Objectives
Develop a framework for case-based device selection & trouble-shooting
Demonstrate assembly of the various uterine manipulator platforms
Demonstrate proper use and setup of the ALLY® UPS
Illustrate clinical correlation with video vignettes
Presenters
Arnold P. Advincula, MD, FACOG, FACS
Chetna Arora, MD, FACOG
Welcome and thank you for attending. This event is brought to you by cooper surgical, a leading provider of medical devices for women's health care. For 31 years, cooper surgical has worked with health care providers to provide highly effective clinic and practice based contraceptive, surgical and obstetric solutions to complement our portfolio of trusted and reliable medical devices. We have also broadened our offerings, investing in the areas of reproductive genomics and in vitro fertilization. We are fully committed to helping improve the delivery of healthcare to women and their families. Cooper surgical manufacturers over 600 clinically relevant medical devices used by health care providers in offices, clinics, operating rooms, labor and delivery suites and reproductive IVF clinics worldwide. Clinicians overwhelmingly say they trust our products for their reliability, innovation and efficiency. Here are some other interesting facts you may not know about Cooper surgical. Since our inception in 1990, our focus has always been women's health care with more than 600 medical devices and over 3200 product numbers across a broad range of market segments. Physicians know and trust our products. We ship over 1450 orders per day, of which 99.7% are shipped the same day. Our customer service department handles over 2100 inquiries per day. We employ 1800 people worldwide. We're pleased to provide this educational opportunity on behalf of cooper surgical. Welcome and thank you for participating in tonight's event. My name is Doug K marketing director for cooper surgical and I will be the meeting manager for this evening's program. A couple of notes on how the demonstration will run. We have an approximately 60 minute live session with interactive questions and answers with dr Advincula and Dr Arora. At the end of the demonstration, they will participate in a dedicated 15 minute Q. And a session. We would also like to extend a special thanks to our colleagues from Dinos. Um that have been great partners in bringing this program together. Our program is the first of a three part webinar series on mastering minimally invasive gynecologic surgery. Tonight's program is entitled mastering Migs won the foundational ins and outs of uterine manipulation. Our distinguished presenters from Columbia University Medical Center and new york Presbyterian Hospital are dr Arnie Advincula, vice chair of the Department of Obstetrics and gynecology and Chief of Gynecologic specialty surgery and dr Chander Arora, Assistant professor of the department of obstetrics and gynecology and the division of gynecologic specialty surgery. Now, dr Advincula and Dr Arora thanks dad for that kind introduction and greetings everybody this evening. Or I guess people are patching in from various time zones around the country and around the world. But thanks to cooper surgical again for sponsoring this event. And I'm really yes, I'm really excited to be with Dr or again I know of a couple months ago. We did a program together. So it's it's great to be with a former fellow and now partner. Yes, definitely. So um this is gonna be kind of really free form um we have a agenda here that we've outlined for ourselves. A lot of things we want to try to cover over the next 60 minutes and so please feel free to send in your questions. I was gonna farm away at us as they come in. Hopefully we'll be preemptively answering these things for you. Um So much we want to share. Right Well why don't we get started? Let's do it. Um You me yeah. You know what one of the things that I think people often forget about with regards to you know manipulation is that it isn't just for hysterectomy. Right? That really it's critical to anything that we do in gynecologic surgery. Right? I mean we get the advantage that we get to move the target organ. Right? And so whether you're doing a hysterectomy or conservative surgery, of fertility surgery the most important in the surgery. Absolutely. I think for hysterectomy whoever's down below manipulating your uterus is probably more than half the case. That's the value of that. So we thought we'd talk about the platforms that are available and start with the historical kind of the tried and true the O. G. Which is the room to handle. Um And then then after the roommate to handle came the arch. So we have the coefficient and then and then the most recent member of the platform is a delineate. Er Now delineate er is very specific to hysterectomy. So what we want to do is just sort of talk about the importance of just setting yourself up for basic manipulation and we're going to talk about the roomy to handle and the arch. Um so you know what I mean, What do you, what's the most important thing when you're getting yourself set up right? Like if you're just having the right equipment, having the right set up and knowing how to use your equipment, I mean, it's really understated that. Typically, you know, the most junior person in the room is getting things ready and the one who's setting up from below the foley goes in, the manipulator goes in, Everyone's ready to go at the top of the belly. But Half the surgery, the most important part is in the 1st 10 minutes of setup. So it's just about getting your equipment and there's only a few things you really need to do. A manipulator, that place one that's right, and we'll talk about that with a model that we have to do that. But you know, the important thing when you utilize like a roomy to handle or an arch is you have to do a tip selection and I just want to talk a little bit about how you use the roomy tips. So there are a variety of tips. I'm gonna start with the ones that are most commonly going to be utilized and that's gonna be the the six inch tips, uh six centimeter, I should say. Uh there's a much more narrow diameter or caliber to the purple, but that's six centimeters, there's a white one that's six centimeters. Then you go to eight. You can see here um with the green, you're going to 10 in the final 12, 12. Exactly. So the way you place these um are obviously the setup here is its dual. So you've got one funnel that you're going to use to blow up the tip balloon, which is going to hold it in the uterus after you've sounded it to make sure it's truly So you use your 10 cc syringe and you're just going to use Saline. We have air here just for demonstration purposes. And as I fill up this balloon at the tip, you have your balloon filling at the side right here and you just clip this shut because the moment you pull this off, the air will come right back out. But that retains the air within the bubble and its side opening, which is important. And that's something we'll get back to a little bit later is the location of this balloon when you inflate it. And then the other piece that you're going to see tubing wise is for chroma perturbation. So the nice thing about rumi tips is you've got a way to secure it in the uterus and you can chrome apart debate but let's go ahead and release this and talk a little bit about how we attach these. So when you attach this for example to Rumi handle. I'm gonna go with the white one. I'm just gonna pick this one. Just, you can see the whole range of sizes. This is also six inches or six centimeters but of a slightly thicker diameter. You'll place this on the end. Can you pick this based on, you know, sounding the uterus and then the diameter you can choose based on, you know, the caliber of the cervical, cervical. And I find this is helpful a lot in, in patients who you need you to manipulation but it's a reproductive aged patient. Um, you know, you don't want to necessarily, you want to struggle to dilate and you can get this in a lot easier for the rest of the roomy tips are all the same diameter. When you start with the white all the way on up but you just twist onto the end and then you have this and there are channels on the sides that you can literally place the tubing just to keep it out of the way neat and organized And I don't know if you want to show putting it on this one here. Like getting a Yeah, sure. So why don't I take, I'll take the eight tip and I do the similar setup. There's channels for both sides of it equally as well. And what's nice about it is