How to Use a Uterine Manipulator in Laparoscopy: Insertion, Sizing and Pitfalls

Preparation: what to check before you start

Before the patient is draped, confirm the device and its size range, the presence of all parts (shaft, handle, tip, cup or balloon where relevant), the integrity of the packaging or the sterility indicator of a reusable set, and the availability of a spare. Prepare the accompanying instruments: speculum, tenaculum, uterine sound, dilators and, if chromopertubation is planned, dye and a syringe.

The REDA gynecology instruments range lists the Cusco, Pederson, Collin and Sims specula, Hegar uterine dilators, uterine sounds and tenaculum that are normally on this tray. A bimanual examination under anaesthesia, performed by the surgeon, gives the orientation and size of the uterus before the instrument goes in.

How to insert a uterine manipulator

The sequence is generally as follows. Place the speculum, identify the cervix and secure the anterior lip with a tenaculum if the design requires. Measure the cavity with a uterine sound to know the depth and the direction. Dilate the cervix if the chosen tip needs it. Introduce the tip along the axis of the uterus without force until the fundus is reached, then fix it as the design specifies, for example with a balloon, a screw or a cup.

Check that the manipulator moves the uterus freely in all directions and that the handle does not obstruct the surgeon's or assistant's access to the vaginal area. In many designs the tip is positioned under laparoscopic vision at first to verify the movements.

• Speculum, cervix exposure, tenaculum if needed
• Sounding for depth and axis
• Dilation to the size needed for the tip
• Insertion along the axis without force
• Fixation as per the design (balloon, screw, cup)

Sizing the tip and the colpotomy cup

Choose the tip length from the sounded depth so that it sits correctly in the cavity and does not reach the fundal wall too hard. For hysterectomy, the cup or delineator should match the cervix and fornix: a cup that is too small will not outline the fornix, and one that is too large cannot be seated. Many systems offer several sizes, which is why the standard set should include a range.

Always follow the maker's table for sizes and be ready to change size if the first choice does not seat. The choice of design is discussed in our guide to uterine manipulator types and names.

Using the manipulator during laparoscopy and chromopertubation

In laparoscopy the assistant moves the uterus on the surgeon's request: anteverting to expose the posterior cul-de-sac, lateralising to open the broad ligament, lifting to stretch the vessels. Keep movements smooth and use the handle's mechanical advantage rather than force. In hysterectomy the cup is pushed up to define the fornices before the colpotomy.

For chromopertubation, dye is injected through a channel or cannula while the surgeon watches the fimbrial ends. Make sure the system is sealed against back-flow and the syringe is purged of air. The role of the manipulator among the other devices is covered in the list of laparoscopic hysterectomy instruments.

Common pitfalls and reprocessing

Typical problems are a false passage or perforation caused by insertion without sounding, a cup of the wrong size, a leaking balloon, a loose fixation that lets the uterus slip, and tissue trauma from excessive force. Prevent them by sounding, sizing, testing the balloon where applicable and keeping the assistant trained.

After the case a reusable device must be cleaned and sterilised exactly as the instructions say; a disposable one should be discarded. The economics are explained in the article on reusable and disposable manipulators. To ask Beckfinity about devices and accessories, use the contact page.