ROBOT-ASSISTED HYSTERECTOMY USING THE DA VINCI SURGICAL SYSTEM UNIVERSITY OF MICHIGAN HEALTH SYSTEM ANN ARBOR, MICHIGAN Wednesday, September 20, 2006

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1 ROBOT-ASSISTED HYSTERECTOMY USING THE DA VINCI SURGICAL SYSTEM UNIVERSITY OF MICHIGAN HEALTH SYSTEM ANN ARBOR, MICHIGAN Wednesday, September 20, :00:10 ANNOUNCER: Today surgeons from University of Michigan Health System in Ann Arbor will perform a robot-assisted hysterectomy using the da Vinci Surgical System from Intuitive Surgical. The minimally invasive procedure will be performed by Dr. Arnold Advincula, Associate Professor of Obstetrics and Gynecology and Director of Minimally Invasive Surgery, Division of OBGYN at the University of Michigan Health System. The da Vinci System enables the GYN surgeon to tackle more complex pathology while using a minimally invasive approach. For many patients, da Vinci surgery can mean less pain and scarring, less blood loss, reduced risk of complications, shorter hospital stays, a much quicker recovery, and faster return to normal daily activities when compared to conventional open surgery. Please send your questions to the OR at any time by clicking on the MDirectAccess button on your screen. 00:01:10 ARLEEN H. SONG, MD, MDH: Hello, and welcome to the University of Michigan Hospitals. My name s Arleen Song. I m an Assistant Professor in the Division of Minimally Invasive Surgery in the Department of Obstetrics and Gynecology. And today we will be performing a robotassisted laparoscopic hysterectomy. During the procedure, we will be taking your questions, and we encourage you to send those in. You can either do that now or throughout the procedure. And before we get started talking about robot-assisted laparoscopic hysterectomy, I d like to go ahead and introduce my colleague, Dr. Arnold Advincula, who is currently at the surgeon s console. Dr. Advincula? 00:01:49 ARNOLD ADVINCULA, MD: Hello, and good afternoon. Welcome to the University of Michigan. My name is Arnold Advincula, and I m an Associate Professor here in the Department of Obstetrics and Gynecology. I also direct our Minimally Invasive Surgery program here. This afternoon we are very excited to be demonstrating to you live by way of webcast a Robot-assisted Total Laparoscopic Hysterectomy. It is a new minimally invasive way of completing a hysterectomy, and it is something that we have basically been implementing here at our institution for quite some time now as another option for women who have to undergo a hysterectomy. So really, without any further ado, what I d like to do is really just turn things right over to the operative field to kind of show you what is going on with this case. Basically, what we ve done so far is put some trocars into the patient and actually dock the robot. And actually, what I might do here, just to give you a general prospective before we even got o the console, is just since we have the camera rolling in here--is just sort of give you a view of the operative field here externally. At the bedside is actually my senior fellow, Dr. Sangeetha Senapati, who s going to be assisting me as the bedside assistant. And as you can see here, we have one of the components of the da Vinci surgical system, which is how we re going to be doing this robot-assisted total laparoscopic hysterectomy. It s a three-arm system: two operating arms on the left and the right, and a

2 camera holder that s holding an endoscope that gives us 3D vision. And you can see that there are four trocars in this patient. Basically four Band-Aid-sized incisions are made on the patient s abdomen. And Dr. Senapati will show you one of the accessory ports that we have right here, which is how we will provide things like suture and suction and counter-traction. The other component of the system is actually the console. We re going to pan over to that right here. That s the surgeon console, and this is where I control the system and actually am able to view the operative field with three-dimensional imaging. So I m going to go ahead and give you a sense here of what it actually looks like when I m at the console. All right. I actually if you re wondering why I have socks on, it s because it s easier for me to feel the pedals on the da Vinci console itself. Is there a pretty reasonable external view? Good. So why don t we go ahead and go to an internal view now? Okay, so here we have a patient who is actually in her mid-40s with metamenorrhagia, who also has had some dysmenorrhea associated with it, but actually has never had any children. She s a G0, nulla gravida, who actually, despite providing her with options such as conservative medical management and including conservative surgical management, has really opted to go with definitive surgical treatment in the form of a hysterectomy. I m sure many of you are probably wondering why we re not doing this vaginally. The fact that she hasn t had any children before isn t necessarily a contraindication to doing this vaginally, but when you do her exam, she actually doesn t have much uterine descent and has a very narrow introitus and vaginal opening that we really can t see much, even with a speculum in there. So that s why we re approaching this thing in a minimally invasive fashion with a laparoscopy done robotically. So here you can see the overall anatomy view. This is the uterus right here, fallopian tube and ovary. And in this case, she s in her mid-40s and she had opted to preserve her ovarian function, so we re going to leave those behind. Here s another fallopian tube, ovary with a small cyst hanging off of it. This is what we call the posterior cul-de-sac. And the anterior cul-de-sac right here. And you can see that s the bladder right here and the bladder reflection. You can see a little bit of endometriosis here. Go ahead and flip the uterus up. Okay, and you re probably wondering what this bulge is back here. And I m sort of trying to provide you with a lot of overview very early on in the beginning here, just so you have a perspective of how we re going to be doing this. So clearly it s laparoscopic, it s robot-assisted. One of the things that we do to facilitate that is we put a special manipulator inside the uterus that has a ring that goes around the cervix. Maybe, Arleen, you can talk a little bit about that while I go over to the side table and set up the model. Just to give people a perspective, you may want to pan through on some of the images that we have. And I ll go ahead and off to the side table to show that. 00:06:54 ARLEEN H. SONG, MD, MDH: Sure. We will bring up a photo of our uterine manipulator and our colpotomy ring, which is necessary for a hysterectomy, on our slides. But basically, what we re seeing here is a model of the uterus. And around the cervix, there s a blue ring, and that is the colpotomy ring. And that s the bulge that you see in the abdomen that Dr. Avincula was pointing out. And here s Dr. Avincula with a live version of this exact model. 