Table of Contents
- Procedure Summary
- Authors
- Youtube Video
- What is Demystifying the Hohl Uterine Manipulator?
- What are the Risks of Demystifying the Hohl Uterine Manipulator?
- Video Transcript
Video Description
Uterine manipulators play an important role in gynecologic surgery. At total laparoscopic hysterectomy, manipulators provide exposure of important anatomical landmarks and increase the distance between the ureters and bladder, and uterine arteries by facilitating cephalad movement of the uterus. The Hohl uterine manipulator is the most studied uterine manipulator and has been highlighted as easy to handle, although difficult to assemble. In a randomized controlled trial, the Hohl manipulator was demonstrated to facilitate shorter time from skin incision to uterine detachment as compared to the colpo probe manipulator. In this video we review the evidence for use of the Hohl uterine manipulator, its advantages, and disadvantages, as well as address the challenges associated with assembly by providing a step-by-step educational tutorial on its assembly, insertion, and manipulation. We also review the assembly and insertion of the cancer tip attachment for organ preserving surgeries in patients with uterine/cervical cancer or pre-cancer.
Presented By
Affiliations
St. Michael’s Unity Health Toronto
Trillium Health Partners
University of Toronto
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What is Demystifying the Hohl Uterine Manipulator?
“Demystifying the Hohl Uterine Manipulator” refers to clarifying the complexities and nuances of this specific surgical tool, which is used to maneuver the uterus during gynecologic surgeries, particularly laparoscopic and hysteroscopic procedures. The Hohl uterine manipulator is designed to provide stability, optimal positioning, and accessibility to the uterus, enhancing precision and visibility for the surgeon.
- Understanding Evidence and Use: Reviewing clinical evidence on the effectiveness, safety, and outcomes associated with the Hohl manipulator.
- Assembly Guidance: Providing clear instructions on the correct way to assemble the device, as its effectiveness depends on proper assembly.
- Insertion Techniques: Offering a step-by-step approach to inserting the manipulator safely, minimizing risks like perforation or injury to surrounding tissues.
- Best Practices: Highlighting best practices to ensure optimal performance during surgery, which helps prevent complications and improves surgical outcomes.
By breaking down these aspects, “demystifying” aims to make the tool more accessible to medical professionals, particularly those new to using it, and to reduce any ambiguity surrounding its application in surgical settings.
What are the Risks of Demystifying the Hohl Uterine Manipulator?
Exploring the risks of using the Hohl uterine manipulator involves understanding potential complications associated with its assembly, insertion, and use in gynecologic surgeries. Key risks include:
- Uterine Perforation: Improper insertion technique may increase the risk of uterine wall perforation, potentially leading to bleeding and further complications.
- Infection: Incorrect handling or assembly can introduce bacteria, raising the risk of postoperative infection, especially in minimally invasive surgeries.
- Trauma to Surrounding Tissues: If not positioned accurately, the manipulator may inadvertently affect surrounding organs, such as the bladder or bowel, potentially leading to trauma or injury.
- Increased Pain or Discomfort: Misalignment or excessive pressure from the device can cause discomfort, both during and after the procedure.
- Technical Challenges: Misassembly or lack of familiarity with the device can lead to operational difficulties, impacting the effectiveness of the surgery and possibly extending procedural time.
To mitigate these risks, careful training on assembly, insertion techniques, and handling is essential, along with adherence to sterilization protocols and real-time monitoring during procedures.
Video Transcript: Demystifying the Hohl Uterine Manipulator
Demystifying the Hohl Uterine Manipulator for Total Laparoscopic Hysterectomy. Mobilisation of the uterus plays an important role in gynaecologic surgery. It provides exposure of important anatomical landmarks and defines vaginal fornices, contributing to safe and successful dissection of tissues. Uterine manipulators also increase the distance between the ureters and bladder and the uterine arteries by facilitating cephalad movement of the uterus.
In this video, we will discuss the Hohl uterine manipulator, which is commonly used during total laparoscopic hysterectomy. We will begin by reviewing the evidence for its use, followed by an educational tutorial on its assembly and insertion. The Hohl is a reusable uterine manipulator, with a ceramic cup that will not be damaged by cautery during the colpotomy. The internal rod is screwed into the cervix, which facilitates a tight connection, maintaining pneumoperitoneum during the colpotomy.
