Textbook of Simplified Laparoscopic Hysterectomy:
Practical, Safe and Economic Methodology
 

Chapter 13

Instructions to the Vaginal Assistant

Instructions are given to the assistant at the vaginal end so that all future verbal commands are understood and followed:

1. Move the manipulator towards the patient’s left thigh (this brings the fundus to the patient’s right side);
2. Move the manipulator towards the patient’s right thigh (this brings the fundus to the patient’s left side);
3. Move the manipulator handle towards the floor (this makes the fundus become acutely anteverted in order to gain access to the posterior aspect of the uterus);
4. Move the manipulator handle towards the ceiling (this retroverts the uterus);
5. Move the handle towards the patient’s right thigh and twist it anticlockwise (this maneuver brings the left lateral uterine wall structures towards the midline and increases their accessibility); and
6. Move the handle towards the patient’s left thigh and twist it clockwise (this brings the right lateral uterine wall structures towards the midline and increases their accessibility).

A firm instruction is also given to the vaginal assistant to maintain pressure (a cephalad push) on the manipulator throughout the operation in order to exert upward placement (from the pressure on the manipulator) of the uterine structures. Continuous cephalad pushing on the manipulator is protective by elevating the uterus and letting the bladder and ureters fall away from the operative field. This action simulates the activity in open laparotomy whereby the uterus is pulled upward throughout the operation. An additional benefit of the continuous upward push on the manipulator and the complete understanding of the directions for positional changes on the part of the assistant is that it allows the surgeon to focus his/her full attention on the key operative steps (Video 9: Sankpal’s modified uterine manipulator and range of movements in total laparoscopic hysterectomy).