00:07:30 ARNOLD ADVINCULA, MD: So can you see this live right now? So this is a uterine model right here. And basically, what we re doing is we re taking a colpotomy ring and we re placing it around the cervix, and that s the bulge that you see laparoscopically. You see that here. And we basically transfix a special manipulator that sits around that. And once we inflate this balloon it sits into place, and that s how we are able to manipulate the uterus and also to perform our total laparoscopic hysterectomy. This is called a co-colpotomy [sp?] ring. We used a smaller size because her cervix really isn t that large, and it s also the size that fits readily into her vagina. And you can see that here is what we call a ZUMI uterine manipulator. And then we have a special balloon that we slide into the vagina. The reason we do so is that once we create a culpotomy or incise on top of this blue ring, we basically end up with an outlet for the air that fills her belly, the pneumoperitoneum that allows us to

3 work inside her abdomen laparoscopically. So this balloon gets inflated during the course of the procedure with about 60 to 90 cc s of air, and that s what helps maintain pnemoperitoneum in the vagina as we make a pulpotomy incision. So this is basically the setup that you re seeing there, and this is the manipulator that my assistant, Dr. Senapati is utilizing to give me the exposure that I need. So why don t we go ahead to the internal view? I m going to go ahead and get started with the case, and I m going to have Dr. Song kind of give you a little bit of an overview of sort of our rationale of why we do this, a little bit of background on hysterectomy. I m going to go ahead and get started with this case here. 00:09:02 ARLEEN H. SONG, MD, MDH: Sure. As we re watching, I ll just be talking and Dr. Advincula will just pop in whenever. As most of the physicians know that are probably watching this, approximately 600,000 hysterectomies are performed each year. And by age 60, probably one-third of women will have had a hysterectomy, and the majority of these, about 90 percent, are going to be for benign indications, such as fibroids or abnormal bleeding, as this woman has, endometriosis or pelvic pain. And traditionally, hysterectomies have been performed abdominally or vaginally, and vaginal hysterectomy was the first true minimally invasive surgery, minimally invasive hysterectomy. And certainly that is, even now, the least invasive form of hysterectomy. But 75 percent of all hysterectomies are abdominal, and so there has been a movement to try to make this procedure less invasive. And that started with the advent of laparoscopy several decades ago, and in the late 1980s, LAVH was introduced. This progressed to laparoscopic supracervical hysterectomies, and now we perform total laparoscopic hysterectomies with conventional laparoscopic techniques. So 00:10:22 ARNOLD ADVINCULA, MD: I m going to interrupt you for one second. In case people are wondering here what I m doing, this patient in particular wishes to retain her ovarian function, so what I m doing is I m just coming across her pedicles are very nicely attenuated, so they re easy to see I m coming across the uteroovarian and the fallopian tube here just so I can drop this ovary out of the way. It s well off the pelvic side wall, so in times of noting where the ureter is, we re far from that. And I m just coming across this thing with a special bipolar device. It s a Gyrus PK dissecting forcep that actually allows us to, with bipolar current, come across this in a hemostatic fashion. But go ahead, Dr. Song. I don t want to interrupt you. 00:11:09 ARLEEN H. SONG, MD, MDH: No, that s fine, and actually I was just about to make a comment that this particular patient has great anatomy and no previous surgical history. But certainly, if she had endometriosis or previous surgeries where the anatomy wasn t so great, you could certainly open up the rich peritoneum and dissect out the ureter if necessary, take down adhesions much easier laparoscopically with this device than you would with a conventional laparoscopy. And I think that kind of brings us to what the limitations of conventional laparoscopy are, or the limitations that people have with a laparoscopic approach to hysterectomy. 00:11:43 ARNOLD ADVINCULA, MD: This right here is a round ligament. I m just going to interject here intermittently, just so people understand the anatomy. Another one of the attachments to the uterus. I m just going to come through here with cold-cutting. Go ahead, Dr. Song. 00:12:08 ARLEEN H. SONG, MD, MDH: Now traditionally these hysterectomies have been performed laparoscopically with conventional laparoscopy, or what we call straight sticks, sometimes, laparoscopy. And this can have some challenges. There s definitely a limited degree of motion within the body, the hand movement can be counter-intuitive, and the view of the operative field is on a 2D monitor, which is different than the robotic system, which is a 3D monitor. And we can talk about that a little bit further when we talk a little bit more about

