By Dr Reza Lankarani, General Surgeon
Founder | Surgical Pioneering Newsletter and Podcast Series
Editorial Board Member | Genesis Journal of Surgery and Medicine
BMC Surgery, Published online August 9th
https://doi.org/10.1186/s12893-025-03078-2
This 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. Summary
This 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. Background
Laparoscopic 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. Objectives
The 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 time
Blood loss
Intensive Care Unit (ICU) requirement
Postoperative pain
Length of hospitalization
Pathologic quality indicators (TME completeness and lymph node harvest)
4. Methodology
Study 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 Findings
Significantly 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 significant difference (p = 1.000).
Postoperative ICU Admission: No significant difference (55% manipulator group vs. 35% non-manipulator group; p = 0.34).
Hospital Stay: Slightly shorter in the manipulator group (4.55 ± 0.69 days vs. 5.80 ± 3.10 days), but not statistically significant (p = 0.10).
Postoperative Pain Scores: Marginally higher in the manipulator group (6.00 ± 1.72 vs. 5.20 ± 1.79), but not statistically significant (p = 0.16). The authors note this "may reflect individual variability or minor uterine trauma."
No Adverse Impact on Oncological Outcomes:Lymph Node Harvest: Slightly lower in the manipulator group (18.2 ± 5.3 nodes vs. 22.0 ± 9.0 nodes), but not statistically significant (p = 0.19).
Metastatic Lymph Node Counts: Equivalent (p = 0.73).
Completeness of Mesorectal Excision: High and comparable in both groups ("complete excision achieved in 80% and 75% of patients in the manipulator and non-manipulator groups, respectively"). No significant difference (p = 0.94).
Pathologic Response to Neoadjuvant Therapy: No significant difference among treated patients (p = 0.32).
Safety: "No difficulty in placement, uterine perforation, or intraoperative complications were observed" related to the uterine manipulator. This was attributed to placement by a gynecologic oncologic surgeon under laparoscopic imaging guidance.
Demographics: Generally similar between groups, though the manipulator group had a statistically significant higher proportion of ASA III patients (p=0.018) and a higher proportion of distal rectum tumors (40% vs. 15%). Tumor staging and size were comparable.
6. Discussion and Implications
The study provides compelling evidence that uterine manipulators are a "useful adjunct" in laparoscopic rectal cancer surgery for female patients. Their primary benefit lies in "significantly improv[ing] intraoperative exposure" in the narrow confines of the female pelvis, thereby potentially facilitating safer and more efficient dissection. Crucially, this enhanced visualization does not come at the expense of oncological completeness (e.g., TME quality, lymph node yield) or increased perioperative complications.
The authors suggest that this "relatively simple and inexpensive intervention" could contribute to more consistent technical outcomes, particularly for trainees or less experienced surgeons, and potentially shorten the learning curve for deep pelvic dissection. While the study is single-centered and retrospective with a small sample size, the findings are consistent with theoretical benefits seen in other surgical fields and previous descriptive studies in colorectal surgery.
7. Limitations
Single-center study: Limits generalizability.
Retrospective design: Introduces potential for selection bias (surgeon preference, unrecorded anatomical considerations).
Small sample size: Limits statistical power to detect subtle differences in outcomes (e.g., pain, complications).
Subjective exposure assessment: VAS scores were surgeon-rated and lack inter-rater validation.
Selected patient cohort: May not fully reflect broader colorectal cancer populations.
* Future research should focus on:
Larger, multicenter prospective studies with standardized protocols.
Evaluation of functional outcomes (urinary and sexual) and long-term oncologic outcomes (recurrence and survival).
Assessment of specific patient subgroups (e.g., obesity, narrow pelvis, low rectal tumors) who might benefit more from manipulator use.
9. Conclusion
The study concludes that "the use of uterine manipulators in laparoscopic rectal cancer surgery for female patients significantly enhances intraoperative exposure without negatively affecting key oncologic or perioperative outcomes." This supports their consideration as a valuable tool, especially in cases where difficult pelvic access is anticipated.
By Dr Reza Lankarani, General Surgeon
Founder | Surgical Pioneering Newsletter and Podcast Series
Editorial Board Member | Genesis Journal of Surgery and Medicine
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