Uterine Manipulator Assistance in Laparoscopic Rectal Cancer Surgery for Female Patients 🅴

By Dr Reza Lankarani, General SurgeonFounder | Surgical Pioneering Newsletter and Podcast Series Editorial Board Member | Genesis Journal of Surgery and MedicineBMC Surgery, Published online August 9th https://doi.org/10.1186/s12893-025-03078-2This article from BMC Surgery investigates the utility of uterine manipulators in laparoscopic rectal cancer surgery for female patients. The study aimed to determine if these devices, commonly used in gynecology, improve surgical exposure in the confined pelvic space without negatively impacting patient outcomes. Researchers conducted a retrospective cohort study comparing 40 patients who either received or did not receive a uterine manipulator during their procedure. The findings indicate significantly improved intraoperative exposure with the manipulator's use, while other perioperative and oncological outcomes remained largely unaffected, suggesting it's a safe and beneficial tool for challenging pelvic dissections.1. SummaryThis study investigates the utility of uterine manipulators in improving intraoperative exposure during laparoscopic rectal cancer surgery in female patients, a procedure often complicated by anatomical constraints. The retrospective cohort study found that uterine manipulators significantly enhance intraoperative exposure without negatively impacting key oncological or perioperative outcomes. While commonly used in gynecological procedures, their application in colorectal surgery has been minimally explored. This research provides statistically supported evidence for their safe and effective use as an adjunct tool, particularly in challenging deep pelvic dissections.2. BackgroundLaparoscopic rectal surgery is the preferred approach for rectal cancer due to its advantages in pain reduction, faster recovery, and comparable oncologic outcomes to open surgery. However, in female patients, the "anatomical constraints" of the pelvis, specifically the "uterus and adnexa," can "obscure the surgical field," making deep pelvic dissections challenging. This limitation can hinder the surgeon's ability to mobilize the rectum fully and assess surrounding structures, potentially affecting the quality of total mesorectal excision (TME) and nerve preservation. Uterine manipulators, routinely used in gynecologic and urologic procedures to improve visualization and access, are hypothesized to offer similar benefits in colorectal surgery. Prior literature on their use in colorectal settings, however, is "sparse."3. ObjectivesThe primary objective of this study was to determine whether the use of a uterine manipulator enhances intraoperative exposure in female patients undergoing laparoscopic rectal cancer surgery. Secondary objectives included evaluating the impact of manipulator use on:Operative timeBlood lossIntensive Care Unit (ICU) requirementPostoperative painLength of hospitalizationPathologic quality indicators (TME completeness and lymph node harvest)4. MethodologyStudy Design: Retrospective descriptive cohort study.Setting: Kartal Dr. Lütfi Kırdar City Hospital’s General Surgery Department.Participants: 40 female patients (20 with manipulator, 20 without) who underwent elective laparoscopic rectal resection for rectal adenocarcinoma between October 2024 and January 2025.Exclusion Criteria: Male patients, patients with prior total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH-BSO), emergency surgeries, and procedures converted to open surgery.Data Collection: Retrospective review of patient medical records, including demographics, clinical features, operative data (e.g., duration, blood loss, "surgeon-rated exposure quality assessed via a visual analog scale (VAS)"), and postoperative outcomes.Uterine Manipulator Placement: Conducted by a gynecologic oncologic surgeon under laparoscopic imaging guidance. The appropriate length of the uterine manipulator (SecuFix UM) was determined by hysterometer measurement.Statistical Analysis: SPSS software used for descriptive statistics, chi-square tests for categorical variables, and Student’s t-tests or Mann-Whitney U tests for continuous variables. "Statistical significance was defined as p < 0.05."5. Key FindingsSignificantly Improved Intraoperative Exposure: The most notable finding was the "significantly better" intraoperative exposure in the manipulator group (VAS 8.8 ± 0.9) compared to the non-manipulator group (VAS 6.05 ± 1.5; "p < 0.001"). This supports the hypothesis that manipulators provide a clearer operative field.No Significant Differences in Key Perioperative Parameters:Operative Time: Similar in both groups (149.3 ± 35.9 min with manipulator vs. 153.5 ± 32.8 min without; p = 0.70).Bleeding: No statistically significant difference in blood loss exceeding 300 mL (10% in both groups; p = 1.00).Anastomotic Leakage: Occurred in 2 patients (10%) in each group, with no