4 the robotic system. You can also have somewhat of an unsteady image, and there s definitely a learning curve for advanced cases. Most people will learn how to do procedures such as cystectomy, oophorectomy, diagnostic laparoscopy, tubal ligations in residency. Learning more advanced cases, such as total laparoscopic hysterectomies, are not necessarily the case. And to learn that can take quite a number of cases. So those are some of the challenges of conventional laparoscopy. 00:13:16 ARNOLD ADVINCULA, MD: Okay. Dr. Song, what I d like to do is just show them a little bit more what I m doing here. They can see here that one of the things that I m trying to do is as I ve come across the broad ligament, I ve dropped the ovary out of the way. I ve come through the round ligament and now I ve separated the anterior leaf and the posterior leaf of the broad ligament. And what I m doing is I m working towards these rings. You can see the bulge of that ring that I was talking about earlier here in the pelvis. I m just kind of drawing up a few things here. What I d also like to try to do here as I create what we call a bladder reflection because we have to kind of drop the bladder out of the way when we do a total laparoscopic hysterectomy so I want to also try and take this endometriosis that s right here and excise that with the specimen. But you can see here, there s an anterior leaf and a posterior leaf. And all I m going to do is just come around this, and as Dr. Song indicated, you can see that one of the advantages we get compared to traditional instruments is sort of that flexibility, the come-around thing. So here s some endometriosis, and I want to come around that so I don t leave any of that behind. 00:14:39 ARLEEN H. SONG, MD, MDH: The EndoWrist system has seven degrees of movement, and that really mimics your own human wrist movement, and that s probably, besides the 3D vision, for laparoscopy the major advantage of using the system and why it allows us to be able to do more difficult laparoscopic cases. And I m sure he may give you a demonstration on the movement of these. 00:15:06 ARNOLD ADVINCULA, MD: You can see here so, the flexibility so what I m doing right now is my ureter is way lateral out here, but I m also working very hard to make sure that I skeletonize my uterine vasculature here. Because that also, as I do that to the posterior leaf of the broad ligament, allows the ureter to drop further out of the way. I m just trying to get a grip here. I m just skeletonizing this a little bit right here, making sure I don t get into any vessels prematurely. 00:15:40 ARLEEN H. SONG, MD, MDH: So people often ask, you know, what is the advantage of using the robotic system, or why would we even want to employ this technology. And certainly, now we re definitely moving toward a more minimally invasive approach. Laparoscopic surgery uses much smaller incisions and allows for shorter hospital stays, less EBL, typically. And robotics allows us, again, to do more advanced surgery. We can mimic actually what we do. When we do an open case or an open abdominal hysterectomy, we can suture vascular pedicles, we can suture the vaginal cuff abdominally as opposed to doing that vaginally, as in a LAVH. And I m not sure if Dr. Advincula may at some point show us an example of suturing, even though we can do the majority of this surgery with cautery. And right now he s taking down the bladder flap to take the bladder out of harm s way. 00:16:51 ARNOLD ADVINCULA, MD: That s right, so I m just working on dropping this down right here. You can see that here. All right. So you can see here, we re just bringing that bladder down. All right. Go ahead and push the uterus up and in. Great. Beautiful. You can see there s the bulge of that ring, and we re working on getting this bladder reflection down. It s a little bit adherent in this case because she does have some endometriosis in the anterior cul-de-sac. We re just going to continue to push this down real gently. This is what we want to see here. And I m skeletonizing here the posterior leaf of the broad ligament. You can see

5 that being done here. And at some point, once this is skeletonized, I m going to be able to actually take and basically coagulate and essentially ligate my uterine vessels, which I m going to show you here shortly. Here s part of them right here. But essentially, these vessels right here that you see right here are my uterine vessels. And I m just dropping the bladder out of the way. You can see that happening here. 00:18:22 ARLEEN H. SONG, MD, MDH: The other use of the colpotomy ring is for us to identify the internal oss [sp?], and that lets us know where the uterine arteries are and where we would like to cauterize those or ligate those, because the ureter, as the surgeons know, does run just beneath the uterine artery. And so we utilize the colpotomy ring to feel or to identify where we will be cauterizing or ligating the uterine arteries. Now one thing that we do not have with the robotic system is haptic feedback. And Dr. Advincula may speak a little bit more to that while he s doing his surgery, but we certainly, once you start using the system, you begin to rely on your visual cues, which we probably do anyway, but you rely on them much more so with this system. And pretty soon, you don t even realize that you don t have haptic feedback. 00:19:14 ARNOLD ADVINCULA, MD: You can see here that I ve sealed my uterine vessels that are coming up and in. My ureter is way lateral out here. And I m going to hand this over so people can see that. But that s because I ve dropped my broad ligament on the posterior leaf, that is. So leave that well out of the way. You can see the ureter s right here, coursing right here. See it right there. Way lateral. We re using the ring as a landmark. And you can see I m pushing on this ring. And my assistant can probably feel me pushing on that. And the key is, I d like to really create a nice bladder reflection here, just so that when it comes time to closing the vaginal cuff we have nice margins to the edge of the colpotomy. You can see here this is vagina that s going to be through here on the other side. What I ve managed to do is basically pinch closed these vessels here, and I m using this Gyrus PK dissecting forcep that you can probably hear a little of that generator in the background. And I m just closing up what I would call my backbleeding here, ascending branches to the uterines. So that s it right there. So we re going to go to the other side now. We ve done one side of the hysterectomy. Basically, we re going to do the same thing on