this part here is kind of a soft cushion. So all you do is you place the tip of it in through here and there's a little channel that it fits right in and you just screw it right on top. Then on the sides there are the same channels. Sometimes I like to use like a dilator or something on the side just to roll it in so you can just fill it in the spot and then I just slip fingers all the way down. Then there's two little grooves that you just are able to stick it in. It's important that they go in the grooves and we'll talk about that later when we particularly show with the co cup coefficient cup and then attaching it to the ups. So the uterine positioning system. So there are definitely grooves on the sides that help you place this to keep it out of the way. And I don't find it as critical when you're not doing a hysterectomy with these handles because I sometimes find it's easier just to let the tubing hanging off to the side. But certainly this is the set up. Now, this is important when you're just doing straight out manipulation, you're not taking the uterus out, but you need to be able to, you know, move the uterus back and forth. The nice thing about rumi to handle is you can articulate at the discipline at the level of the, of the cervix and, and the whole device can then also be a lot of degrees of movement does require a bit of a learning curve to definitely master that. But once you do um you got a lot of degrees of freedom with this and then with the arch it's it's more following. Just the curve. Yeah. Just because as you know the pelvis, the with the uterus itself, it's kind of sitting in that whole sacred bowl and the whole purpose of just getting to those vital structures. You just have to push to lift and it has that natural curvature. Now let's say you want to do a hysterectomy, you still have to do the same step. But the next piece to that is then choosing the copa to me cup. So both of these work with something called coefficients but they're specific to either room to handle or the arch. Yeah. So just for demonstration purposes. So after you've put the tip on, so you've already sounded the uterus, you have your tan akron, you have your speculum having been placed first, then you're going to assemble your manipulator. So we have the arch with the roomy tip selected this, then goes in through the south. So this piece will slip in pretty readily. Then you just push this through so that the piece now is free floating within the device. There's a little piece here that's blue, you make sure that's lifted and released, there's a groove in the handle and that's why it's important to have those pieces clipped in so that the tubing stays external to the coefficient cup, you clip it in, it's pretty gentle right there, it'll slide Then with one hand, I typically just slide this in until it reaches the cervix itself. Sometimes when you're holding this, you can kind of use your left or your non dominant hand to hold it and use your dominant hand to kind of slip it into the vaginal enteritis. Sometimes either lubricating it or being able to just kind of navigate it by moving it slowly. And the key thing here is that again, the beauty about this is it's back loaded, right? So, uh you always want to keep this, this is the set up when you're going to place it in a uterus that you're gonna do a hysterectomy on, right. So you have to go through all the same steps as we showed you earlier with the exception that you've added a coefficient. And now you're in the process of placing this. You gotta put in the uterus, inflate the balloon, get that situated, get all your stuff out of the way, and then you're gonna slide this down as it should be a sweeping motion and you're going to feel this, there's an audible and almost a palpable click. And then once it's in you have to remember to lock it in place and this when you'll feel it. This should be if you've sounded correctly, which is truly vital that will make sure that this is accommodated for the length of the cervix but all the way up to the funding of the uterus. So this is flush with the cervix which as we are discussing hysterectomy cul pa to me, you want this as tight and close to that for nick's as possible. In a similar situation occurs with the with the coefficient for me to handle right? You do all the same steps, you gotta sound, get the right tip length on there. Then you're adding this piece right? You're gonna add this piece that again is similarly um back loaded, right? So you want to make sure that this this goes in the proper location so that when you're when you're placing this you can you can slide it, it's back loaded, right? So that you can have this pulled back. So it's not in your way anybody has used the original roomy handle knows that you had to front load the device. And that would make things really complicated because you have a cup sitting on the end and you're trying to place the roomy tip and the cup all at the same time. Now it's it's back loaded and similarly you're going to slide this forward and it's gonna be a similar situation where it's gonna, once it's in the right location it's gonna click into place. There's a lot of different little, there's, it's almost like palpable and audible that you have it in the right location. you also can see on here that there's an arrow that shows you where everything should line up, right? So this is properly placed and it is really key, as we mentioned here with the clip that this clip cannot go down if it's in the wrong location. Right? So either of those little things that when you have trainees that are down below or somebody is new to this that you don't appreciate, that you could dislodge the coefficient. So making sure that you have these sort of audible click, it feels right, it looks right. And what would happen if we didn't have this clicked in? So if you don't have it clicked in and you're putting a lot of pressure on the uterus and you're lifting up, you could actually inadvertently slide this cup downward and it's no longer as flesh. And then when you get to the point where say you're making your cul pa to me, you have now made space where there shouldn't be and vital structures, just like the uterine arteries that are there and the ureter. So that click is good feedback. You don't want the copa to me cup to migrate Caudalie during the course of your surgery, because if that happens then it means that you are creating a coupon to me that much lower than you should be. What does that mean closer to bladder closer to your because as the orders come towards the midline that's happening, you know, lower down, right? So you definitely have to be careful of that. But this is the proper setup. But you can see and you know, we have both. You know, it takes some practice to get really down to like where it's like you're doing it like without thinking about it so much and it goes really quickly. But these are the sort of the key things to keep in mind. The question came in just the coefficient from the rumi to the arch look different. The question was are the cup and the tips, are they the same or are they different as well? The cups are the same. And just to segue with cups which is I think a great example here is this is a hard cup. And so there's some different types of cups that are out there. So as you can see some of these have different kind of coloring on them. This is a metal external. So this is important because they say like you're using an ultrasonic device that will you want to avoid spark and melting that cup itself. And so this is designed. So yeah, it's designed for the particular device you're going to use. So I think the first thing to take home is that the roomy tips are the same. Whether it's arch or rumi to same. Roomy tip coefficients are slightly different. But the material on the cup is the same. So from unipolar, it's an old time cup. This is the it's a blue cup that you're going to use for ultrasonic energy. You're going to request the metal cup, right? Because otherwise you're gonna melt these with ultrasonic. And then the other thing to keep in mind is there is a soft cup. Um And that's that's this version here is a slightly darker blue. But I know a lot of jeon oncologists like to use this because for a much more narrower in troy itis or or a trophic or postmenopausal, sometimes it's easier to be able to squeeze that. You can see I can squeeze the cup here, that's that's more significantly more rigid. You can't really do that. But that's the main thing with the core pottery cups. And then