Bob Auerbach
I want to welcome you to CooperSurgical’s sponsored breakfast. My name is Bob Auerbach. I’m 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. We’d 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. We’re 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 he’s going to speak to us regarding conventional laparoscopic hysterectomy. Dr Charles.

Dr Koh
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 it’s 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. That’s the way I did it but I figured that the moment you didn’t have to dissect the ureter, which is what you don’t 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 it’s 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 don’t 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. It’s 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. Don’t 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. We’d like to close the vagina in two layers, which reconstructs the pericervical fascial ring. That’s 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 there’s nothing more to do, you’ve 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. It’s 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 here’s 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 doesn’t 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 you’re 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 it’s a matter of personal preference. So when we get to this stage before uterine artery is desiccated, that’s 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 doesn’t fall asleep or is asleep all the time, depending on which way you look at it, so it’s 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, you’re 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 don’t 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 bursts.

Well here’s a nice example of what to do, actually. If the uterus is very short, we don’t 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, wouldn’t 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 we’re 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, she’s 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 we’ve 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 you’re not an expert in advanced endometriosis certainly not because you’re 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. It’s 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 here’s 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 doesn’t 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 we’ve done many such cases. The cup really helps you because you’re 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 doesn’t molt. So you can access through the same lateral ports. You don’t 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 they’re 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.

We’ll 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 it’s 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 that’s 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 don’t 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 we’re 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 that’s 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 don’t 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 don’t do this anymore because I dissect the ureters. But as I was saying, when you have a fibroid like this that’s 3 kilogram, in this case we use four Gynecare oscillators and two oscillators. Even the permanent oscillator motors break down. And it’s 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 don’t 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 don’t 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.

Bob Auerbach
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.

Dr Advincula
Good morning everybody and thank you very much for the invitation to be here this morning’s 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 it’s 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 I’m going to do is summarize what’s happened with the application of robotics to GYN surgery, particularly hysterectomy. Then we’ll talk about the current needs in both conventional laparoscopy and robot assisted surgery and then I’m going to go into detail regarding tips and tricks involved with the use of uterine positioning system.

So it’s 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, it’s exciting to see that we can have an impact on this particular procedure.

But what’s 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, what’s 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 of 2007.

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 I’m sure we can probably throw in there the way we do our residency training nowadays. Probably all are impacting how we’re 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, it’s 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 laparoscopic hysterectomy.

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, it’s 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. We’ve got a console, a patient’s side cart and a vision system.

Highlight wise, it is the surgeon that controls this system. It’s not a plug and play device where you just push a button and it does the work for you. It’s now 3-D and in many instances high definition. Although there’s no haptic feedback, one of the things that I’ve 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. There’s terminal filtration, motion scaling and of course the ergonomics of being able to sit through whatever case that you’re 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 they’re now wristed. So they’re very familiar with what you’d use in a conventional laparotomic or laparoscopic case.

Now what’s exciting is I’ve been able to take this technology and marry it with the things that I’ve been comfortable with that I’ve grown up with my whole life. Things like uterine manipulator and the RUMI Colpotomizer system.

In particular, I’m such a huge fan of the Colpotomizer system and, again, although it sounds redundant, I think it’s 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, it’s quite proximal to the ureter. But with the use of a Colpotomizer ring, with good upward traction, again that’s 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 you’re going to take your uterine vasculature and where you’re going to perform your colpotomy. Now, again, the caveat to that is that you’ve 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 I’m 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 I’m inspecting and I can see that Colpotomizer ring. It’s been adequate, it’s been correctly placed. I can see the bulge and even though I don’t have to keep any haptic feedback, I know visually that when I push there that’s the location of that colpotomy ring situated around the cervix. And I’m just doing a generalized survey, looking around the field. This is a four arm technique. I’ve got an endoscope in and three wristed instruments in the pelvis. And all I’m doing is planning. I’m just deciding how I’m going to attack this case to get this laparoscopic hysterectomy completed. I’m 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. We’re going to get upward traction when you push upwards. Again, that’s the key, whether you’re doing conventional laparoscopy or robotics, that’s very critical. I’m visually palpating the vessel location of the ring. There’s the Foley bulb, that’s the bladder. I’m good to go.

Next I’m just going to give you a little snippet here of the hysterectomy where we’re 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 we’re 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. It’s pushing the colpotomy ring in to the abdomen. I’m developing my tissue planes just like I do in open surgery. So the key is I’m going to develop the anterior and posterior leaf of the broad ligament and as you push upward and you develop that it’s 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, I’m a big stickler of that because that’s how I was trained. The advantage that you gain with robot assisted surgery is that you can operate like you’re doing open but you’re really in an endoscopic, closed environment. I’m 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, doesn’t matter whether I’m 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 that’s my goal, that’s now working towards, I’m 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. It’s understanding the relationship of the colpotomy ring to your uterine vasculature and to your ureter. And one of the things that I’m a big stickler of when I do cases is I’m always telling my resident or my fellow if I’m the individual seated at the console and they’re 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 I’m 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 I’m 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, it’s 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 I’m going to demonstrate here in a second when you don’t have the upward traction what that does to where you would eventually seal and ligate your uterine vasculature. I’m 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 don’t push it up and you’re 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, that’s a huge advantage of understanding of how to manipulate the uterus and incorporate it with the colpotomy ring. So to me that’s the advantage and that’s critical. That’s the other point. As I talked about upward traction during the course of the dissection, that’s critical, but also being able to maintain it, that’s the other thing. And that’s 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. I’ve ligated already my uterine vasculature. The ureter has dropped well out of harms way and you can see there’s no broad ligament left. It’s 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 I’ve done my dissection correctly, visually palpating where the ring is here and then I can easily come with my monopolar scissor and, again, because I’m wristed, I can very easily circumferentially go around this ring and detach the uterus and cervix. Again, I’m just showing that I visually palpate, make sure I’m 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. I’m working on the opposite side now, just sort of fast forwarding this for the sake of time. You can see I’m 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 o’clock position of the clock. And there you go you have that 5 to 8 o’clock position there that will complete the colpotomy. And again, here’s another key part of the case, for again you also need upward traction because it’s that counter traction that helps you do the detachment at this point in time.

