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A new uterine manipulator for operative laparoscopy and laparoscopic hysterectomy
May 1995, Vot. 2, No. 3
TheJournal of the American Association of Gynecologic Laparoscopists
A New Uterine Manipulator for Operative Laparoscopy and
Laparoscopic Hysterectomy Paula Bernstein, Ph.D., M.D. Abstract A new, reusable uterine manipulator was developed to facilitate pelviscopic surgery and laparoscopic hysterectomy. The device is weighted to hold the uterus in an anteverted position and allow easy access to the culde-sac. It is spring loaded to create a tight seal for tubal insufflation. The instrument is calibrated in centimeters and has a sliding cervical plug that allows it to be inserted into the fundus to a depth of 15 cm for uterine manipulation during laparoscopic hysterectomy. The spring-loading mechanism holds the device firmly to the cervical tenaculum regardless of the depth of penetration, and rotates 180 degrees for use in the retroverted uterus.
Description of the New Uterine Manipulator
As we proceed to perform increasingly complex laparoscopic surgeries, the ability to visualize pelvic structures and manipulate the uterus becomes increasingly important. A good uterine manipulator should encompass the following features: it should provide elevation and anteversion without help from the surgeon or assistant, be equally easy to use in a retroverted uterus, insert to the fundus with calibration for hysterectomy to avoid perforation, and provide a watertight seal to the cervix. We designed a new, reusable uterine manipulator with all these features to facilitate movement of the uterus during operative laparoscopy and laparoscopic hysterectomy (Figure 1).
Figure 2 illustrates the instrument in the configuration used for most laparoscopic surgeries. The proximal inner rod (A) inserts into the cervix and has irrigation holes for tubal insuffiation through the luer lock at the distal end (G). The cervical plug (B) helps create a watertight seal when the spring-loading mechanism (D) is attached to the cervical tenaculum (H). The tension on the spring-loading mechanism may be increased by attaching the tenaculum to a more distal hook. The distal end of the inner rod (E) is calibrated in centimeters so that the surgeon may read the depth
From the Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California. Dr. Bemstein receives royalties from the manufacturer, G.M. Engineering, La Verne, California. Address reprint requests to Paula Bernstein, M.D., 8635 West Third Street, Suite 765, West Los Angeles, CA 90048; fax 310 659 5478. Presented at the 22nd annual meeting of the American Association of Gynecologic Laparoscopists, San Francisco, November 10-14, 1993.
331
A New Uterine Manipulator Bernstein
H v
FIGURE 1.
D
w
The Bernstein uterine manipulator.
of insertion of the proximal rod at any time. The 110-g weighted end (F) holds the uterus in an anteverted position, maximizing visualization of the cul-de-sac and adnexae, and freeing the assistant surgeon or scrub nurse from the task of elevating the uterus. The weighted end also contains a ratchet mechanism that allows the curve of the inner rod (A) to rotate 180 degrees for use with a retroverted uterus. For laparoscopic hysterectomy, the entire outer assembly (C) slides back along the inner rod (A). This is accomplished by rotating the adjustment lock (I) clockwise with respect to the adjustment knob (J). This loosens the outer assembly and permits it to move along the inner rod. When the inner rod has been adjusted to the desired length, it may be locked firmly in place by rotating the lock (I) counterclockwise. This allows insertion of the inner rod to any fundal depth up to 15 cm (Figure 3), and permits the surgeon to move the uterus from side to side and to put the broad ligaments on stretch, simplifying ligation of the uterine arteries and use of the stapler. For disassembly, we unscrew the cervical plug (B) and the adjustment knob (J). The plug and the proximal half of the outer assembly (C) then slide off the inner rod. The adjustment knob (J) may then be unscrewed from its half of the outer assembly for thorough cleaning of all surfaces with screw threads. The instrument is sterilized by autoclave.
