THE UTERINE MANIPULATOR
How to use the Uterine rotator?
Total Laparoscopic Hysterectomy

Choose the size of the hooked head and of the vaginal obturator according to the
size of the uterus and of the vagina.

Dilate the cervix up to Hegar 6 for the small head and Hegar 8 for the larger
head. Introduce the manipulator and open the head. This fixes the manipulator
inside. Check the positioning through rotation : if no adhesions or large myomas
limit rotation, than the uterus can be rotated more than 90В°, thus bringing the
uterine artery anterior and the fornix posterior laterally. This permits to do
surgery of the right side through the middle and left ports.
Steps of hysterectomy
1. Bring the manipulator in retroflexion and push slightly inside, this way elevating
the cervix. The retroflexion will facilitate your vision over the top of the uterus of the
vesicouterine fold and the broad ligaments

With 30 degree rotation left and right coagulate/cut/dissect both round
ligaments and the anterior peritoneum of the broad ligament respectively

Then elevate the bladder, incise the peritoneum and dissect the bladder
downwards

Rotate the uterus 90 degree, thus bringing the uterine artery from 3 or 9 o clock
tot 1 or 11 o clock position. This rotation (in retroflexion) in association with
pushing the uterus to the other side while the assistant pulls the round ligament
to the same side and downwards, exposes directly the broad ligament and the
uterine artery. Dissect the broad ligament, eventually make a window and
coagulate the uterine arteries.

coagulate and cut the infundibulo-pelvicuml/ovarium proprium ligament and
extend excision up to the uterine artery
Uterine Rotator with mock-up uterine arteries. Retrofexion + rotation exposes the uterine
artery much better. The uterine artery can be brought anterior and the fornix posterior
laterally. This permits to do surgery of the right side through the middle and left ports.

rotate the uterus in order to bring the uterine artery upwards, coagulate and cut
the uterine artery and dissect the vessel stump (generally everything can be
done from the middle and left port without changing the instruments. Consider
how retrofexion + rotation exposes the uterine artery much better than a
rotation only and certainly much better than anteversion. Anteversion can be
useful e.g. when a myoma impedes visualisation.
2. With the manipulator straight push the fornix presentor to
visualise the vaginal fornix
open the anterior fornix
rotate the uterus right and the fornix presentor left to expose and open the left
fornix
rotate the uterus and the fornix presentor more ; change instruments i.e. the
unipolar in the left port ; this permits to cut the left uterosacral , the posterior
fornix and generally the right uterosacral
then rotate in order open the right fornix.
carefully coagulate blood vessels
remove the uterus
3. The manipulator with the fornix presentor then is used to
occlude the vagina for suturing.
using the large hooked head , opening at the level of the vaginal cuff permits to
expose the vagina for suturing i.e. binging the cuff anteriorly (especially useful in
obese patients) whereas rotating facilitates suturing with the right (middle) hand

Conclusions : although the steps of laparoscopic hysterectomy remain
unchanged, you will, however, appreciate the functionality of the uterine rotator
whenever your surgery becomes difficult e.g.:
Difficult access: not only with a large uterus, but also when a myoma is
in the wrong place for vision and access, especially to the uterine artery.
Bleeding of the uterine artery: the rotation permits easy and direct
access. The assistant surgeon can help effectively since each uterine
artery can be grasped/occluded/coagulated/clipped through both the left
and the right ports. Moreover by rotation and flexion the uterine artery is
moved out of the pelvis which becomes especially important since the
bleeding can be dealt with without having to aspirate the blood first.
Bleeding of the fornix posterior becomes easily accessible.
Laparoscopic Subtotal Hysterectomy
1. Hysterectomy steps are the same as described above. Rotation facilitates the
cutting of the cervix since after isolation of the corpus uterus; the cervix can be
rotated almost 180В°, thus permitting to cut the posterior part on the anterior
side.
2. After detaching the uterus : retract the manipulator slightly into the cervical
canal and reopen : this permits to manipulate the cervix (pushing the cervix up
and anteriorly)
rotation facilitates suturing
facilitates greatly the suturing of the posterior and anterior
mesh and positioning of the cervix for the promontofixation.
Pelvic Floor Repair
Conservative surgery as myomectomy and endometriosis
The two conservative surgery heads are being redesigned in order to
avoid uterine perforation even if the assistant pushes too stronly
inside.
if the fornix will not be opened, the manipulator is used with the
straigth head and a cervix clamp.