18 The Female Patient | VOL 35 SEPTEMBER 2010 All articles are available online at www.femalepatient.com.

FEATURE

The uterine manipulator is an essential tool for the gynecologic surgeon performing laparoscopic hysterectomy. Descriptions of many available manipulators are presented here, with a discussion of their use.

T he scope of laparoscopic surgery has dramatically expanded over the past 2 decades, secondary to reduced postoperative pain, shorter hospital stay, earlier re-covery, and improved quality of life follow-ing laparoscopic surgery compared with lap-arotomy. The proportion of hysterectomies performed laparoscopically in the United States has increased from 0.3% in 1990 to 11.8% in 2003.1,2 An integral part of laparo-scopic hysterectomy is the placement of a uterine manipulator.

Gamal H. Eltabbakh, MD

Gamal H. Eltabbakh, MD, is President, Lake Champlain Gynecologic Oncology, South Burlington, VT.

Uterine Manipulation in Laparoscopic Hysterectomy

ELTABBAKH

Follow The Female Patient on and The Female Patient | VOL 35 SEPTEMBER 2010 19

FUNCTIONA uterine manipulator performs the follow-ing functions: Raises the uterus and brings it closer to the

laparoscopic surgical instruments, facili-tating the procedure

Manipulates the uterus, thus stretching the side being operated upon

Increases the distance between the uterus and the bladder, the ureters, and the rectum, thus reducing the chance of injury

Could be used to pull the uterus vaginally after its complete detachment

Facilitates identification of the utero-vesical peritoneum, the cul-de-sac, and the vaginal cuff just below the cervical attachment

Maintains the pneumoperitoneum fol-lowing colpotomy.

CHARACTERISTICS Despite their obvious advantages, there are no published reports on whether the use of uterine manipulators reduce operative mor-bidity or decrease operative time. An ideal uterine manipulator will have the following characteristics: Easy to assemble Inexpensive Does not fragment or break down into

pieces during the procedure Has a wide range of movement and mobi-

lizes the uterus in different directions (anteversion, retroversion, and lateral movement)

Is easily placed inside the uterus and will stay in place all through the procedure

The point of articulation is at the external os of the cervix and not at the perineum, thus making movement of the uterus and cervix easier and independent of the pa-tients weight and resistance encountered at the perineum.Some uterine manipulators come in dif-

ferent lengths to adapt to uteri of different sizes. Some have a cannula intended to per-form such functions as chromotubation to test tubal patency. Such a cannula is not a necessary part of the uterine manipulators used for hysterectomy. Some manipulators are reusable (eg, the Hulka clip, the Cohen cannula, and the Pelosi); some are dispos-able (eg, VCare, the Endopath, and ZUMI Zinnanti); and some are partially dispos-

able and partially reusable (eg, the RUMI), such that the tips are disposable but the handle is reusable.

AVAILABILITY There are many uterine manipulators avail-able, and they vary from one country to another and from one hospital to another. The most commonly used manipulators in-clude a sponge stick, the Hulka clamp, the Cohen cannula (Aesculap), the Pelosi (Apple Medical Corporation), the Zinnanti (Hayden Medical Inc), the RUMI System (CooperSurgical), the ZUMI (HNM Medi-cal), UMI (U.A. Medical Products), the VCare (ConMed Endosurgery), the Endo-path (Ethicon Endo-Surgery), the Clear-View (Clinical Innovations), Valtchev (Conkin Surgical Instruments), and EZ Glide (B & H Surgical). The RUMI manipu-lator is often used with the KOH colpoto-mizer ring if total laparoscopic hysterecto-my is to be performed. Some physicians use cervical dilators as uterine manipulators.

New uterine manipulators are being de-veloped by several investigators worldwide. Ramirez and colleagues developed a modi-fied uterine manipulator that allows re-moval of an adequate (2-cm) margin of the upper vagina while maintaining adequate pneumoperitoneum among women under-going laparoscopic radical hysterectomy.3

In the United States, the 2 most com-monly used uterine manipulators for the da Vinci robotic total laparoscopic hyster-ectomy have been the RUMI manipulator with the KOH colpotomizer ring (Figure 1) and the VCare manipulator (Figure 2). Each of these manipulators comes in 3 dif-ferent sizes. Changes in the forward cup polymers allow the VCare to be used with both electrosurgical and harmonic energy sources.

PROCEDUREThe uterine manipulator is placed after an-esthesia is administered. A prophylactic an-tibiotic is given, and the patient is prepped and draped in the usual fashion. A Foley catheter is then inserted and bimanual ex-amination performed to assess the size and position of the uterus. A Pederson or vaginal speculum opened on the side or 1 or 2 Sims vaginal retractors are placed, and the cervix is visualized.

FOCUSPOINTThere are

many uterine manipulators

available, and they vary from one country to

another and from one

hospital to another.

20 The Female Patient | VOL 35 SEPTEMBER 2010 All articles are available online at www.femalepatient.com.

Uterine Manipulation in Laparoscopic Hysterectomy

The cervix of a retroverted uterus, espe-cially one fixed by dense adhesions to the cul-de-sac, is often difficult to visualize. No attempt at insertion of the uterine manipu-lator should be made unless the cervix is clearly visualized and brought into the cen-ter of the vaginal speculum.

The anterior lip of the cervix is then grasped with a single-tooth tenaculum and the uterus sounded carefully to determine the length and the direction of the uterine cavity. Among women with cervical steno-sis, lachrymal duct dilators or small Pratt dilators might be needed before sounding. If severe cervical stenosis is suspected pre-operatively, an overnight insertion of a vagi-nal prostaglandin suppository might help soften the cervix and facilitate insertion of the uterine manipulator.