the one thing that we didn't touch based on is the delineated, which is the sort of the newest generation reason we save that for last is because, you know, these two products, yeah, these two products can be used for hysterectomy and non hysterectomy cases. Whereas the delineate is really exclusively for hysterectomy. Right? You're you're you're going to use this when, you know, you're removing the uterus. Um It's designed to be, again, it's the coefficients already added in. Uh it's ready set to be back loaded at the same principles. You've gotta, you know, um sound the sound helps you set where you're gonna lock this window lock right here. And the one thing we didn't mention is like picking the cup size, right? Yes. So in your kit comes a cervical sizer which you basically if you see on the borders of this right here, it says 2.533 point 54 and four is the max it goes to so similar 2.533 point 54 and we kind of have them all demonstrated here so you can just get a general sense but so like here is a three and we put it on here and when you stop the bar, the bar stops at a three, it's a little hard to see and appreciate here. But basically when you go in with a speculum you're able to then just measure the size of your cervix and you're able to accurately objectively measure to pick out which cup you needs. I do think it's important to always make sure you get the right size don't do one size fits all. I I think that that has some issues when you do that, that bring some element to the case. That might complicate things. Quick question just came in if you're using the Advincula delineate er does that have promo perturbation? And if not if you're you're doing a case where you want to check for patent, see what do you use for chroma perturbation in those cases. Yeah, I mean the delineated, like I said is a hysterectomy device. So there's no there's no promo perturbation tubing in here because you're taking the uterus out, it becomes a moot point. But like we said earlier with roomy too and with the these two channels we have the roomy tips on roomy too and Arch have the ability to come apart just because you probably are seeing three different chords here. So these are the two that came with the room itself. You have your chroma perturbation and then your tip balloon include er and they're actually labeled on here too so you can see them but then there's also one more piece here which is an important part here. So this is the balloon, it actually is meant for a 60 cc syringe. So after you have taken down your Veterans and you're about to do your Koopa. To me, you have to think, you know, the new mo inside the belly can leak out the vagina. So the whole goal is to block that from happening and keep your visualization. So this is a new mo include a balloon. So basically every one of these are equipped with that, whether you're using it for hysterectomy or otherwise so that it is a little bit more universal. And if you hold it this way you can use saline and then as you can see it inflates and it can go up to whatever size you know you feel like you need to use and it can be pulled and retracted and I usually think 62 maybe and I'm going to go up to 90. I usually find 60 to ninety's all you need for this and that's going to hold your normal parent diem in both of us. Like I don't like to inflate this until I'm ready to do the Koopa to me just till the very end. I think it distorts the anatomy a little bit and it just helps you see your plane. If you look at it on the side view here, you see the balloon might elevate the vagina off of the cup and then you blunt a little bit this visualization of the Koopa to me ring. So I I'd like to just say, you know what? We're going to wait until we're ready to call pottery, then we'll inflate this, right? So after you've done the hysterectomy and you've pulled the whole specimen out and it it will come out altogether if it's coming off the vagina or you're releasing it into the upper abdomen if it's too large. But basically, you know, you just, you can leave the balloon inflated if it's coming up from below. The question was why wouldn't you use the delineated for other cases? You know where you would use rumi or the arch is because of the soft tip on the room in the art because from a perturbation, you know, why would you focus that? Just on, it's a good question. A little bit of surgeon preference. I'll be honest with you. You know, it's what you're comfortable with. I was exposed to all of these and even a couple of other delineate ear's and I think it's a product of your training. It's a product of what you feel most comfortable with. Some people really love the room. I personally find these two devices to be more friendly for me, but particularly if I am going to do a hysterectomy, I choose this one because it is a little simpler. It's all inclusive. I do like this one for if you're thinking about other multiple different procedures, all included and we'll get into that whether you're a guy an application later. But it's really a surgeon surgeon preference. I mean, I'm going to share. We're going to move into a segment of the program. We're going to share some clinical correlations and why we like why I choose and I choose is certain manipulators based on what we're trying to accomplish. But it really is a surgeon preference. What you're comfortable with, what your assistant is comfortable with and I just want to before we get any further is a shout out to all the people that are down below because that is one of the most critical jobs in the world. So thank you for the folks who have all the all the to all these years held the manipulator because that's why we find this is a really important part of the webinar series is just setting yourself up for success. But we don't want to touch base on like moving into like just a clinical troubleshooting piece, right? So now you know about how to construct and put these things together. Um but what about like just placing it? Let's let's go to the model, gonna slide over here and show you some things put some gloves on. We're gonna work with the dinosaur model. Uh and it's just been fantastic working with this product because it brings a lot of fidelity to teaching. Um it's about as close as we can get to having to use a cadaver whatever, you know, there's obviously a lot of limitations with using cadavers, there's a lot of benefits of course to but at the same time that makes things a little bit more challenging. Um you know, this is a great model. We actually cut it in half. We kept the cervix in place, so I know that this is not the perfect visualization of the model itself as a whole, but we want to show you how to place this. So this is a sagittal cut force going back to our like looking at MRI's and stuff, but we've created a sagittal cut of the uterus but with the full cervix still in place, just so you can see some finer points that we think are really important, sometimes get lost translation. Yeah. So what I'm gonna do is I'm going to show it to you from start to finish. So he's going to pretend to be the body of the uterus or the whole body and basically remind everybody about like what are the key? At least the bare minimum instruments you need on your bottom table there right here, avoid of the scalpel. That's for future demonstration. But I will say this so you need an open sided bivalve speculum. And that reason why is because when you place the speculum in you want to be able to grab the cervix, whether you grab it horizontally vertically et cetera. But you want to be able to go in through the vagina and then pull the speculum out while leaving the tack in place so that these are the two most critical pieces then. Or even just be able to pull all your instruments out once you place the device right, if you use a close sided speculum you're not gonna be able to extract your equipment because it's going to be around your manipulator then you need a uterine sound just so that you can actually measure to approximate whichever manipulator of any type of manipulator to use and dilator so that you're not forcing it through and then perforating in the wrong direction because you know, uteruses with different pathologies can be sharply averted in any direction you need to dilate. So I've seen a lot of folks going to the O. R. And they're trying to place a manipulator, they don't dilate, it's a problem. You need to dilate. I often say I like to use prattville laters and I used to say at least 21 21 in french with a pratt will accommodate any roomy