And so where’s the hang up? It looks like we’ve got these great tools, the uterine manipulator, Colpotomizer, we’ve got robotic device. Where’s the hang up? Well in robotic surgery the big hang up is that we dock between the patient’s 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 patient’s 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 patient’s side cart is placed strategically between the patient’s 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. It’s much bulkier system. And you can see it sits between the patient’s legs. And of course once it’s positioned between the patient’s legs, we then bring arms into play and that’s really what provides a large portion of that obstruction to the vagina. I’m just going to let this play through. Here’s where we bring the endoscopic arm down. Docking usually takes about one to two minutes. You can see already we’re starting to include visualization and access to our uterine manipulator that is placed in the vagina. Here we go, we’re 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 we’re trying to overcome a solution, you can’t 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 they’re dealing with when they’re trying to assist you during a robot assisted laparoscopic hysterectomy.

So what’s the solution? Well you know what’s exciting is there’s a solution to this problem.

That’s the uterine positioning system. And I’ve had the fortune of being able to evolve with this product as it’s come to its fruition.

And you can see here the concept is simple. It’s basically taking the bedside mountable device that can easily situate itself along the railing on your operating theater table. It’s 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 that’s happened at the same time as the uterine positioning system is the development of the RUMI arch. It’s a bit heavier and beefier, although I’ve 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, I’m a simpleton, I like things to be simple, particularly when I’m teaching them. And you can see this evolution of an arch, it’s 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. Here’s an adapter for the traditional RUMI. And here’s a photograph of an adapter with the RUMI arch for the entire system set up.

So let’s go into the use of the device. So patient positioning, that’s probably one of the first and foremost things you need to consider if you’re 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 you’re 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 patient’s hip. If it’s done correctly they’ll 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 won’t be able to place the bracket of your uterine positioning system onto your table. So as you can see I’ve 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. It’s 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 that’s it – hooked up. I’ll bring in the pneumatic foot pedal, there it is. And once I step on it I can adjust it. And that’s all it takes.

Here’s 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 don’t do that and you step on the foot peddle it’s 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 it’s, again, it’s not draped yet and we haven’t attached the adapter yet.

I’m 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 I’m going to go ahead and select our tip. In this particular case this wasn’t a hysterectomy but I used this clip just to show you how simple it is to apply this device to the uterine positioning position. It’s also much easier to put this tip under this arch. It didn’t take very long at all to twist that into place. There are grooves on the side that will house the tubing. I’ve already grabbed the lip of the cervix with a tenaculum and I’ve dilated the cervix to about 21 French. I’m just removing that chromopertubation tubing so it doesn’t get in my way because in this particular case I don’t 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 I’ve also attached the adapter that’s specific to this RUMI arch onto that uterine positioning system. Go ahead and inflate the balloon and once we do that we’ll bring in the uterine positioning system. So you can see that it’s pretty straightforward. We’re not reinventing the wheel here. Essentially doing the same things that would you in any type of laparoscopic procedure that you’re 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 I’ve got nice range of motion here. I’ve 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 they’re actually probably yelling at me at this point because I’m 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 it’s in place I kind of release the foot peddle and close the clasp and that’s it. And now we’re all set. And you can see for a conventional laparoscopic case you’ve not got your uterine positioning system attached to your RUMI arch.

Now the next step here is we’re going to go ahead and this is the part where we’re really fixing the problem here. For me I’m going to set this aside and I’m just discussing with my team that we have to be very cognizant that as we bring the robotic patient’s side cart into view here we don’t want to run up against this. We don’t want to clash and hit this. We’re 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 you’re going to see here that we’re going to slide that robot into the field. But this is where we’re 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 “S” so it’s a little bit more streamlined but still we’re faced with those issues of having to reach around the patient’s leg during a long case to position the uterus where the surgeon wants it. And that’s the key. That’s where when you have an assistant who gets fatigues during a long case they’re not giving you that classic upward traction, they’re 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 we’re making sure we’re in an appropriate position and that we don’t hit, and I’m just making sure that don’t 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 I’m not going to have to hold this during the entire case. I’m 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 I’m just testing my range of motion here now that I have my laparoscope in place. I’m just making sure I don’t 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 don’t 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 doesn’t matter whether you’re a robotic surgeon or a conventional laparoscopist, you can incorporate this into your surgical armamentarium for hysterectomy whether you’re 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 assistant’s hands so they can actually work through that single port if it’s 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.