Depending on the type of the manipu-lator used, the manipulator might be hooked to the tenaculum (eg, the Pelosi) or the tenaculum removed before inser-

tion of the manipulator (eg, the VCare or the RUMI). Some manipulators are semi-disposable, and the tip to be used will de-pend on the length of the uterine cavity (eg, the RUMI). Some manipulators will need to be assembled immediately before insertion into the uterine cavity, and some disposable manipulators come assembled in different sizes. When using the RUMI or the VCare, a number 0 Prolene stitch is often placed in the anterior lip of the cer-vix, passed through the cervical cap, and tied in order to maintain the cervical cap against the cervix and identify the vaginal fornices just below the cervix.

Some manipulators have intrauterine balloons that will need to be inflated at this time. Some manipulators have a vagi-nal occluder which may be in the form of a balloon (eg, the RUMI) or a lockable sliding distal cup (eg, the VCare). After placement of the uterine manipulator, the surgeons gowns and gloves are changed and the laparoscopic procedure is started.

COMPLICATIONSComplications attributable to the use of uterine manipulators include cervical lac-erations, uterine perforation, laceration of uterine vessels, retroperitoneal or intraperi-toneal bleeding, perforation of the bowel, rectum or bladder, ascending infection, interruption of unsuspected intrauterine pregnancy, and retention of part of the ma-nipulator as a foreign body.

Complications are more likely to happen among postmenopausal women with a ste-notic cervix and women with retroverted or soft uteri. The use of uterine manipu-lators is contraindicated among women who have pyometra or distorted or altered anatomy (eg, vaginal septum) precluding visualization of the cervix, if intrauterine

FIGURE 2. The VCare uterine manipulator.

FOCUSPOINTThe uterine manipulator is placed after anesthesia is administered. A prophylactic antibiotic is given, and the patient is prepped and draped in the usual fashion.

FIGURE 1. The RUMI uterine manipulator and the KOH colpotomizer.Images courtesy of CooperSurgical, Inc.

ELTABBAKH

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pregnancy is suspected, or if the uterus is absent.

Concern has been raised that the use of uterine manipulators during laparoscopic hysterectomy for endometrial cancer might result in pushing cancer cells into the peritoneal cavity, resulting in positive peritoneal cytology and upstaging the can-cer. In a retrospective review comparing surgical stages among women with endo-metrial cancer who were treated with ei-ther laparoscopic hysterectomy or through laparotomy, Sonoda and colleagues found a higher incidence of 1988 International Federation of Gynecology and Obstetrics (FIGO) stage IIIA (positive peritoneal cytol-ogy) among women who had laparoscopic surgery.4 However, in a prospective study among 42 women with endometrial cancer treated with laparoscopic hysterectomy performed with the help of the Pelosi uter-ine manipulator, Eltabbakh and Mount found no difference in the incidence of ma-lignant cells in the peritoneal washings performed before and after the placement of the uterine manipulators.5

Additionally, the Gynecologic Oncology Group study that randomized 2,616 pa-tients with endometrial cancer into sur-gery by laparotomy or laparoscopy (using different types of uterine manipulators) found a relatively higher positive perito-neal cytology among women who had lap-arotomy compared to laparoscopy (11.3% vs 6.1%, respectively, P=.052).6 The signifi-cance of positive peritoneal cytology

among women with early-stage low-risk endometrial cancer is controversial, and the most recent FIGO staging system for endometrial cancer removed positive peri-toneal cytology as a staging criterion.

CONCLUSIONUterine manipulators facilitate laparo-scopic hysterectomy. The type of manipula-tor used will depend on the type of hysterec-tomy, patients characteristics, available instruments, and surgeons preference.

The author reports no actual or potential conflict of interest in relation to this article.

REFERENCES 1. Wu JM, Wechter ME, Geller EJ, Nguyen TV, Visco AG.

Hysterectomy rates in the United States, 2003. Obstet Gynecol. 2007;110(5):1091-1095.

2. Farquhar CM, Steiner CA. Hysterectomy rates in the United States 1990-1997. Obstet Gynecol. 2002;99(2):229-234.

3. Ramirez PT, Frumovitz M, Dos Reis R, et al. Modified uterine manipulator and vaginal rings for total lapa-roscopic radical hysterectomy. Int J Gynecol Cancer. 2008;18(3):571-575.

4. Sonoda Y, Zerbe M, Smith A, Lin O, Barakat RR, Hoskins WJ. High incidence of positive peritoneal cytology in low-risk endometrial cancer treated by laparoscopically assisted vaginal hysterectomy. Gynecol Oncol. 2001;80(3):378-382.

5. Eltabbakh GH, Mount SL. Laparoscopic surgery does not increase the positive peritoneal cytology among women with endometrial carcinoma. Gynecol Oncol. 2006;100(2):361-364.

6. Walker JL, Piedmonte MR, Spirtos NM, et al. Lapa-roscopy compared with laparotomy for comprehen-sive surgical staging of uterine cancer: Gynecologic Oncology Group Study LAP2. J Clin Oncol. 2009;27(32):5331-5336.

FOCUSPOINTAlthough the

uterine manipulator is

an essential tool for the

surgeon performing

laparoscopic hysterectomy,

there are a number of

attributable complications.

In this issue...

Supported by Teva Womens Health, Inc.

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