the other side. So why don t we go ahead and flip things over here? Actually, what I might do well, I m going to see here if I can we may not have to flip my instruments. Occasionally what we ll do is flip the instruments to opposite so that I can get a different angle, but because the flexibility has been pretty good here, we may not have to do that. So let me just stick with this here. 00:21:03 ARLEEN H. SONG, MD, MDH: Now while you re taking down this tube and uteroovarian complex, I thought we d just talk a little bit initially about patient positioning and how to kind of get started with this, because you guys were not able to see how we were able to position this patient. And so we have a nice slide showing another patient to show kind of how this works. We place the patient in dorsal lithotomy position. We use Allen stirrups. We found that those worked a little bit better than yellow fin stirrups, which we also use. But I think that these will position the patient s legs at the appropriate angles. And as you can see, it s pretty much a 90-degree knee angle. We pad and tuck the arms at the sides, taking care to see where their fingers are and make sure that the positioning is just perfect, because certainly you want to avoid any kind of neuropathy or nerve injury. And then the patient will be placed in steep Trendelenburg following port insertion. And it s important, I think, just to make note that discussing what you re going to do with the anesthesiology team is really important because this patient is going to be in this position for the next several hours, and they will not be able to move their position without undocking the robot. So good communication with your anesthesia team and what they feel the patient can tolerate for the next several hours is key. All our patients have a bowel prep that helps to

6 decompress the bowel and get that out of the way for us, and then we will decompress the stomach with an OG tube and the bladder, obviously, with a Foley. 00:22:50 ARNOLD ADVINCULA, MD: I m just doing the same thing I m doing on the other side here as Dr. Song is taking a short break here, in terms of just letting me explain what I m doing here. This is, again, separating the tube and the ovary from the uterus, since she wishes to preserve her ovarian function. And then this is the round ligament now, and we re just going to come across this round ligament. I m going to go ahead and put some bipolar energy on here. All right. What I m doing here is as I apply this bipolar energy source which the advantage of this particular device is we get tissue impedance feedback is that once I get this essentially almost like a seal here, I m coming across coldly with scissors so I don t disrupt what I ve just accomplished with the bipolar. All right. Same thing here. I m going to work on developing the anterior leaf of the broad ligament, finish up the bladder reflection. Big believer of, you know, if you stick with the avascular tissue planes, you encounter very little bleeding. It also helps you see better. And that s one of the advantages of the da Vinci surgical system is that we have such enhanced visualization. Unfortunately, those viewers out there probably can t really appreciate what it is that I get to see in here when I get this nice three-dimensional image. And although I don t have any haptic feedback or tactile feedback on my instruments, I actually gain a lot because I have these instruments that move with much more dexterity than what I call conventional laparoscopic instruments. 00:25:06 ARLEEN H. SONG, MD, MDH: So I just thought we d show a little schematic of where your ports are placed and where these two instruments you re seeing on the screen are, the da Vinci instruments. And we utilize a three-arm system here. The newer model is a four-arm system. And the two EndoWrist instruments come in on the right and left lateral quadrants, and you can see that on the schematic. It s labeled b. Those are 8 mm trocars. And then we have the camera port, which is labeled as a, and that s a 12 mm port. 00:25:45 ARNOLD ADVINCULA, MD: My Gyros is my Gyros unplugged? 00:25:48 ARLEEN H. SONG, MD, MDH: And that s where the camera goes, and it will sit there for the entire case. That s usually at the umbilicus, but for some patients they need to have their camera port above the umbilicus, and we usually place that using a left upper quadrant entry and doing that under direct visualization. Now c indicates our accessory port, and that s where your bedside assistant will have a port that they can utilize to place suction, bring needles into the operative field, cut your sutures. But you can see actually for the majority of the hysterectomy, Dr. Advincula is pretty independent with just these two instruments. We also have an assistant at the bedside that is manipulating the uterus and ensuring that the uterus is pushed up as far as possible, just to help drop the ureters away or bring the uterus to the side. The accessory port can be anywhere from a 5 to 15- millimeter, depending on what you re doing. We use a 5/8mm bladeless trocar, and we can put our needles in through there and bring it up fairly easily. If you use a four-arm system, you can have one more EndoWrist or one more da Vinci trocar, and that would be probably around where d is indicated on this four-arm system slide. And that just helps give the surgeon at the console a little bit more independence, in terms of manipulating the uterus. In gynecological applications we see it a little bit more. The oncologists are definitely using that to help with their node dissection. And again, port placement is most of the battle, I think. Pre-surgical planning is the key to any successful surgery. And in this case, knowing where your ports need to be. Sometimes they need to be a little bit lower on the pelvis, sometimes they need to be mid-abdomen, and that depends on the size of your uterus and what you re trying to accomplish. So these are obviously just

