How to Use the Uterine Rotator?

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

·  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.