• Joseph Nassif and Arnaud Wattiez.
• Institut De Recherche Contre les Cancers de L'Appareil Digestif/European Institute for Tele Surgery and Strasbourg University Hospitals Faculty of Medicine, Strasbourg University Strasbourg, France.
• Surg Technol Int. 2010 Oct 1; 20: 225-31.

AbstractLaparoscopy was considered marginal to surgical specialties before 1990. Rare innovations in instruments were done. With the realization of the first laparoscopic hysterectomy, this surgical route gained wide acceptance during the 1990s. Technical advances were made by instrument companies offering a wide variety of instruments to surgeons and by surgeons themselves to cope with problems during laparoscopic procedures. Manipulators are among the first instruments that surgeons suggested to ameliorate laparoscopic performance. Instruments that have multiple functions (i.e., grasping, cutting, coagulating) are more and more appreciated because surgeons can avoid changing instruments during surgery. Manipulators offer multifunctional assistance during gynecologic surgical procedures. They are useful for exposure purposes and also for reproductive surgery (and hysterectomy). This article explains the benefits and help that a manipulator can provide, especially in total laparoscopic hysterectomy. In the latter intervention, the manipulator will help to expose the pelvis by moving the uterus in any direction, to identify structures and find anatomical landmarks such as the vaginal fornices for culdotomy, and to avoid complications by pulling the ureter away from the operative field. Also, it is useful to avoid carbon dioxide leakage at the vaginal opening and to retrieve the surgical specimen. Each step is shown in a photograph with the specific hand movements corresponding to the manipulator's handling. We think that the use of manipulators during laparoscopic surgery is very useful and helps to reduce operative time.

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