The cup and rod come in a range of sizes, making it customisable to each patient’s anatomy. Disadvantages include increased bleeding when the manipulator is screwed into the cervix and lack of rotational movement. Given the manipulator’s multiple parts, assembly can be challenging at first and requires practice. A review article published in 2015 on ten different uterine manipulators demonstrated that the Hohl manipulator was the most studied.
It was highlighted as providing good uterine elevation and was easy to handle, although difficult to assemble. We aim for this video to address this challenge. This review highlighted that few studies exist on manipulators’ safety and efficacy and few studies have sought to compare different uterine manipulators. A more recent randomised control trial conducted by our team at St Michael’s Hospital in 2017 randomised a total of 91 patients undergoing total laparoscopic hysterectomy to a Hohl manipulator or a Colpo probe.
This study identified that the Hohl manipulator was associated with significantly shorter insertion time, colpotomy time and overall time from skin incision to uterine detachment. There was no difference in thermal damage of the vaginal cuff between manipulators. The Hohl comes with several sizes of ceramic cups, metal tips and spiral inserts, which allows the surgeon to adjust the manipulator to the size of the patient’s cervix.
If planning vaginal morcellation, the largest ceramic cup size should be chosen to optimise space for morcellation. Start by inserting a bivalve speculum to visualise the cervix. Place a tenaculum on the anterior lip of the cervix and sound the uterus. Choose the tip that is the most appropriate length based on sounding and attach it to the spiral insert, which is chosen based on the visualised diameter of the cervix.
This should be screwed in as shown here. The length from the base of the spiral insert to the end of the tip is measured, ensuring it is no longer than the sounded length to prevent perforation. The base of the spiral insert is then screwed into the long metal rod. A tightening winch can be used, as demonstrated here, to tighten the connection between the spiral insert and the metal rod. The second part of the manipulator is assembled, consisting of the overlying sheath and ceramic cup.
First, the small metal screw is partially tightened, as shown here. The appropriate size cup is chosen based on the visualised circumference of the cervix. And this is attached to the top of the sheath by aligning the notches on the two components. An overlying screw is brought around the base of the cup and screwed tightly. With traction on the tenaculum, the metal tip is passed through the cervix and the spiral insert is screwed into the cervix, ensuring that vaginal tissues are avoided.
The overlying sheath is then passed over the rod. Lubricant can be placed on the ceramic cup to assist with vaginal insertion. As the ceramic cup is passed through the enteritis, it is important that the rod is not pushed upwards to avoid uterine perforation. This is ensured by only placing pressure on the handle of the overlying sheath rather than the metal rod. The cup is then guided up and around the cervix. If not yet previously attached, the small screw is then placed on the sheath handle and screwed in all of the way.
During manipulation, this screw should always point upwards, indicating that the longer end of the cup is posterior. The device should not be rotated. The manipulator is now ready for use and can be manipulated to push the uterus in, retrovert and antevert, to allow visualisation of the anterior and posterior vaginal fornices laparoscopically and facilitate the colpotomy.
In patients with premalignant or malignant conditions such as endometrial hyperplasia, endometrial cancer or cervical HSIL, the cancer attachment is used, rather than the spiral insert, to avoid disrupting pathologic assessment of the cervix. Again, the uterus is first sounded and the metal tip is chosen based on the sounded length. The chosen tip is clicked into the top of the long metal rod, as shown here.
When inserting the metal tip through the cervix, the jaws are left partially open to be able to grasp the anterior lip of the cervix. Of note, the tenaculum should be placed on the posterior cervix to leave space for the jaws of the manipulator anteriorly. Once the tip has passed through the cervix, the jaws are tightened by tightening the black hand wheel, which is placed over the end of the metal rod. This wheel is then removed and the overlying sheath with ceramic cup are then placed in the same fashion as previously demonstrated.
In summary, we have discussed an evidence-based rationale for use of the Hohl uterine manipulator at total laparoscopic hysterectomy. We reviewed, step by step, the assembly and safe insertion of the Hohl manipulator for benign disease, as well as the cancer tip attachment. We hope that this video helps to facilitate safe and efficient placement of the Hohl during total laparoscopic hysterectomy.