Comparing two Uterine Manipulators During Total Laparoscopic Hysterectomy: A Randomized Controlled Trial

Study Objective To compare 2 different types of uterine manipulators (i.e., tight fitting vs loose fitting) used for total laparoscopic hysterectomy (TLH). Design A randomized controlled trial. The primary end points were time for colpotomy, time from skin incision to detachment of the uterus, and histologic assessment of thermal damage to the vagina (Canadian Task Force classification I). Setting A university teaching hospital. Patients All consecutive women scheduled for TLH from May 2014 to December 2015. Patients were excluded if pregnancy or malignancy was suspected or uterine size exceeded 20 weeks' gestation. Interventions Patients were randomized to undergo TLH with 1 of the following uterine manipulators: (1) Colpo-Probe Vaginal Fornix Delineator (Cooper Surgical, Inc, Trumbull, CT) or (2) Hohl manipulator (KARL STORZ AG, Tuttlingen, Germany). Measurements and Main Results A total of 91 patients, 49 in the Hohl manipulator group and 42 in the Colpo-Probe group, were included in the final analysis. There was no difference in patient characteristics, uterine weight, or estimated blood loss. The median time for insertion of the manipulator (2 minutes [interquartile range (IQR), 2–5 minutes] vs 6 minutes [IQR, 5–7], p < .001), the median time from skin incision to detachment of the uterus (55 minutes [IQR, 41–70] vs 65 minutes [IQR, 58–79], p = .004), and the median time for colpotomy (7 minutes [IQR, 5–10] vs 12 [IQR, 8–17], p < .001) were shorter with the Hohl manipulator. Thermal damage to the vagina varied greatly and ranged from 32 μm to 5232 μm but was not significantly different between groups (median maximum thermal damage = 1043 μm [IQR, 682–1934] vs 1522 μm [IQR, 884–2144], p = .211). Conclusion Use of the Hohl manipulator results in a shorter operative time from skin incision to detachment of the uterus during TLH. Although the colpotomy time is shorter using the Hohl manipulator, this did not translate to less thermal damage to the vaginal cuff. Further studies comparing uterine manipulators are warranted to find the optimal instrument for ease of surgery and decreased thermal spread.