7 the typical placements, but based on what you re doing, you re going to put your ports in maybe slightly higher position, maybe a little more lateral. 00:28:07 ARNOLD ADVINCULA, MD: I want to just show a little bit of what we re doing right now. You can see here there s a bulge. This is the ring right here. And you can see the bladder has come down pretty nicely here, and all we re doing is just kind of cleaning up any areas here that might potentially hang the bladder up so we can keep it well out of the way. And then we re just going to skeletonize a lot of this tissue here. Again, it s just being real meticulous to make sure that we don t get into our uterine vessels, because you can see them right here. See this pulsating vessel right here? That s the uterine vasculature coming up. And although some individuals may just go ahead and try to coagulate all this bundle, I m a big advocate of basically skeletonizing things so that you only treat the tissue that needs to be treated and don t overcoagulate. So here we ve got the bladder coming down really nicely here. And this right here is essentially our uterine vessels right here that we re going to need to seal. Again, because we develop the posterior leaflet of the broad ligament also, what that does is it allows us to drop again, we have nothing but vessels here and it lets us drop that ureter nicely out of the way so that we don t put it at any risk during the course of this case. And you can see here just because of the visualization that we have, we can easily do that. And the flexibility I haven t had to really exchange any instruments out so far on this case. 00:29:55 ARLEEN H. SONG, MD, MDH: We do have an question regarding the PK forceps that we re using right now, or our vessel sealer, and that s what Dr. Advincula is using currently to coagulate and to seal the uterines. And the question is, Have you found PK forceps are superior to bipolar forceps for coagulation and speed? And frankly, I think that they re an excellent tool for vessel-sealing and for coagulation. I think you certainly are able to seal larger vessels with the PK than you would with traditional bipolar. 00:30:30 ARLEEN H. SONG, MD, MDH: Absolutely. I definitely think it s much more efficient, because you can see here, basically we are done with most of the hysterectomy, short of my just basically clamping these vessels here. We re going to be basically ready to cut and create our colpotomy and remove this uterus and cervix. I m going to go ahead and seal this. What it does is, because it gives you tissue impedance feedback, we don t over-desiccate tissue. And by not over-desiccating tissue, we get a much better ligation or coagulation of that pedicle. And you can see how that quickly times out because it s reading the impedance, and I don t get a lot of excessive thermal spread and charring. It s just a much more efficient way of doing it. Certainly, you can use traditional bipolar, and those instruments do come with the Da Vinci system, but we found that with doing GYN cases, and in particular hysterectomies, this really is helpful. All I m doing at this point is you know, here s the ring. This is the middle of the ring right here. You can see the ring, and the bladder is nicely down. We re going to be creating our colpotomy up along this edge. I ve sealed no lower than the middle of this ring right here. And I m just sealing along the descending branch of the uterines and just getting what we call jus the back bleeding so that when I do eventually create the colpotomy, I don t have to worry about suctioning excessively to get rid of any o the back bleeding that s coming from the uterus the blood that s trapped in the uterus. So I think that just right here, I think that we ve got almost all of our blood supply to the uterus. I think at this point now, what we re going to do is we re going to inflate that balloon that we placed in the vagina. 00:32:10 ARLEEN SONG, MD: So one of the questions is to describe the instruments that we re using right now, and what s in there right now is monopolar scissor and the PK dissecting forceps, and that s all he s used so far. Certainly, there are other instruments available. There and you will see, pretty soon, the needle driver. There are also graspers and tenaculums and

8 cautery hooks, DeBakey forceps, cautery forceps, which as a little bit more heavy-duty forceps. So there are a multitude of instruments used, but ideally, you want to do things in the most efficient way possible. So we try to use the least number of instruments, and as you can see, we ve only used two and have not had to switch out yet until we get to our needle drivers. 00:33:01 ARNOLD ADVINCULA, MD: I m just double-checking here to make sure we have all of our uterine blood supply. Occasionally, you can get an aberrant vessel. So I m just checking here, make sure that A, that our bladder s down, and I m very happy with that because where I m going to be cutting is far from my bladder reflection. Is the balloon up? Great. SO there s a balloon that s inflated in the vagina now, and that s the balloon that I showed all of you earlier. 00:33:20 ARLEEN SONG, MD: And I ll show a picture of that just in case people don t remember. 00:33:29 ARNOLD ADVINCULA, MD: So I m just making sure the bladder s down. It s down nicely. Uterus is starting to look ischemic, which in other words, to us who are visualizing this, it s starting to look a bit on the purple side of things, and that s because it s lost its blood supply. I m just going to go ahead and seal this right here. This is basically just some back bleeding. That s trapped blood within the uterus, and it s just a pedicle that I just kind of brushed up against. Again, that s okay. So we re going to go ahead and do now is we re going to go ahead and cut the uterus and the cervix out. The bladder, again, is down. I ve got the uterine pedicle sealed. Here again is one of those pedicles. I m just going to show you where I ve sealed and just going to re That s one of the pedicles that sealed. I m going to make a circumferential incision around this. It s essentially like doing an interfacial hysterectomy, what we re doing here and detach the uterus and the cervix. As you can see, we ve been running here for about half an hour. We re ready to cut what we would call the specimen out. And my bedside assistant, Dr. Senapati, has the uterus basically with some upward traction on the manipulator. The balloon is inflated, and I m going to go ahead and make an incision right here. 00:34:52 ARLEEN SONG, MD: He s making an incision at the top of the colpotomy ring, and again, you can t technically feel that with robotic arms, but you can certainly see the bulge, and if you had any questions about it, he could ask Dr. Senapati to kind of identify that with her through the accessory port with her instrument. But you can you can see where the bulge is, and the blue here we re seeing come through is the top of the colpotomy ring, and there s Dr. Senapati. 