A B
C-
E
F
FIGURE 2. The Bernstein uterine manipulator configured for operative laparoscopy with an anteverted uterus. See text for details.
higher pressures, even when the Cohen cannula was held against the cervix, exerting countertraction with the tenaculum. 1 The disposable balloon catheters, although superior for tubal insuffiation and infertility evaluations, are, once again, not weighted and, in this era of cost containment, disposable and in the long run more expensive. The Scott reusable instrument is not weighted and cannot be used at all for tubal insufflation. 2 The Grandi manipulator has the same shortcomings? The Semm reusable instrument has a suction mechanism that holds a metal cup to the cervix. 4 Because of interpatient variability in the size and shape of the cervix, it frequently fails to maintain a tight seal, and once again, there is no weight. Hasson developed a ballooned uterine elevator cannula that combines a Foley catheter mounted on a malleable metal tube with an optional 200-g weight. 5 By varying the size of the catheter and tubes, elevation and tubal insuffiation were successfully performed in uteri of varying sizes during 100 open laparoscopy and minilaparotomy procedures. Before designing our instrument, we used the Corson weighted reusable manipulator for most of our operative laparoscopies. 6 Although it held the uterus in an anteverted position, we found several other problems in using it. It is not spring loaded, and it was difficult to maintain a tight seal for insufflation. The attachment to the tenaculum often slipped, and we found ourselves frequently attaching the tenaculum to
Discussion
A number of uterine manipulators have been used in the past for diagnostic laparoscopy and tubal insufflation. The Cohen cannula, perhaps the most widely used, has several features in common with our instrument, but also several major disadvantages. It is not weighted and therefore does not hold the uterus in an anteverted position. It is difficult to reconfigure for the retroverted uterus, as the cone must be unscrewed and reattached, a process usually requiring several attempts. Comparison of the intrauterine pressure produced during tubal insuffiation in the Cohen cannula versus the Bard and Harris-Kronner disposable balloon catheters found that the balloon catheters achieved significantly
FIGURE 3. The Bernstein uterine manipulator configured for laparoscopic hysterectomy.
332
May 1995, Vol. 2, No. 3
TheJournal of the American Association of Gynecologic Laparoscopists
the manipulator with tape. When we tried to insert it into the fundus for laparoscopic hysterectomy, the hook would not slide far enough back to hold the crosspiece of the tenaculum. The most sophisticated of the earlier uterine manipulators, the Valtchev is a reusable instrumentv that overcomes many of the disadvantages of other models. It consists of two rods, one of which is spring loaded, and an attached cone with an assortment of uterine obturators. The cone pivots and allows the uterus to rotate 130 degrees about the axis of the internal os. The manipulator locks in place once the desired orientation has been achieved. Successful visualization of pelvic structures was reported in 518 cases. The recently developed Pelosi uterine manipulator s appears quite similar in design, although it differs in the configuration of the hand control. In addition, it has an attachment for inserting an illuminator into the vagina, which facilitates the performance of colpotomy. The U-elevator9 is designed for use with the patient in the supine position. Its handle rests on the sterile field so that it can be manipulated by the surgeon. Because the instrument is not fixed to the cervix, it requires the application of pressure to obtain a tight seal for tubal insufflation. The disposable ClearView manipulator 1~uses a rotating handle to control a balloon tip, which pivots at the cervical os and allows anterior, posterior, and lateral motion of the uterus. It is clear that sophisticated operative laparoscopy requires a versatile uterine manipulator. We have now used the prototype of our instrument for 40 laparoscopic surgeries including hysterectomy, myomectomy, oophorectomy, ovarian cystectomy, adhesiolysis, and coagulation of endometriosis. We have found it easy to insert into both anteverted and retroverted uteri. The weighted end has provided excellent exposure of the cul-de-sac and adnexae. We have needed an assistant to adjust the manipulator only to expose the bladder flap and to move the uterus to a far lateral position during laparoscopic-assisted vaginal hysterectomy (LAVH). We have experienced no problems with cervical tears from the tenaculum and no slippage of the cervical plug, and have found the seal adequate for easy insuffiation. We did experience one fundal perforation during LAVH in a large uterus. This did not cause any bleeding or interfere with the completion of the procedure. As inserting the rod 3 cm into the
cervix will provide adequate anteversion in the majority of cases, we recommend inserting the instrument to the uterine fundus only for hysterectomies. Our operating room staff, once familiar with the instrument, has had no problem with disassembly or reassembly after sterilization.
