FEATURE

Uterine Manipulation
in Laparoscopic
Hysterectomy

Gamal H. Eltabbakh, MD

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.
18 The Female Patient | VOL 35 SEPTEMBER 2010

he scope of laparoscopic surgery

has dramatically expanded over
the past 2 decades, secondary to
reduced postoperative pain,
shorter hospital stay, earlier recovery, and improved quality of life following laparoscopic surgery compared with laparotomy. 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 laparoscopic hysterectomy is the placement of a
uterine manipulator.
Gamal H. Eltabbakh, MD, is President, Lake Champlain
Gynecologic Oncology, South Burlington, VT.

All articles are available online at www.femalepatient.com.

ELTABBAKH

FUNCTION
A uterine manipulator performs the following functions:
Raises the uterus and brings it closer to the
laparoscopic surgical instruments, facilitating 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 uterovesical peritoneum, the cul-de-sac, and
the vaginal cuff just below the cervical
attachment
Maintains the pneumoperitoneum following colpotomy.

CHARACTERISTICS
Despite their obvious advantages, there are
no published reports on whether the use of
uterine manipulators reduce operative morbidity 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 mobilizes 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 patients weight and resistance encountered
at the perineum.
Some uterine manipulators come in different lengths to adapt to uteri of different
sizes. Some have a cannula intended to perform 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 disposable (eg, VCare, the Endopath, and ZUMI
Zinnanti); and some are partially disposFollow The Female Patient on

and

able and partially reusable (eg, the RUMI),

such that the tips are disposable but the
handle is reusable.

AVAILABILITY
There are many uterine manipulators available, and they vary from one country to
another and from one hospital to another.
The most commonly used manipulators include 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 Medical), UMI (U.A. Medical Products), the
VCare (ConMed Endosurgery), the Endopath (Ethicon Endo-Surgery), the ClearView (Clinical Innovations), Valtchev
(Conkin Surgical Instruments), and EZ
Glide (B & H Surgical). The RUMI manipulator is often used with the KOH colpotomizer ring if total laparoscopic hysterectomy is to be performed. Some physicians use
cervical dilators as uterine manipulators.
New uterine manipulators are being developed by several investigators worldwide.
Ramirez and colleagues developed a modified uterine manipulator that allows removal of an adequate (2-cm) margin of the
upper vagina while maintaining adequate
pneumoperitoneum among women undergoing laparoscopic radical hysterectomy.3
In the United States, the 2 most commonly used uterine manipulators for the
da Vinci robotic total laparoscopic hysterectomy 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 different sizes. Changes in the forward cup
polymers allow the VCare to be used with
both electrosurgical and harmonic energy
sources.

FOCUSPOINT

There are
many uterine
manipulators
available, and
they vary from
one country to
another and
from one
hospital to
another.

PROCEDURE
The uterine manipulator is placed after anesthesia is administered. A prophylactic antibiotic is given, and the patient is prepped
and draped in the usual fashion. A Foley
catheter is then inserted and bimanual examination 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.

The Female Patient | VOL 35 SEPTEMBER 2010 19

Uterine Manipulation in Laparoscopic Hysterectomy

FIGURE 2. The VCare uterine manipulator.

FIGURE 1. The RUMI uterine manipulator and the

KOH colpotomizer.
Images courtesy of CooperSurgical, Inc.

FOCUSPOINT

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

The cervix of a retroverted uterus, especially one fixed by dense adhesions to the
cul-de-sac, is often difficult to visualize. No
attempt at insertion of the uterine manipulator should be made unless the cervix is
clearly visualized and brought into the center 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 stenosis, lachrymal duct dilators or small Pratt
dilators might be needed before sounding.
If severe cervical stenosis is suspected preoperatively, an overnight insertion of a vaginal prostaglandin suppository might help
soften the cervix and facilitate insertion of
the uterine manipulator.
Depending on the type of the manipulator used, the manipulator might be
hooked to the tenaculum (eg, the Pelosi)
or the tenaculum removed before inser-

20 The Female Patient | VOL 35 SEPTEMBER 2010

tion of the manipulator (eg, the VCare or

the RUMI). Some manipulators are semidisposable, and the tip to be used will depend 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 cervix, 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 vaginal 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.

COMPLICATIONS
Complications attributable to the use of
uterine manipulators include cervical lacerations, uterine perforation, laceration of
uterine vessels, retroperitoneal or intraperitoneal bleeding, perforation of the bowel,
rectum or bladder, ascending infection,
interruption of unsuspected intrauterine
pregnancy, and retention of part of the manipulator as a foreign body.
Complications are more likely to happen
among postmenopausal women with a stenotic cervix and women with retroverted
or soft uteri. The use of uterine manipulators is contraindicated among women
who have pyometra or distorted or altered
anatomy (eg, vaginal septum) precluding
visualization of the cervix, if intrauterine

All articles are available online at www.femalepatient.com.

ELTABBAKH

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 cancer. In a retrospective review comparing
surgical stages among women with endometrial cancer who were treated with either 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 cytology) 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 uterine manipulator, Eltabbakh and Mount
found no difference in the incidence of malignant 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 patients with endometrial cancer into surgery by laparotomy or laparoscopy (using
different types of uterine manipulators)
found a relatively higher positive peritoneal cytology among women who had laparotomy compared to laparoscopy (11.3%
vs 6.1%, respectively, P=.052).6 The significance 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 peritoneal cytology as a staging criterion.

CONCLUSION
Uterine manipulators facilitate laparoscopic hysterectomy. The type of manipulator used will depend on the type of hysterectomy, 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 laparoscopic 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. Laparoscopy compared with laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic
Oncology Group Study LAP2. J Clin Oncol. 2009;
27(32):5331-5336.

FOCUSPOINT

Although the
uterine
manipulator is
an essential
tool for the
surgeon
performing
laparoscopic
hysterectomy,
there are a
number of
attributable
complications.

In this issue...

The Myths and Facts

of Intrauterine

Contraception
Bleeding Profiles

Supported by Teva Womens Health, Inc.

Follow The Female Patient on

and

The Female Patient | VOL 35 SEPTEMBER 2010 23