00:35:20 ARNOLD ADVINCULA, MD: Dr. Senapati, what she s do, she ll occasionally give me some suction, irri suction just to get the smoke out. You can see as you can see here, I m just going to meticulously and this is the part which likes to bleed a little bit. So I just kind of preemptively we ll come in here like this and sort of coagulate that area. I m going to stay away just get away from my bowel and also away from my uterine pedicle. So I m coming up along here. So I m going to try to release this, and Dr. Senapati s giving me nice upward traction. You can see I m just going to follow this blue ring all the way around. And what s nice about doing the colpotomy is although I do a laparoscopy with just conventional straight instruments, it is so much easier to wrap around and do your colpotomy because you can see so much easier. So I m going to go ahead and flip to the other side. I don t want to get too asymmetric. Let me see here if we can can you sort of tilt it a little bit to the other side? Great. Okay, maybe I didn t go far enough oh, I did go far enough over, good. So again, we re going to come across here. And this a part that wants to sometimes ooze. So I m just going to preempt it. I m just coming around here. Dr. Senapati s anticipating my every move, and so she is basically giving me a little bit of exposure

9 posteriorly as I come around this ring, and she gives me enough traction upward, but not too much that it prematurely pushes the ring in. 00:38:04 ARLEEN SONG, MD: Dr. Advincula, how many hysterectomies do you think you ve done so far with da Vinci? 00:38:08 ARNOLD ADVINCULA, MD: Oh, gosh, to be honest with you, I couldn t give you an exact answer. It s been quite a few over the past five years. Certainly, it s a method that we ve found to be very, as you know it s just very efficient, and we re able to just you know, because of the dexterity of the instrumentation and our visualization, we re able to again, it s almost like an interfacial hysterectomy. You can see the coming back into the posterior vagina here. Can you give me a little bit more upward traction there? Great. Because of the better visualization and look at this flexibility that I have to kind of wrap around this thing 360 degrees. I can take care of things that are more complex laparoscopically that I might otherwise struggle with with conventional laparoscopy. And I m not saying that these procedures can t be done with straight sticks. It s just that it makes it a little easier and more efficient for us to do so. 00:39:16 ARLEEN SONG, MD: I think there s definitely, you know, a couple reasons to go to Da Vinci now with in our program, we tend to 00:39:23 ARNOLD ADVINCULA, MD: So the uterus and cervix and completely detached. Dr. Senapati s now going to deliver this into the vagina, and we re going to close the vaginal cuff. So we may have to potentially what we may do here is in order to see a little better because she does have a fairly tight vaginal introitus, we may not be able to pull this into the vagina. We may need to undock one of the arms because occasionally when we try to pull out our manipulator, what happens is the the manipulator comes off the uterus, and then the uterus is still sort of hung up. So we re just going to gently pull that through. Dr. Senapati, do you need a tenaculum or anything like that to grab it with? I think you do because I heard the manipulator pop off. So what we ll do is let me get some gloves here. Do you want some assistance with some gloves? Okay. If you want, you can bring the camera here just so you can see what Dr. Senapati s doing. If you can pan in here, she s just trying to reach around between the legs, and this I have to say is just sort of one of the one of the limitations that we do tend to encounter when we do robot-assisted cases in GYN is because the system sits between the patient s legs, it can occasionally make it difficult to extract specimens, but we ve gotten our own little method here for doing so. And we just tend to reach around these arms and grab onto the cervix and slowly pull that into the vagina. While we do this, Dr. Song, you may want to address any issues that you find important to 00:40:58 ARLEEN SONG, MD: Sure, just going back to what we were talking about, we had an question regarding where we think hysterectomies are going in terms of utilizing the da Vinci, and I think that there s a couple, you know, reasons couple reasons that we may you would consider using da Vinci, and there s certainly a population of surgeons who may not be doing routinely advanced laparoscopic surgery, total laparoscopic hysterectomies, and robotics allows us to shorten our learning curve for that and to learn how to do this and offer a minimally invasive approach to patients without needing to go over that go through that long, long learning curve of doing conventional laparoscopy and overcoming those limitations. It definitely levels the playing field for the novice laparoscopic surgeon and the expert. Certainly, we have we train fellows here at the University of Michigan, and they learn very quickly how to do laparoscopic hysterectomies and laparoscopic myomectomies on the da Vinci. So it really does level the playing field between those who are fellowship trained and a generalist who has access to the system, I think. And, I don t