tip. It just makes it less of a complicated process if you do that and we have a couple on here, whichever one, Hagar's prats, whichever. So basically I will place the speculum into the vagina. And so what I'll do is here, once I can see the cervix and view, I'm going to open it up, I'll lock it in place and I'll have Arnie hold it for me just so I can demonstrate a little bit easier for you to see. So the speculum is in place and it's a little bit on the narrow side, that's okay. And so when I'm gonna come in from just like I would from below and I'm looking through here, let's do a vertical, grab, like grab 1 10 acura um tooth in the cervix and one outside vertically, I just feel like I can pull a little harder and not like tangentially have a rent in the cervix, but I know you'd like to grab, I'm a horizontal person, but to each their own right. So basically then I'll take the uterine sound and all I'm gonna do is, I'm gonna obviously follow the internal loss, but we open this here to kind of give you a demonstration with this uterus kind of cut in half. Is that basically right through here? We were setting this up before. Yeah, just the internal side so. Perfect. So we're now that we're inside the uterus, I'm gonna come up to the fungus and I like the subtle cut because you can kind of get a real time view. So now that I'm here, I'm gonna feel for the length of my servant, my length of my uterus, I'm gonna put my finger on the inside the speculum, pull it out, get my measurement. Okay? My uterus measures about 8.5. It's important to know that we're in between sizes here. Right? So then I would go and measure to about an 8. 8.5 on here. Now I'm going to dilate the cervix. So same setup as before. We've had our models thawing for a little while just to have it ready for today. Perfect. Again, like I said 21-23 French with a dilator. Um These are Hanks and the one downside. I don't like about having that little collar on there. Is um here, let me just help you. There we go. Is that with the collar? Sometimes you can't get up into the cavity where you really need to be dilating past the internal. Ask if you have a long cervix. So just be aware that sometimes you'll have a long service and you can't get in and it makes it difficult to get all the way past the internal for the sake of demonstration, dilated this one up just to show, So now that I've dilated this out, what I'm gonna do now is I'm actually going to take the speculum out but the macula um will stay so I'm just gonna release my speculum before you do that. I will add that. I know you like to take everything out and then place because you're pulling on the server because sometimes it's high, it's high up, you can place it with the first with the speculum in the same kind of concept and it's in. So now we're gonna hold this here, I'll release this. Obviously you have the body to help you hold things in place to side, opening spec comes out, this is why you need to open sided by about speculum is you wanna be able to remove it and work with things without it being caught in your speculum, right? And then we would have already at this point inflated the balloon. So now that I have so important thing here is I wanted to demonstrate is if you say you don't have it put as high up to the funding as you thought and say I'm blowing up the balloon, what if I blew up the balloon here, you're gonna get a lot of resistance because you're gonna blow it up from this side here and you're never going to get the right torque on your uterus, right? So if I actually inflated it here and I push this and I locked it up when I'm trying to anticipate their uterus. Imagine the poster aspect the fungus just dripping back. And if you have a big poster uterine, my oma or any my omagh's for that matter, you're never going to get the right torque on your uterus. So, I mean, the key thing here too is that before you take anything out like your speculum, the first thing I do is once I place this is I do inflate the balloon, right? You inflate the balloon to inflate inflate it right now and you can see it opening up right here. So there's the balloon is inflated and this automatically locks. You don't have to like clip anything in this way, It's not going to fall out by accident while you're tooling around trying to get the speculum. And I've used it purely for the purposes of getting it through right. And so I'm at the level of the fungus. Now this is, it slips and slides. It's pretty, pretty straightforward. But if you look at this we're just gonna have the slide right up to the cervix and I know where I'm at because I measured the uterine fungus from here. So I said about an 8.5 and right here, I'm going to clip this in at the fungus and it locks now you're already in. So there's a window lock here that correlates with the sound, right? So where she sounded. Uh and so that's proper placement. Right? And then again, just take home point is, you know, we chose the right cup. This needed a four centimeter copa to me cup. Um, it sounded appropriately and the tip is right towards the fund issue. You want to be through the fund this, but you want to be at the funds so you can actually manipulate, like, as as I said, you don't want to have this thing being sitting down here low, um down at the lower uterine segment. And then if you have a top heavy large bulk of uterus, you're just going to lose your manipulation capability. Um The other thing I want to make sure we bring up is um, If you don't sound the roomy tip properly, particularly with let's do the smaller ones. Right? So let's take this one for instance, say you measure this is six cm and let's say that it's a much bigger uterus. Yeah, you stop or there's an adhesion or you don't realize that you're not at the fungus and you're blowing this up. But the balloon is here on the side, right? Let's take this out. So the balloon deflated and then it just backs up fully. So imagine if you're putting this in from here, right? And this should be flushed up against the cervix. Now if you notice like I'm I'm as high as I can possibly go. But I don't realize that because I don't have the perfect sagittal cut when we're doing our case, right? So what I'm gonna do that, but as you can see, like what we're trying to demonstrate here is the balloon is buried in the cervix and at first you're like, okay, wait, maybe this is a good thing. What if it's like I can't get inside the uterus. This may be a better way to facilitate, say like a difficult entry. There are challenges with that. There are two reasons why your balloon won't go up. It's going to be you're too short on the roomy tip and you're literally sitting in the cervix still the canal or you're in a false track, Right? And so a lot of people say, well, I can't get the balloon to inflate and then they pop it trying so hard and I'm like, I can't, I can't fill this up, I'm hitting resistant. And that's because this thing is not sounded appropriately, it's a short roomy tip. It needed to be, you said 88 to 9, right? Yeah. And this is only the six. So you're you're literally sitting in the cervical canal. And I think that's an important take them, a lot of people, you know, will struggle and say, I can't get the tip to inflate and that's why you're either false track or you're sitting in the cervix, right? So that's the importance of making sure you sound I think also really important point is don't take this spot this particular step for granted if it's difficult entry, go in up top and then go back and do the manipulation under visualization because it really is a make or break point of the game. Right. Questions came in just about seating the cup, right. One of them was, do you ever get a service that is flushed with the vagina? Right. And if so, how do you get the cup seated? And the second one is uh the surgeon said that uh sometimes he has to attach his cup with a stitch. Right. Do you have to do that with these products? So what do you do? Well, the stitch is an easy one to answer with this device. You do not have to attach it with suture. It literally picture with delineate or any of these products. If you do it properly. If you sound correctly, choose the correct cup, this is going to lock in the appropriate location and it's gonna it's gonna be correct. It's gonna be up against the porn X. And and actually, I don't like to put a stitch because then I can't I don't want to lose my ability to rotate the handle around, right? And so it's not uncommon that you're pushing from an upside down handle to get a different