Because
my team is always into parallel tasking, my assistants have already placed my endoscope
ports in and have a laparoscope in and theyíre actually probably yelling at me at
this point because Iím taking too much time doing this and being the right limiting
step to get things started. But here we go. We just step on the pedal and bring
this in. This is the adapter that is designed specifically for the RUMI arch. Once
itís in place I kind of release the foot peddle and close the clasp and thatís it.
And now weíre all set. And you can see for a conventional laparoscopic case youíve
not got your uterine positioning system attached to your RUMI arch.
Now the next step here is weíre going to go ahead and this is the part where weíre
really fixing the problem here. For me Iím going to set this aside and Iím just
discussing with my team that we have to be very cognizant that as we bring the robotic
patientís side cart into view here we donít want to run up against this. We donít
want to clash and hit this. Weíre going to part this off to the side. You can either
do this, which is park it off to the side or completely detach it from the manipulator
and then park it to the side, reattach it once the robot is in place. What youíre
going to see here that weíre going to slide that robot into the field. But this
is where weíre actually trying to overcome that problem of decreased vaginal access
during the course of a robot assisted case. This is a much small system, this is
an ďSĒ so itís a little bit more streamlined but still weíre faced with those issues
of having to reach around the patientís leg during a long case to position the uterus
where the surgeon wants it. And thatís the key. Thatís where when you have an assistant
who gets fatigues during a long case theyíre not giving you that classic upward
traction, theyíre not holding it steady for you, particularly during the critical
parts of the procedure where you need to be avoiding injury to the ureter, developing
your dissection planes. And this is where you get that advantage. You can see here
that weíre making sure weíre in an appropriate position and that we donít hit, and
Iím just making sure that donít hit the uterine positioning system.
And this just to show you finally, and during the course of a case I can have myself
and my assistants step on the pedal. And I can go ahead and move the positioning
system with the scope in view already. And I know Iím not going to have to hold
this during the entire case. Iím going to pan back here in a second just to show
you what it means to have to interplay as a bedside assistant with this large device
surrounding your patient. You can see Iím just testing my range of motion here now
that I have my laparoscope in place. Iím just making sure I donít have any issues
with being able to move the uterus where I want it to be during the course of my
operating procedure. Again, here you can see that I can easily reach around the
legs, position the system where I want it and then leave it and lock and go.
So let me summarize here with some technical pearls with the use of this particular
device. You certainly want to optimize your patient position. You want to pay attention
to the location of stirrup brackets on your table rails. To maintain the centering
of this uterine positioning system on that large crossbar that you see being attached.
You want to pay attention that when you dock the robot you never want to step on
the pedal without holding the handle, particularly once attached to the uterine
manipulator within your patient. And you also want to pay attention to table spikes
at the end of your bed at the end of a case so that you donít inadvertently damage
your uterine positioning system.
But the bottom line is that you can see that this has applicability to both robot
assisted and conventional laparoscopic cases. It doesnít matter whether youíre a
robotic surgeon or a conventional laparoscopist, you can incorporate this into your
surgical armamentarium for hysterectomy whether youíre doing benign or cancer surgery,
dealing with adnexal surgery, again in a reproductive surgery where you need to
maintain a fixed position of your uterus so that you can actually do your surgery
the way you want it. And also even if you look ahead into the future, less SPA/GYN
procedure. You know Laparoendoscopic single site surgery or single port access surgical
procedures where you want to be able to free up one of your bedside assistantís
hands so they can actually work through that single port if itís at the level of
the umbilicus you can allow it to help you triangulate the target organ so that
you can do these single port access procedures. So really the range is in many ways
limitless. I guess the only limit is your imagination in terms of how you want to
apply this to your practice.