10 know, Dr. Advincula, if you have any other thoughts about that. For those of us who do conventional laparoscopy and do total laparoscopic hysterectomies via conventional laparoscopy, it allows us to do more difficult cases that would be done via laparotomy with this technology, and I think that s probably one of the greatest benefits of it. 00:42:27 ARNOLD ADVINCULA, MD: If we can go back in, you can see here I don t know if you saw that at all, but we went ahead and delivered the uterus into the vagina here, and you can see that. That purple structure is the fundus of the uterus. Here s my bladder reflection. The bladder is nicely back, up and out of the way, and here s the cut edges of the vaginal cuff. Here s my sealed uterine vessels here and here. And what we re going to go ahead and do now and if you lift this up, you can the uterosacrals coming in through the back of the vagina. They re essentially still attached because we did this in an interfacial fashion. What I m going to do now is change out my instruments, though, once Dr. Senapati changes her gloves over because she had to reach in between the patient s legs to deliver the uterus. Sometimes we ll have to morcelate a uterus in order to get it to fit out the colpotomy. In other words, we come in with a tissue morcelator and shave down the uterus. In this case, because we used to smallest ring available, it did make it a little bit of a tight fit to get that uterus out through that small colpotomy. So we re going to change my instruments out now, and what we can do is we can show you how we do that. Why don t you come around with a camera with an external view here, and we re going to go ahead and put in a what we call a mega-needle driver. It s like a heavy needle driver that allows us to hold CT2 needles, which are what we re going to use to close the vaginal cuff here much more securely. And you can see here why don t we go ahead and focus in a little closer if you can go ahead and let s get a closer here. Yeah, let s see if we can get a little tighter on this one here, and you can see the instrument, and you can see how she attaches that to the arm on the right-hand side here. And because all she did was remove the instrument and then replace a new one, it keeps the memory of the last position. There s going to be some flashing green bars that we seen on the monitor here, and it puts my instrument right back to where it was before. We re going to go ahead did you go ahead and put a largeneedle driver on the other side already? Great. So what we re going to do here now is you can see we have a the mega-driver. And you can see the difference here. I m going to bring it in up close. Here s the mega-driver. Here s a regular large-needle driver. Definitely a big difference, you can see that in terms of how these instruments relate to each other. This is just a much nicer instrument when you re closing vaginal cuff. My assistant, Dr. Senapati has now brought in suture. What we do is we take CT2 needles, and we just bend them oh-so slightly here, cut about 6 inches, and what we re going to do here is make sure I don t have the bladder at all in my vaginal cuff closure. Take a nice healthy bite back from my cut edge. I also want to make sure that I get vaginal mucosa. Let s see here, I m going to do an interrupted figure 8. Secure my angles. Again, getting vaginal mucosa here. This right here can oftentimes be one of the parts of a hysterectomy that can be problematic for individuals is the suturing part, and you can see here I m just going to go ahead and make sure I get a nice healthy bite, and once we close this case, once we close the vaginal cuff, we will essentially be done with our hysterectomy. And the main thing that we ll need to do then hopefully we ll have some to show you that is undock the robot from the patient and then close our trocar sites we put in laparoscopically. 00:46:18 ARLEEN SONG, MD: And as you can see, this closure is essentially identical to an abdominal hysterectomy closure using figure of 8s, and the visualization is great. We can see exactly where our bladder flap is, and we ve taken that bladder flap down so that we can get enough of that vaginal cuff to get a good closure, and that s one point I d like to make is that, you know, you want to make sure that you re outside of the cut edge, as Dr. Advincula was, and outside of that the area that s had thermal effect because that tissue is a little weaker, and you want to make sure you have good healthy tissue in there with each stitch.

11 00:46:55 ARNOLD ADVINCULA, MD: Yeah, those are important so you don t get a because you want to make sure that you minimize the amount of heat that you apply to the vaginal cuff when you create your colpotomy. Having a nice bladder reflection allows you to take nice big healthy bites when you close. You can see here we re just closing the vaginal cuff. 00:47:16 ARLEEN SONG, MD: And one of the questions from one of our viewers sounds like a patient, wants to know what the complications are during and after the operation, and vaginal cuff the opening of the vaginal cuff following the surgery is one risk that that can occur after any hysterectomy, including this one, and risks of this hysterectomy are similar to risks of vaginal or abdominal hysterectomy, and that s injury to any of the surrounding structures, such as your bowel of your bladder, ureters, bleeding, infection certainly a risk. These are all risks, though, however, of all the other approaches of hysterectomy, and it also depends on the patient. You know, patient previous surgical history, the reason the patient s having the surgery. Is it fibril? Do you have a larger uterus? Do you have endometriosis, previous scarring? Those are all things that are going to contribute to what your risk profile is for a surgery. So so that s something that, if you re planning on having a hysterectomy, you need to discuss with your physician. You obviously need to discus with them what approach they re comfortable with. There s some physicians who are much more comfortable with an abdominal approach versus laparoscopic, and that s something to have a candid discussion with your physician about. 