anti british and I don't want to pin it down with a stitch. So I don't you don't you don't need to stitch with the cocoa pottery cup. Um before we jump to answering the question about no Cervix or flush Cervix. One of the things that we can show with that other model here. Um sometimes we're gonna, you know, one of the big issues that you're into is like that previously operated on Cervix. That's like cyanotic, right? And one of the things that you mentioned there is this 11 blade. You know, sometimes you can see the dimple of the Cervix. You can't, you can't, but if you can at least see the dimple and you're having trouble trying to dilate. Like I hate lockable duck probes personally. I know, you know, I hate those because I think they force you to make a false track because they're so fine that when you push hard enough you'll go anywhere. So I just like to take a 11 blade and I just create a little bit of a cruciate incision. So I go, You know this way and I just rotated 90° and push it again and and cut right at that dimple. And usually that's all you need to just break that scar tissue up the psychiatric. So it's a scar that's there at the cervical, opening the external loss or the new external loss based on the prior surgery and then you can dilate, right? And I often try to start with a little bit of a fatter not the, not the biggest dilator, but I take the smallest. It's bigger than a sound, but not your massive because I just find this is going to allow you to find the right track as opposed to going with a really pointy narrow, skinny dilator or you know, somebody else finder, obviously that will work too. But um let's go to that question. That's a great question. The person who sent that question in because that is a common problem, right? It's common enough that we wanted to prepare for it. We actually have a model. Afghanistan helped us develop a model here to kind of just demonstrate. So this is a uterus sand cervix basically. So uterus is here and what we did here, this is like just work with us here. This is the vaginal vault here, like ex vivo with this model that they built and the vaginal wall interior has been open. So you can see like inside, right, you can get a view that there's no cervix sitting inside this cold. To me, this is just truly this is absent. The cervix is gone. But the good news is that it is the take home point. It doesn't matter that you don't have a cervix in the physical vagina itself, right? The most important thing is getting in. Obviously there's a there's a whole new set of challenges, right? Like when you don't have a cervix in the vagina, you know, your dilation part is gonna be a little bit tricky getting getting the tip into the proper cavity. But there's no cervix here. And so it doesn't matter because as long as you can place the uterus appropriately sound and get it into the cavity inflate the balloon because the balloon is inflated and you bring the bottom cut down whatever you use, this will work. And then when you look at it from above laparoscopically you're going to see the Koopa cup right? Like you're going to see this delineated for you. Like any other case that you would do laparoscopically because you are as flush as you are. You're not going to be doing like an upper vaginal ectomy. You truly are just flush up against the lower uterine segment. So it doesn't change anything. The hardest part of those cases is actually getting into the cavity. But once you're in and I usually just for the most part because you can't size the cervix you don't have unless the vagina is really narrow. I typically will utilize like a 3.5. Yeah, I mean that's probably the most common cup size most people will use is a 3.5 but I'll choose the 3.5. Really place that flush up against the foreign X. Make sure you lock it down whatever you know, obviously sounding is key but it will be in the right location and you shouldn't have any issues. I hope that answers the question for our viewer. But we're gonna come back here for a few seconds just to talk about um like case application. Right? And so basically, you know you have the armamentarium of gynecologic surgeries that you can do right? We have hysterectomy, myomectomy and axel surgeries, european procedures, lots of different things and you can apply your uterine manipulators to any of those things. So we talked about surgeon preference but we also want to talk a little bit about creating some efficiencies. And one of the things that we didn't touch based on earlier is that two of these devices, the roomy to handle and the arch also accommodate tips that are designed for Euro gynecology procedures. So I'm gonna grab these here and then these are the blue tips. So blue tips, these are sort of like the original, the 1st 1st ones that came out and there's one that's hollowed out. That's a secret cervical, first cervical pixie, right? This blue tip and then there's a solid ones, the small and largest for your actual um have you noticed these have the same sort of appearance as the roomy tips? So they basically go on these two handles the same way. So I'm going to take this off. So you can demonstrate on that one just so people can get an understanding of how that works basically the piece screws in just like you did with the roomy tip. But what's nice about this is that you have exactly what you need to just whether it's just from the top of the cuff and you can push up against this and you're able to dissect down your bladder, dissect down to the post your vagina and then you're able to place your mesh and so they work on either either one of these handles. And so I think it's important to know that that's fairly straightforward in terms of placement but then there's a whole nother set of tips called the hoyt tips. Also designed to flatter. They're designed for sacred cervical pecs as well as cotopaxi. And an important kind of distinction here is that this device here will just slide in and you'll hear an audible. Thanks my there you go. Yes. And so basically and then it'll just click in and so you'll you'll hear that click right? And so this is just kind of your wider fan so it's not your generic blue tip. And then all you do to lift it off is just pull this little lever and then just kind of twist it right back off. And these only work with the with the arch handle, they do not work on the roomy handle. And again delineate er this is sort of not part of that platform because delineate is for history distract me. You could do a hysterectomy with delineate er and then switch handles and you're you know you're a guide procedure like you're doing a super cervical hysterectomy than a cervical pixie. But if you want to be efficient you probably from the beginning you would use if you're going to use like a hoyt tip you probably use disposables will go away and now you have a different piece and you just have the same handle basically. Right? So there's some things to think about as you choose, it's part of your selection process right? How to be efficient, not getting too many handles on the field and just working with one. Um The one thing we do want to cover before we switch gears and talk about ally, which is the unique positioning system is one of the things that we love to do because we do a lot of large is the staged corp A to B. And if we can keep up that video because again we're talking about case selection. Why do we choose the things that we choose? Right. So I'm gonna walk up here and cheat in a peaceful free to add commentary because I know you do this a lot too but as this video is playing um you know, one of the things that we have found extremely helpful and that's why I choose to delineate er actually um and you can see that this is a fairly large, you get appreciate it. It's a pretty big uterus and I chose this because what is one of the biggest things we struggle with with a big uterus, it's visualization and it's getting down to the very base you get everything down and then you can't see a dang thing when it comes to papa, To me. That's right. And you struggle to do the Koopa to me, right? So I showed you here, this is about a 20 plus weak uterus. And we're gonna leapfrog here, jump ahead. And now we're at the point where we've got everything down right? You've got the broad down, you've secured the vessels. And what do we do? We do? Well above the cup. So the cup is there, right? That's the cup. But what are we doing? We're going higher. We are just doing a super cervical. Like we're at the level of what I would call it narrows and that's