By and large, one of the most difficult aspects of any laparoscopic surgeon when dealing with the female pelvis is uterine manipulation.

The level of difficulty has been raised in many laparoscopic cases predominately due to inappropriate manipulation. This not only interferes with the procedure at hand but also limits the surgeon's inspection for other pathologies in the pelvis. A lubricated sponge stick can be placed into the posterior fornix of the vagina. There are several problems with this approach. It does not allow for the uterine fundus to be manipulated either out of the pelvis or into the pelvis away from the bladder.

Several uterine manipulators have been specifically designed just for these purposes. They are useful in procedures where the assistant holding traction may stand between the patient's legs allowing the surgeon to use both hands for the procedure. The Hulka tenaculum is a commonly used device for uterine manipulation. During the pelvic examination under anesthesia, the position (e.g., anteversion or retroversion) of the uterus is assessed. A single tooth tenaculum is used to grasp the anterior lip of the cervix. Gentle traction is pulled toward the examiner to straighten out the angle often present between the cervical canal and the anteverted or retroverted uterine fundus. The Hulka is then placed with the

Small injuries to the dome of the bladder can often be managed with prolonged bladder drainage. When surgical repair is required, this can often be accomplished with laparoscopic suture techniques. If injury occurs at the time of hysterectomy, transvaginal repair is also an option

By and large, one of the most difficult aspects of any laparoscopic surgeon when dealing with the female pelvis is uterine manipulation.

curve of the tenaculum pointing in the direction of the uterine fundus. If the uterus is retroverted, flipping the tenaculum into the ante-verted position is performed once placed into the uterine cavity. When the uterus is placed in the anteverted position, the tooth is clamped on the anterior lip of the cervix, and the single tooth tenaculum is removed.

The Rumi manipulator is another useful device. This is placed in a similar fashion to the Hulka. Once placed, it may be locked into either an anteverted or retroverted position. Several other benefits of this device include the ability to inject dye into the uterus to assess tubal patency and the ability to accommodate the Koh device (51). This Koh device is useful during laparoscopic hysterectomy. The system consists of a pneumo-occluder and a cup, combined with a uterine manipulator usually the Rumi manipulator. The cup, which is both visible and palpable, is placed over the cervix to delineate vaginal fornices, thus ensuring safe desiccation and avoiding ureteral dissection during colpotomy (51).

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