Conclusion The Bemstein uterine manipulator combines some of the most useful features of previous uterine manipulators, and has specific adaptations for laparoscopic hysterectomy and the retroverted uterus. References
1. Jessup MJ, Grainger DA, Kluzak TR, et al: Diagnosing proximal tubal obstruction: Evaluation of peak intrauterine pressures using four common cannula techniques in extirpated uteri. Obstet Gynecol 81:732-735, 1993 2. Scott JW: A new uterine manipulator for use at laparoscopy. Am J Obstet Gynecol 147(4):458-459, 1983 3. De Grandi P: A new uterine manipulator for gynecologic laparoscopy. Int J Gynaecol Obstet 18(4):248-250, 1980 4. Semm K: Pelviskopie und hysteroskopie. Farbatlas und lehrbuch. Stuttgart, FK Schattauer Verlag, 1976 5. Hassan HM: A modified ballooned uterine elevator cannula. J Reprod Med 25(2):72-74, 1980 6. Corson SL: Two new laparoscopic instruments: Bipolar sterilizing forceps and uterine manipulator. Med Instrum 11(1):7-8,1977 7. Valtchev KL, Papsin FR: A new uterine mobilizer for laparoscopy: Its use in 518 patients.Am J Obstet Gynecol 127:738-740, 1977 8. Pelosi MA, Kadar N: Laparoscopically assisted hysterectomy for uteri weighing 500 g or more. J Am Assoc Gynecol Laparosc 1(4):405-409, 1994 9. Gregerson E: The U-elevator. A new manipulator for gynecologic laparoscopy. Acta Obstet Gynecol Scand 73(6):508-510, 1994 10. Sharp HT, Williams R Hatasaka HH, et al: Comparison of the ClearView uterine manipulator with the Cohen cannula in laparoscopy. J Am Assoc Gynecol Laparosc 2(2):207-211, 1995
333
TheJournal of the American Association of Gynecologic Laparoscopists
A New Uterine Manipulator for Operative Laparoscopy and
Laparoscopic Hysterectomy Paula Bernstein, Ph.D., M.D. Abstract A new, reusable uterine manipulator was developed to facilitate pelviscopic surgery and laparoscopic hysterectomy. The device is weighted to hold the uterus in an anteverted position and allow easy access to the culde-sac. It is spring loaded to create a tight seal for tubal insufflation. The instrument is calibrated in centimeters and has a sliding cervical plug that allows it to be inserted into the fundus to a depth of 15 cm for uterine manipulation during laparoscopic hysterectomy. The spring-loading mechanism holds the device firmly to the cervical tenaculum regardless of the depth of penetration, and rotates 180 degrees for use in the retroverted uterus.
Description of the New Uterine Manipulator
As we proceed to perform increasingly complex laparoscopic surgeries, the ability to visualize pelvic structures and manipulate the uterus becomes increasingly important. A good uterine manipulator should encompass the following features: it should provide elevation and anteversion without help from the surgeon or assistant, be equally easy to use in a retroverted uterus, insert to the fundus with calibration for hysterectomy to avoid perforation, and provide a watertight seal to the cervix. We designed a new, reusable uterine manipulator with all these features to facilitate movement of the uterus during operative laparoscopy and laparoscopic hysterectomy (Figure 1).
Figure 2 illustrates the instrument in the configuration used for most laparoscopic surgeries. The proximal inner rod (A) inserts into the cervix and has irrigation holes for tubal insuffiation through the luer lock at the distal end (G). The cervical plug (B) helps create a watertight seal when the spring-loading mechanism (D) is attached to the cervical tenaculum (H). The tension on the spring-loading mechanism may be increased by attaching the tenaculum to a more distal hook. The distal end of the inner rod (E) is calibrated in centimeters so that the surgeon may read the depth
From the Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California. Dr. Bemstein receives royalties from the manufacturer, G.M. Engineering, La Verne, California. Address reprint requests to Paula Bernstein, M.D., 8635 West Third Street, Suite 765, West Los Angeles, CA 90048; fax 310 659 5478. Presented at the 22nd annual meeting of the American Association of Gynecologic Laparoscopists, San Francisco, November 10-14, 1993.