like level of the internal loss, right? So whether uterus narrows down, we're gonna do um a super cervical. And the key here is once we find the shaft is we pull that shaft and we back out of the uterus and into the perennial cavity. But you just dropped all the pathology posterior and you can lift up and you don't have anything in your way exactly. So basically you pull back and you anti flex, you can complete the amputation of the uterine corpus here and again, this is played in faster speed for the sake of time. But when you do this, what ends up happening is you are simplifying your core pa to me right? And how often do you do this in a given week, Probably fairly often feel like the majority of our youth are pretty large. But what's nice about it is, you know, make a very difficult case and exceptionally easy case in comparison at least you know because you've done something where you basically just lopped off the majority of the specimen and now you can see everything. Stop this for a second, then the video. Um and we're gonna freeze it here before we go to the last piece which is the copa to me. Um Yeah it's just to demonstrate here again that what we're doing is and that's why I choose this particular device because as you saw here when we were doing the super cervical, what you know, here's the placement, right? Let's pretend that we have a ghosted uterus here. And I'm doing this super cervical, right? So my assistants pushing in, we're doing a super cervical. You have to be able to leave the cup in place and slide the shaft back while the cup doesn't move. That's the key here. Right. With the other devices you actually, if you pull back the ruby tip, you're going to be pulling back not just the tip but the copa to me cup out of the vagina. And I always worry about dislodging the copa to me cup during your surgery. What this allows us to do what you saw here is I keep the cup pushed in all the way. All I'm doing is unlike and bringing the shaft back and popping it through the opening that we make as we're doing the super cervical so that I can actually then anti flex, lift up that cervix, finish the amputation and then go back into the copa to me and you can play the copa to me peace now if you want. But I found that that is extremely important because now look, it's it's it's just so much easier to see where the copa to me cup is because I don't have this huge bulky 18 week uterus sitting in my face. We can get it done and it's a lot safer to do. It takes a few extra minutes to do the staged a pottery piece. But that is the one thing I find extremely helpful stability for the coke up to stay in place and for me to slide this while the coke cup is just up into the for next right. And some other tips and tricks, you know, when you pull you deflate the balloon as you're pulling it through. And then when you push your and you've actually now amputated off the cervix, you can blow up the balloon again. Because if you blow up the balloon, you sandwich that cervix in and once you do your call pa to me, it comes out with the actual device and if you don't have it inflated. Like I don't at this point, it's good to inflate the balloon. Once you release the cervix so that you don't like leave it in the abdomen by accident. So when you're pulling it back out, you're going to see here, we're going to inflate the balloon here and it just drags the cervix with you. So Let's jump gears because I think we have about 10-15 minutes left here, which we wanted to reserve for uterine positioning system and so we can stop the video and just for the sake of like what we're going to show you here, ignore the box trainer. It's here to demonstrate some additional things with the uterine positioning system. And we want to talk about sort of the steps and how we do things, right? So for those of you are not familiar with the ally union positioning system, it is a great tool. We utilize it all the time. Not just for hysterectomy, but for a lot of the procedures. We do myomectomy at next stage four. Endo you have to work on a poster, obliterated cold a sack. It's nice to park the uterus up and do all of your work. Right? So the first thing we have to do is you have a patient that gets placed on the bed putting her to sleep. You're gonna put some brackets on. So you're gonna start with your usual bracket. So we'll have brackets loaded here, right? So usually you put brackets on the bed and then your patient gets put to sleep, we're gonna, once they're off to sleep, you're gonna grab a stirrup and we're only gonna put on one stirrup on this. So put that on. An important thing to keep in mind is where we place the stirrup, right? We want this at the edge of the bed rail, right? So the stirrups on and basically, once the stirrups on and we do it on both sides, we're gonna essentially, legs go up in the sodomy and then we're going to take the bottom of the bed off, right? And again, ignore the box trainer. They're gonna some simulator for this demonstration, but I'm gonna go ahead and take this off the bed, right? And now you have this ready to go. And so what we're gonna do is we're gonna lift this up a little bit with the legs so we can place this and it's going to use the cart, right? Yeah. Don't lift it all. It can be heavy if you're pulling from a distance, but basically there's a blue handle here with little finger grips, kind of like rock climbing. Similarly, a blue part here, and that's just to demonstrate how to lift it straight up. It's going to take the card out of the way the foot pedal attached to it, so you're going to take that off and is also an electrical plug. Now it's pre plugged for us in this case, and what you do is you have to have enough space and I want to move out of the way, just to demonstrate first to have enough space between the two brackets so that you can actually fit this in. If you happen to have it too close, you won't be able to fit it with this actual wedge as well and then slide it forward and slide it so they're all kissing and then you lock it in place so it doesn't wiggle, you'll turn on the switch, which activates the arm so that then have to step on the pedal and I can bring the arm up and for the sake of visualization, I'm just going to bring this up so you can see the ally. So this is the ally hooked up and so it's up and then we're gonna talk a little bit about the draping system that exists for this because it's very specific to the manipulator that we're going to use. But you can see here that this is how you position it and then now you can go about your business prep the patient, dear exam whatever this is manipulators much time. It's very quick. But one of the things that we've learned and I have to give a lot of credit to our scrub tech rents is one of our scrub techs at our hospital and he just one day I walked in the door and he figured out that you can do some efficient things with the setup, so we're gonna, we're gonna rewind. Okay, so right before we take it off, let's show you like, if you're disassembling this right, you're done with your case when the most important things you want to do to store this properly is you want to step on the pedal and let this fall to the ground so that it's basically all loose. The goose neck is flaccid and then you want to turn it off right, because that lets it stay loose, right? If you just turn it off without stepping on the pedal, it's gonna freeze in whatever location you had it and then we're going to undo the, so I'm just going to undo the bracket per usual, you have the cart ready to go to turn the cart right here and I'm gonna lift it out, that's okay. And then I'm going to place it in the corps is here in the front, so I'm just gonna place it in the front right here, it falls right in the grooves and the sides right there and you're ready to go this, then stores underneath and the courts go underneath and you're good to go. But we learned something about an efficiency that exists that really makes a lot of sense to us. And so they put it all back together. So the just for the sake of time, I'm going to leave this on. But normally when you walk into the O. R. Room, you know, the bed is just there and maybe not gonna start ups, etcetera. So you, all you need is one side, the leg will be down one side preloaded. You have your space here. Now I'm gonna put the uterine manipulator back on, so I'm gonna grab it up again two hands using the blue and I'm just going to basically slide this piece and as I would kiss it, it's under the bed and I'm gonna lock it in place, it's