Minimally invasive gynecological surgery (MIGS) has transformed the landscape of women's healthcare over the past three decades. Procedures that once required large abdominal incisions and lengthy recoveries are now routinely performed through small ports or even natural orifices, resulting in less pain, shorter hospital stays, and faster return to normal activities. At the heart of this transformation lies not only surgical skill but also the instruments and technologies that make these approaches feasible, safe, and teachable.
Dr. Rosanne Marie Kho has been at the forefront of this evolution. Currently Professor and Chair of the Department of Obstetrics and Gynecology at the University of Arizona College of Medicine – Phoenix and Banner University Medical Center Phoenix, Dr. Kho has built a career dedicated to advancing pelvic surgery through innovation, education, and the thoughtful adoption of new technologies. Her work has focused particularly on preserving and revitalizing the vaginal approach to hysterectomy, which she views as a "21st Century approach" when augmented by tools and techniques borrowed from laparoscopy and robotics.
This article explores the instruments and technologies that Dr. Kho has championed in her practice, from self-retaining retractors and advanced energy devices to table-mounted camera systems. These tools are not merely adjuncts to surgery; they are enablers of a philosophy that prioritizes patient outcomes, surgical education, and the preservation of time-honored techniques that remain highly effective when properly supported.
Vaginal hysterectomy has long been recognized as the least invasive route for removing the uterus when feasible. It avoids abdominal incisions entirely, offers excellent outcomes, and is associated with fewer complications than abdominal approaches. Yet its use has declined significantly over the past two decades, replaced by laparoscopic and robotic procedures that offer superior visualization and easier teaching.
The reasons for this decline are instructive. As Dr. Kho has explained, vaginal hysterectomy is both difficult to teach and difficult to learn. "With laparoscopy or robotics, you use a camera to project a magnified view of the procedure on a screen and everyone can watch. Until recently, you couldn't do that with the vaginal approach – the operating field was visible only to the surgeon through a tiny opening," she noted. Additionally, throughout vaginal surgery, two assistants were traditionally occupied holding retracting tools that open the labia and expose the vagina, making it difficult for them to observe and learn the procedure.
These challenges are not merely educational; they affect patient care. A greater majority of hysterectomies are still performed abdominally, despite evidence supporting vaginal and minimally invasive approaches when feasible. To address this gap, Dr. Kho and her colleagues have modified techniques and adopted instruments that bring the advantages of laparoscopy and robotics to the vaginal surgical field.
One of the most transformative technologies Dr. Kho has adopted is a table-mounted camera system called the Vitom, manufactured by Karl Storz. This system utilizes a 90-degree camera that projects the vaginal surgical field onto an external monitor, allowing everyone in the operating room to see what the surgeon sees.
The implications of this seemingly simple innovation are profound. "With the Vitom, whatever I'm seeing is transmitted simultaneously to a screen, which is not only helpful as a teaching tool, but also makes the procedure much safer because all of the participants – the anesthesiologist, scrub nurses, circulators, and assistants – are able to visualize what's happening and can participate in the case," Dr. Kho explained.
For surgical education, this technology bridges a critical gap. Residents and fellows can now observe vaginal surgery in real time, understanding the anatomy, the steps of the procedure, and the decision-making processes that were previously hidden within the confines of the vaginal canal. For patient safety, the shared visualization allows the entire operative team to anticipate needs, respond to changes, and maintain situational awareness throughout the case.
The Vitom represents a broader principle in Dr. Kho's approach: instruments should not only facilitate the surgeon's work but also enhance the collective capability of the surgical team. By democratizing visualization, these tools transform vaginal surgery from a solo performance into a collaborative endeavor.
Another key innovation in Dr. Kho's instrumentarium is the self-retaining retractor system—a frame that attaches to the operating room table and provides consistent, reliable exposure to the vagina without requiring two surgical assistants at the bedside.
Traditional vaginal surgery often demands that assistants hold retractors for extended periods, a task that is physically demanding and prone to fatigue. As the case progresses, retraction may become less consistent, potentially compromising visualization and safety. The self-retaining system eliminates this variability, maintaining steady exposure throughout the procedure.
The benefits extend beyond the operating room table. "The assistants are not fatigued and can focus on how to learn the procedure," Dr. Kho noted. Instead of serving as human retractor holders, they can observe, ask questions, and develop the cognitive and technical skills necessary for independent practice. This shift from passive holding to active learning represents a fundamental improvement in surgical training.
Self-retaining retractors also enhance efficiency. With consistent exposure, the surgeon can work more deliberately and with greater confidence, potentially reducing operative time and the risk of inadvertent injury to surrounding structures. For complex cases involving large uteri or adhesions, this reliable exposure can make the difference between a successful vaginal approach and conversion to laparotomy.
Vaginal surgery often requires the surgeon to clamp, cut, and tie blood vessels in a confined space with limited visibility. For large uteri or cases with extensive vascular pedicles, traditional suturing techniques can be challenging. Dr. Kho has adopted advanced bipolar handheld energy devices that allow surgeons to seal hard-to-reach blood vessels efficiently and securely.
"When we're operating on a large uterus, it's hard to clamp, cut, and tie the blood vessels with your fingers and short instruments. So we are using the new technology to facilitate the procedure," she explained. Advanced bipolar devices deliver focused electrical energy that simultaneously seals and cuts tissue, creating a reliable hemostatic seal without the need for sutures.