331
A New Uterine Manipulator Bernstein
H v
FIGURE 1.
D
w
The Bernstein uterine manipulator.
of insertion of the proximal rod at any time. The 110-g weighted end (F) holds the uterus in an anteverted position, maximizing visualization of the cul-de-sac and adnexae, and freeing the assistant surgeon or scrub nurse from the task of elevating the uterus. The weighted end also contains a ratchet mechanism that allows the curve of the inner rod (A) to rotate 180 degrees for use with a retroverted uterus. For laparoscopic hysterectomy, the entire outer assembly (C) slides back along the inner rod (A). This is accomplished by rotating the adjustment lock (I) clockwise with respect to the adjustment knob (J). This loosens the outer assembly and permits it to move along the inner rod. When the inner rod has been adjusted to the desired length, it may be locked firmly in place by rotating the lock (I) counterclockwise. This allows insertion of the inner rod to any fundal depth up to 15 cm (Figure 3), and permits the surgeon to move the uterus from side to side and to put the broad ligaments on stretch, simplifying ligation of the uterine arteries and use of the stapler. For disassembly, we unscrew the cervical plug (B) and the adjustment knob (J). The plug and the proximal half of the outer assembly (C) then slide off the inner rod. The adjustment knob (J) may then be unscrewed from its half of the outer assembly for thorough cleaning of all surfaces with screw threads. The instrument is sterilized by autoclave.
A B
C-
E
F
FIGURE 2. The Bernstein uterine manipulator configured for operative laparoscopy with an anteverted uterus. See text for details.
higher pressures, even when the Cohen cannula was held against the cervix, exerting countertraction with the tenaculum. 1 The disposable balloon catheters, although superior for tubal insuffiation and infertility evaluations, are, once again, not weighted and, in this era of cost containment, disposable and in the long run more expensive. The Scott reusable instrument is not weighted and cannot be used at all for tubal insufflation. 2 The Grandi manipulator has the same shortcomings? The Semm reusable instrument has a suction mechanism that holds a metal cup to the cervix. 4 Because of interpatient variability in the size and shape of the cervix, it frequently fails to maintain a tight seal, and once again, there is no weight. Hasson developed a ballooned uterine elevator cannula that combines a Foley catheter mounted on a malleable metal tube with an optional 200-g weight. 5 By varying the size of the catheter and tubes, elevation and tubal insuffiation were successfully performed in uteri of varying sizes during 100 open laparoscopy and minilaparotomy procedures. Before designing our instrument, we used the Corson weighted reusable manipulator for most of our operative laparoscopies. 6 Although it held the uterus in an anteverted position, we found several other problems in using it. It is not spring loaded, and it was difficult to maintain a tight seal for insufflation. The attachment to the tenaculum often slipped, and we found ourselves frequently attaching the tenaculum to
Discussion
A number of uterine manipulators have been used in the past for diagnostic laparoscopy and tubal insufflation. The Cohen cannula, perhaps the most widely used, has several features in common with our instrument, but also several major disadvantages. It is not weighted and therefore does not hold the uterus in an anteverted position. It is difficult to reconfigure for the retroverted uterus, as the cone must be unscrewed and reattached, a process usually requiring several attempts. Comparison of the intrauterine pressure produced during tubal insuffiation in the Cohen cannula versus the Bard and Harris-Kronner disposable balloon catheters found that the balloon catheters achieved significantly
FIGURE 3. The Bernstein uterine manipulator configured for laparoscopic hysterectomy.