already there. So we go into the operating room all the time now and on one side of the bed which is your patient is going to come in on this side on the left hand side and they're going to get on the table. We already have the ups set up because it's not in the way. And we've got the you got the stirrup on the bed, one strip on the bed. So this is a huge efficiency because then the only thing I need to do is put the second stirrup on, take the bottom off. And we're good to go. Now this setup only works. The caveat is it only works if you have a bed that comes apart. Some old beds don't come apart and you have to literally lower the entire foot in order to put the ups on and then you have to make sure the ups comes off before you start doing anything with the bottom of the bed or you're gonna break your positioning system. But this to me is like a great way to have some efficiencies here, right? So we're gonna go ahead and I'm going to take this bottom off now that we haven't hooked up and we want to show you kind of a little bit live and just because I want you guys to see a little bit better, I'm going to take the stirrup off just so that you have a better visualization. So I'm gonna actually gonna take this off. I'm gonna sit down. Okay, great. So I can show like some key elements with things like draping. And so this is a dilemma and it's important to know that you have, there's adapter drape because this is obviously not sterile, right? So you can clean it, but it's not something you need to move throughout the case. So we have a drape that's already kind of pre opened. But basically this is a clip and this drape goes across this whole thing. So the important thing to see here is we have two fresh ones but you need a specific adapter for the delineate er only works with the correct and sometimes in my own are even if we use this thing all the time, people just routine B will grab the white one because we use this a lot because we do a lot of reproductive surgery. So we use this a lot. So white is for arch and roomy to handle. Right? And you see the markers on here, it'll tell you which way to orient this whether you're, you know, if you're if you're going to use an arch, it's going to be facing this way where the our channels here, if it's going to be a roomy, you're gonna rotate it so the room is towards you, right? The roomy handle drawing. So I'm gonna have to delineate already in the dinosaur model. And so it's pretty straightforward in terms of just looking at how this goes into place. Now if we have a we without the drapes will do it with the drapes. One of the things that you're doing this, it just came in was a question if you could troubleshoot as you're doing this manipulator placement, right? If anyone's having a challenge with that. And the second thing is if you could show balloon inflation in a post ablation uterus, yeah, we can definitely do that. So um so you can definitely troubleshoot because you're going to troubleshoot everything you need to do with placing a manipulator before you attach it. This is the last thing you do, you've done this. So we're pretending now it's like a cooking show. Now we've baked the cake and we're gonna we're adding the ice, this is the icing, right? So so we're gonna we're gonna take this and we're gonna, I'm gonna put this on, right? And so this is your sterile, you're gonna add this. So you're going to place this two little handles on here. So you just pull this down and you've got it covered, right? So now this whole thing is sterile and then you can actually touch this and not contaminate anything. And all these have unique ways of being attached to the adapter. Great. Right? So this again specific only to delineate er we can place this here and once it's on we clip it and now it's holding my manipulator handle. The most important thing is never step on the pedal. If you're not holding your manipulator because this is a fairly heavy arm, it's just gonna fall right. So you definitely want to be able to like if you're gonna do something then you're gonna you're gonna step on this and you're gonna manipulate right? And let's go to the inside view real quick just so we can show you what that looks like. This is the view of a model, which is fantastic in that. It has all the key elements of a G. Y. N. Surgery and you can tell that when I step on the pedal here, I'm gonna bring this out of the way here so you can see this, I can push in and I can angle it so that I'm going I'm tilting this to the to the patient's right so that I can see the left, right and I just let go and I can start to do my hysterectomy which is so nice because say if I'm coming in and I'm doing myomectomy or endo surgery and to flex it and you're just like this so myomectomy, whatever it's parked. And what's nice is that? You've you've put something here with the physical need. You physically need something to hold the uterus up. You don't have to put a resident or a P. A. Or any sort of surgical assist. Which gosh, we love them. They do so much for us but you can bring them up top and they can actually put their hands on. And if you're doing a sacred cotopaxi, nobody really wants the job of holding. It's a long time the tip, right? Yeah. But you can just park it with this and you're set for the whole surgery, right? And you can set it where you want it. The key for this though too is when you do this again is a lot of times it's not just a one handed operation. You you will do two hands to play around a little bit with the goose neck. So you can get the angles that you need so that you can you can get the positioning that you want right. So I'll use two hands when I do that. I think that's critically important. But this works with really any um any of the of the of the handles again, it's just specific. So blue goes to delineate and if you grab the other one, the white one itself, I have it right here and that goes with the piece, it's partially connected right here. I didn't finish clicking it so you can show them that so you know the same kind of concept, right? So there's a little groove in the back and it just takes a little bit of practice. You know, I will say the first couple of times I use this, it was a little hard to figure it out because it's not something new. But once I got it there's a little groove where you click it and this whole thing just then we'll snap and it's pretty simple. I will admit this is probably the one that requires the most finesse but once you get it down, you know, you're good and you know, I know we didn't spend any time with the physical model. This a little bit of a segue for us. Obviously there's a lot to teach off of this for finer points and nuances for th that's going to be the next installment of the webinar series. We are going to spend the entire time of the webinar with the simulator with the model going through some of the kind of nuanced things that we've learned along the way that are important for a really good outcome with your T. L. H. S. Um but you can see that this is kind of the setup here. Yeah. So there was a question actually just came in. Uh that was interesting in a surgeon said that he has a colleague that works in a community hospital where they have ally, he's in an academic center. And the administration says they don't really need the help because they have so many helpers there. What would you say to them from an educational perspective and an academic center for getting allies. It useful there. And I think that the I mean it speaks volumes. I kind of hinted at it a little bit before, but there's a physical need for uterine manipulation. You have to have something or someone doing that job. And if you can make it a thing instead of a person, that person that trainee that staff that other, they are free to do other things. Whether if it's staying involved in the O. R. Case itself for doing other clinical responsibilities, you have now freed up an entire persona to be able to engage in surgical education. Say you're on a dual console. You have now something pa you can actually physically teach your trainee and you don't even have to step away. I mean I call it gives you some educational freedom. We have a dual console in one of our cars robotically and what it does, let's say you're doing a robotic myomectomy. Well, you know, we're doing a you know, difficult post era lo poster fibroid, we put this manipulator in, you know, put in the arch with the tip, the tip in an arch and attach it to the ally. We can deflect that uterus and it just parks and then