-
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
Follow The Female Patient on and The Female Patient | VOL 35
SEPTEMBER 2010 23
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.
Intrauterine Contraception
Bleeding Profiles
The Myths and Factsof