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10 practical, evidence-based suggestions to improve your minimally invasive surgical skills now

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Consult urology to place a ureteral stent for 6 weeks to ensure complete healing of the potential injury.

8. Vaginal cuff dehiscence

Recognize that vaginal bleeding and sudden watery discharge are the most common presenting symptoms of vaginal cuff dehiscence after hysterectomy.

Kho RM, Akl MN, Cornella JL, Magtibay PM, Wechter ME, Magrina JF. Incidence and characteristics of patients with vaginal cuff dehiscence after robotic procedures. Obstet Gynecol. 2009;114(2 pt 1):231–235.

With a mean time to presentation postoperatively of approximately 6 weeks, vaginal cuff dehiscence occurs at a higher rate after laparoscopic and robotic hysterectomy (with the latter, reported to be as high as 4.1%) than it does after abdominal or vaginal hysterectomy, and is often triggered by coitus. Your efforts to reduce the risk of this complication should include 1) limited use of thermal energy when performing colpotomy and 2) paying attention to placing sutures into healthy vaginal tissue.


Place patients directly on egg-crate foam for robotic surgery. Doing so results in minimal movement on the table, even in the maximal Trendelenburg position.

Klauschie J, Wechter ME, Jacob K, et al. Use of anti-skid material and patient positioning to prevent patient shifting during robotic-assisted gynecologic procedures. J Minim Invasive Gynecol. 2010;17(4):504–507.

This tactic is economical and isn’t associated with any risk of brachial plexus injury—a complication that can occur with incorrect use of the shoulder blocks that are commonly used to prevent slipping.

Position robotic ports at least 10 cm apart to avoid interference by the robotic arm. You need a distance of at least 15 cm from the symphysis to the umbilicus to have adequate room between camera and pelvis.

Matthews CA, Schubert CM, Woodward AP, Gill EJ. Variance in abdominal wall anatomy and port placement in women undergoing robotic gynecologic surgery. J Minim Invasive Gynecol. 2010;17(5):583–586.

Because African-American women often have shorter lower-abdominal dimensions than white women, they sometimes require port placement above the umbilicus. Interference by the robotic arm will frustrate many novice robotic surgeons; this easy technique prevents these problem situations in most cases.

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