332
May 1995, Vol. 2, No. 3
TheJournal of the American Association of Gynecologic Laparoscopists
the manipulator with tape. When we tried to insert it into the fundus for laparoscopic hysterectomy, the hook would not slide far enough back to hold the crosspiece of the tenaculum. The most sophisticated of the earlier uterine manipulators, the Valtchev is a reusable instrumentv that overcomes many of the disadvantages of other models. It consists of two rods, one of which is spring loaded, and an attached cone with an assortment of uterine obturators. The cone pivots and allows the uterus to rotate 130 degrees about the axis of the internal os. The manipulator locks in place once the desired orientation has been achieved. Successful visualization of pelvic structures was reported in 518 cases. The recently developed Pelosi uterine manipulator s appears quite similar in design, although it differs in the configuration of the hand control. In addition, it has an attachment for inserting an illuminator into the vagina, which facilitates the performance of colpotomy. The U-elevator9 is designed for use with the patient in the supine position. Its handle rests on the sterile field so that it can be manipulated by the surgeon. Because the instrument is not fixed to the cervix, it requires the application of pressure to obtain a tight seal for tubal insufflation. The disposable ClearView manipulator 1~uses a rotating handle to control a balloon tip, which pivots at the cervical os and allows anterior, posterior, and lateral motion of the uterus. It is clear that sophisticated operative laparoscopy requires a versatile uterine manipulator. We have now used the prototype of our instrument for 40 laparoscopic surgeries including hysterectomy, myomectomy, oophorectomy, ovarian cystectomy, adhesiolysis, and coagulation of endometriosis. We have found it easy to insert into both anteverted and retroverted uteri. The weighted end has provided excellent exposure of the cul-de-sac and adnexae. We have needed an assistant to adjust the manipulator only to expose the bladder flap and to move the uterus to a far lateral position during laparoscopic-assisted vaginal hysterectomy (LAVH). We have experienced no problems with cervical tears from the tenaculum and no slippage of the cervical plug, and have found the seal adequate for easy insuffiation. We did experience one fundal perforation during LAVH in a large uterus. This did not cause any bleeding or interfere with the completion of the procedure. As inserting the rod 3 cm into the
cervix will provide adequate anteversion in the majority of cases, we recommend inserting the instrument to the uterine fundus only for hysterectomies. Our operating room staff, once familiar with the instrument, has had no problem with disassembly or reassembly after sterilization.
Conclusion The Bemstein uterine manipulator combines some of the most useful features of previous uterine manipulators, and has specific adaptations for laparoscopic hysterectomy and the retroverted uterus. References
1. Jessup MJ, Grainger DA, Kluzak TR, et al: Diagnosing proximal tubal obstruction: Evaluation of peak intrauterine pressures using four common cannula techniques in extirpated uteri. Obstet Gynecol 81:732-735, 1993 2. Scott JW: A new uterine manipulator for use at laparoscopy. Am J Obstet Gynecol 147(4):458-459, 1983 3. De Grandi P: A new uterine manipulator for gynecologic laparoscopy. Int J Gynaecol Obstet 18(4):248-250, 1980 4. Semm K: Pelviskopie und hysteroskopie. Farbatlas und lehrbuch. Stuttgart, FK Schattauer Verlag, 1976 5. Hassan HM: A modified ballooned uterine elevator cannula. J Reprod Med 25(2):72-74, 1980 6. Corson SL: Two new laparoscopic instruments: Bipolar sterilizing forceps and uterine manipulator. Med Instrum 11(1):7-8,1977 7. Valtchev KL, Papsin FR: A new uterine mobilizer for laparoscopy: Its use in 518 patients.Am J Obstet Gynecol 127:738-740, 1977 8. Pelosi MA, Kadar N: Laparoscopically assisted hysterectomy for uteri weighing 500 g or more. J Am Assoc Gynecol Laparosc 1(4):405-409, 1994 9. Gregerson E: The U-elevator. A new manipulator for gynecologic laparoscopy. Acta Obstet Gynecol Scand 73(6):508-510, 1994 10. Sharp HT, Williams R Hatasaka HH, et al: Comparison of the ClearView uterine manipulator with the Cohen cannula in laparoscopy. J Am Assoc Gynecol Laparosc 2(2):207-211, 1995
333