I consider the console my resident or fellow sits at the heart of the case and let them do otherwise. Somebody's got to be down there holding it. It's the same thing like with lexi or any procedure like you know, you can free up that individual to now be a more active in the surgery. And I just find it's also safer like when you're doing certain parts of an operation where you're suturing you really want the target organ to be steady. Yeah. So yeah, I mean you don't need to have all these extra bodies but I also think it's probably the wrong way that we have always check the nose this like as an educator, I feel like we do things backwards. Sometimes in academia we train people too much to to live in an environment where there's too much help and then there's a culture shock when you get out in the clinical practice and you realize oh my God I don't have all these extra hands that I used to have. It's just me and the scrub tech or me and the scrub tech in the circulating nurse. Well I love autonomy and surgery. I like to be able to do most of my procedures with the least amount of hands on the field. I just think it eliminates some variability, which I think is important. But we can do, we do a lot of like robotic myomectomy and once you set yourself up, you'll need a lot of assistance, right? Maybe somebody up top suctioning periodically. Human error. Right? If you start getting tired from holding a really heavy uterus and There starts to be a little bit of a decline and you don't realize it because it's a slow loss. You're getting closer and closer to your urine in your bladder. I don't think anybody who's the person down below all the time will appreciate not wanting to be there for like a 2-3 hour surgery, right? Like that's probably the least favorite place anybody wants to be. So that's really the value. I think the more operation to do in the greater variety than you see a value. It's not just a hysterectomy device, it's a device we use for a lot of different different procedures. Also an ally. And I think I want to make sure I understand this question. Uh, if you're using the ally with the cephalopod pressure you get from the ally and you are in a a bladed uterus, does that pressure allow you to to not inflate the balloon if it's a challenge basically. Because if I'm understanding correctly, the allies holding it in place. So yeah. So you've obviously just like we had mentioned before, you have to hold static pressure, right? You can't blow up the balloon. Otherwise it could slip out and then you'll have to find your cup repeatedly throughout, It's even better to be frankly honest with you because if you have an ally hooked up, you know, for sure it's going to be out the whole, you don't have an assistant that's going to fall asleep and like accidentally start to like draw it backwards and then you're gonna it's gonna not be in the uterus anymore. Like you're you're always going to be able to have like that tip is always going to be where it needed to be pushed up even if the balloon was not inflated. So yeah, that's an advantage If we're reading your question or hearing it correctly um is a is a key thing to keep in mind. I had a question come in about a lie. Oh my Oma. Which delineate er which manipulator would you use for that? And why? Well again, I don't we don't use if you're doing conservative surgery and you're saying why am I in for myomectomy? Myomectomy. I'm assuming it's because we're doing myomectomy surgery, we typically use the me to handle the coefficient because you save on cost and unnecessary. Use the delineated itself is not necessary. So again, the linear really just for me, but if I'm doing a myomectomy case and let's say this is a sounds big uterus sounds to 10 centimeters. This is what we're going to have. This is what's going to be attached to the to the ally and it's what we choose to use. I mean, I tend to use the our channel all the time because I just I don't need a lot of manipulation at the level of service. I just need this thing needed to be pushed in and the flexor tilted off to the side to do my surgery and this part is reusable, right? So you can put it in your trays for things that you decide, and then you just get peel packs for each of the tips or the coefficient. That's what we do, what I prefer in terms of which manipulator you use and why? For cervical y? Oh my Oh my Oh, well, that's a good question. Actually, actually didn't even think about addressing, like when you have, I think that it's a layered one. That's a great, it's a great question. I mean, it's challenging regardless to say these are meant to fit a cervix, right? So it doesn't fit on a server. I mean, you're not going to get a core pottery cup on a cervical, my oma cervix, right? If you if you have a large fibroid in the cervix, you're not going to get a cup in there. Now, what you can do is, and what I typically will do, and I don't know what she has been doing since she's now in a full fledged attending, doing these cases on her own. But I will at times just placed, I'll just use a roomy tip, right? Uh and manipulator, just so I can get manipulation. And let's say we're doing a hysterectomy. I'm assuming this is a question about your hysterectomy. It's kind of big cervical fibroid. I'm gonna do this so I can place and get that uterus up and into the abdomen and then you're gonna do a myomectomy. You know a lot of times you're gonna have to do a cervical myomectomy first to like get that cervix to become normalized shape. And then you can go back down and you can place a coefficient or delineate or whatever you want to use to be able to do your surgery. So a lot of cases where you have large fibroids down below and you really can't place um you're a manipulator with the Koopa to me, cup the way you want it to be done. That's where you have to really understand the anatomy of your patient and individualize it. And to be honest like these are tools to help you use whatever skill set you have and grow your skill set. And you should always be starting especially if you're not familiar with you devices or any devices for that matter. You start with an easier case and you build up your skills with progressive pathology and using these devices at the same time, I wouldn't just jump in and do a service. You're using like the positioning system. You're going to start with not so difficult a case to understand how to use it to your advantage. But yeah, I think cervical fibroid cases are difficult cases. There's no doubt about that. And sometimes just the manipulation of the uterus itself culpa to me aside with the cup is just enough to at least give you the visualization. You need to safely laterally take your uterine arteries so it's enough to give you that extra arm. It's also important to know that sometimes you can't even get the manipulator and so sometimes you may have a cervical myeloma case where it's going to be a struggle. Even placing the roomy tip. Forget about the cup just getting a roomy to go through the cervix into the cavity so you can manipulate it again. Those are cases where and again we approach these robotically. We'll do a cervical myomectomy first and then you can get the anatomy normalized. It's all about like normalization of anatomy so that you can get the surgery done. It's the basic principles really absurd. Known to unknown right? Take that known cervical myeloma out and now you've got a known and it becomes an easier case. So for sure. So I am getting notes that we are at the end of our time. Yes. Whenever I work with both of you. The time was very fast. We're getting lots of complimentary notes of the content was very compelling. I want to thank you both. Dr Advincula and dr aurora for a very interesting presentation. It's appreciated. Well, thank you for having us again and we look forward to the next installment where we can actually spend more time in the simulator. Cover a lot of things about the actual th case itself. Good. Good. Let us know if you would like a follow up demonstration from your cooper surgical sales representative. So thank you. Thank everyone for joining us this evening. We look forward to seeing you and your colleagues at the second in the mastering MIG series and that is mastering migs to surgical simulation to increase proficiency in hysterectomy and reproductive surgery. And that will be on october 28th. So again, thank you for joining us. Thank you DR and DR Arora. Thank you so much. Thanks everybody for patching in.
Arnold P. Advincula, MD, FACOG, FACS
Chetna Arora, MD, FACOG