These devices are particularly valuable in vaginal surgery because they extend the surgeon's reach and precision beyond what traditional instruments allow. They enable the management of larger uteri vaginally, expanding the population of patients who can benefit from this least invasive approach. The technology also reduces blood loss and operative time, contributing to better patient outcomes and faster recovery.
Tissue extraction is a critical consideration in minimally invasive gynecological surgery, particularly when the uterus or fibroids are too large to remove intact through the vagina or small laparoscopic incisions. Power morcellation, which uses a rotating blade to fragment tissue, has been the subject of FDA warnings due to concerns about the inadvertent dissemination of malignant cells.
Dr. Kho has focused her research efforts on manual morcellation and tissue containment strategies. "We don't use power morcellation during vaginal surgery, but the same concerns apply to manual morcellation – the surgeon could inadvertently cut up tissue containing malignant cells and spread them through the abdomen," she noted. Her work involves developing ways to contain the specimen before morcellation and creating algorithms to assess a patient's risk factors for cancer before surgery.
This research reflects a broader commitment to safety in minimally invasive surgery. Instruments for tissue extraction must balance efficiency with containment, ensuring that the benefits of small incisions do not come at the cost of oncological safety. Dr. Kho's approach—using containment bags and preoperative risk stratification—represents a thoughtful integration of technology and clinical judgment.
For Dr. Kho, instruments are not only tools for surgery but also vehicles for education. Her academic career has been dedicated to "the adoption of surgical innovation to facilitate the performance and teaching of vaginal hysterectomy". This dual focus is evident in every technology she champions.
The Vitom camera system, the self-retaining retractor, and advanced energy devices all share a common feature: they make vaginal surgery more teachable. By providing visualization, stable exposure, and simplified hemostasis, they lower the barriers to learning this challenging approach. Residents and fellows can progress from observation to assisted performance to independent practice with greater confidence and safety.
Dr. Kho's educational reach extends beyond her own operating room. She has served as a senior editor for the Journal of Minimally Invasive Gynecologic Surgery (JMIGS) and as Director of the AAGL Practice Guidelines Committee. She currently serves as President of the Society of Gynecologic Surgeons (SGS). Through these roles, she has influenced how minimally invasive gynecological surgery is taught, practiced, and evaluated across the specialty.
Her contributions to educational forums are extensive. At the 26th Annual SGS Post Graduate Course in Advanced Gynecologic Surgery, she served as a moderator and speaker, leading sessions on vaginal surgery and surgical skills development. These courses typically include hands-on laboratories for vaginal hysterectomy and sling procedures, tissue extraction stations for power and manual morcellation techniques, and robotic simulation. Through such venues, Dr. Kho ensures that the next generation of surgeons has access to the instruments, techniques, and mentorship needed to excel.
Dr. Kho's instrument choices are grounded in research and evidence. Her publication record includes studies on robotic hysterectomy technique and outcomes, comparisons of robotic and laparoscopic myomectomy, and systematic reviews on topics such as transvaginal ultrasound for adenomyosis diagnosis. She has also contributed to randomized controlled trials evaluating surgical positioning and instruments, including a study comparing candy cane and boot stirrups in vaginal surgery.
This research orientation ensures that instruments are adopted based on demonstrated benefits rather than novelty alone. When Dr. Kho advocates for a technology—whether the Vitom camera, self-retaining retractors, or advanced bipolar devices—it is because evidence and experience support its value in improving surgical outcomes and education.
Instruments alone do not define minimally invasive surgery. Dr. Kho's career demonstrates that the true measure of minimally invasive approaches lies in their integration into a coherent surgical philosophy—one that prioritizes patient safety, respects anatomy, and values education.
The instruments described in this article are not ends in themselves but means to an end: the delivery of effective, safe, and teachable surgical care. The Vitom camera makes teaching possible; the self-retaining retractor frees hands for learning; the advanced bipolar device extends the reach of vaginal surgery; and containment strategies for morcellation ensure safety. Together, they enable a practice that honors both innovation and tradition.
Dr. Kho's specialization in complex benign gynecologic conditions—including chronic pelvic pain, endometriosis, abnormal uterine bleeding, and fibroids—reflects this philosophy. These conditions often require nuanced surgical judgment and the ability to adapt instruments and techniques to the individual patient. The toolbox she has assembled provides the flexibility needed to address diverse clinical scenarios while maintaining a commitment to the least invasive approach possible.
Dr. Rosanne Kho's contributions to minimally invasive gynecological surgery extend far beyond the instruments she uses. Through her clinical practice, research, teaching, and leadership, she has advanced a vision of surgery that is technically excellent, educationally accessible, and patient-centered.
The instruments she has championed—table-mounted cameras, self-retaining retractors, advanced energy devices, and containment systems for morcellation—are tangible expressions of this vision. They represent the marriage of technology and technique, enabling surgeons to perform procedures that were once difficult or impossible to teach and learn.
As Chair of Obstetrics and Gynecology at the University of Arizona College of Medicine – Phoenix and President of the Society of Gynecologic Surgeons, Dr. Kho continues to shape the field. Her work ensures that the instruments of minimally invasive surgery are not merely tools of convenience but instruments of education, safety, and patient benefit. For the countless women who benefit from these approaches, and for the surgeons who learn from her example, her legacy is one of thoughtful innovation in service of better care.
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