00:48:35 ARNOLD ADVINCULA, MD: But certainly, as Dr. Song indicated, there are you know, the key structures that we worry about are things like the ureter, the bladder, bowel, which you can see sitting right here. This is large bowel. And so we just want to make sure that we are always cognizant of where those structures are so that we don t inadvertently injure them during the course of a hysterectomy. But a lot of that can also be affected, as she said, by the level of the pathology that you re dealing with, and certainly, that s one of the advantages of doing things robotically is that your vision is just fantastic. The thing is, I can see things that my colleagues in the room just don t see because I m the person that s seated at the console here. Maybe we can zoom in. Can we do a picture in picture, by any chance? I just want to see if it s possible. Why don t we just back and forth so they can see what happens when I m suturing. Show me some external views here. If you can see here, I m just if we can get a camera view of my hand sewing and then go back and forth. All right. So I m sure we re still on the internal view here, and you can see I m just doing a all right, so I m just what my hands are doing it s very natural in terms of making you know, doing my throws on my suturing. You can see here that whatever my hands are doing, that is exactly what s happening on the operative field. Great. So I m glad you could see that. All right, we re ready to go ahead and cut this other corner stitch here. 00:50:22 ARLEEN SONG, MD: No, again, there s no tactile feedback, so we rely most almost all on our vision of how tight to pull these sutures, and certainly, when people are first practicing, there s some suture that does get broken, but you can because the visualization is so good, you can actually see suture 00:50:42 ARNOLD ADVINCULA, MD: That s a great point, Dr. Song, is that there s definitely a bit of a learning curve to suturing robotically because of the absence of tactile feedback. However, it s exactly as you stated. You have to trust your vision to know where the proper tensioning of tissue as it comes together you can see here as the tissue s coming together. You can see here, boom, they re getting that, and you just learn to trust the way tissue deflects and what the properly thrown knot looks like, and again, you can see here I m making sure that we get vaginal mucosa because I want to make sure that we don t have that slip out because that s always a source of potential source of bleeding. You can do interrupteds

12 here. You can run this. It s really surgeon choice as to how you want to close the vaginal cuff. I tend to like to do interrupted figure of 8s here just because I don t like to bunch up the vaginal cuff. So, again, I m going to give you a little bit of global perspective here. 00:51:54 ARLEEN SONG, MD: And I think with this patient, it s important to note that she -- because of her had no descent whatsoever and somewhat of a narrow vaginal caliber, as you could tell, actually, from trying to remove that specimen, that she would have probably if she didn t have a laparoscopic option, would have had an abdominal hysterectomy, which would have been a longer length of stay, certainly, in the hospital, a longer recovery time, and with this, she ll probably go home tomorrow. They could certainly eat when they re hungry, and in terms of her post-op recovery, she s going to be feeling a lot better a lot sooner than if she had an abdominal approach. 00:52:35 ARNOLD ADVINCULA, MD: Okay, another stitch please. We re almost closed with the vaginal cuff here. Probably within another few minutes, we ll have the vagina cuff closed, and then basically, that will will let you pan in here. I mean, already you can see the vaginal cuff is almost closed because you don t see that uterus anymore. You can see here, this is the operative field. Here s my ovary on this side, which we re keeping in place. Here s the other ovary on this side here, which we re keeping in place also. I m going to hold on a second here. I ll bring in my vision. I think this might the last stitch that we throw. Oops, let s see here. Let s see if I can get this into my assistant s instruments. There we go. Great. 00:53:20 ARLEEN SONG, MD: You guys you might be wondering why he straightened the needle a bit, and that s because the accessory port we use is a 5-8, and there needs to be just a little bit of bend to the needle to get it through that port, but we found that we can use a little smaller port is we bend out needles a little bit, and they go in and out just fine through that. Certainly if you re not comfortable with that or you re using a different type of needle, you can put a little bit larger accessory port to bring your needles in and out, but that is why he straightens it just a little bit. It s not really about the suturing. 00:53:52 ARNOLD ADVINCULA, MD: And you can see here, when Dr. Senapati was trying to grab my suture how it s not necessarily easy for her to do so because she doesn t get the same 3-D vision that I get. So I get to cheat a lot because I get to see everything in threedimensional view. Let s see here. Just want to make sure I get the vaginal mucosa closed all the way here. I think this is going to be the last suture because it looks like it pretty much closed the cuff all the way here. So once we tie this, we ll pretty much be done with our hysterectomy. So you can see, it doesn t take very long to do these endoscopically. And the nice thing about it is it s also very ergonomic for the surgeon because I ve been seated the whole time. So when are we yes, I think we re getting a lot of questions, so why don t we go ahead and try to answer some of those if we can as people are watching here. 00:54:58 ARLEEN SONG, MD: One of the one question that s come up is: Are there instances in which a robot-assisted procedure is not an option for hysterectomy? And I I think that s a great question. I think that it s you you want you re going to want to assess, you know, why you re having a hysterectomy and then discuss your surgical approach. If you have a very large, fibroid uterus, you may not be a candidate for laparoscopy, whether it s with a da Vinci system or whether it s with conventional laparoscopy. If you happen to have had multiple laparotomies or large incisions, you may not be a candidate for a laparoscopic approach, and that, again, is going to be based on your history, surgical history, and the pathology, or the reason that you may need a hysterectomy. 00:55:45 ARNOLD ADVINCULA, MD: Absolutely. I 100% agree with Dr. Song. It a lot of the decision-making really comes down to is a patient a safe candidate for laparoscopy, and