This work was approved by the Institutional Ethics Committee of Sichuan University, and an informed consent was obtained from individual participants for taking and publishing the photographs. Between December 2019 and May 2020, we performed manipulator-free laparoscopic radical hysterectomy in 26 cases with early cervical cancer. The modified tumor-free techniques, including uterine manipulator-free manipulation and enclosed colpotomy, were described in details as follows. Patients underwent laparoscopic radical hysterectomy with pelvic lymphadenectomy under general anesthesia. The patient was placed in the Trendelenburg position.
1. Manipulator-free manipulations of the uterus
A total of 4 ports were used (10-mm camera port 2cm above the umbilicus, 5-mm port at McBurney’s point on the right side for the assistant, and two 5-mm ports on the left side for the surgeon, one was symmetric with the McBurney’s point another was the midpoint of lower left port and camera port.) (Fig. 1A). A suture needle with a 1-0 non-absorbable suture was passed through the skin into the abdominal cavity from right upper quadrant. The suture was made in the fundus of uterus and the other side of the suture got out of the abdominal cavity through the left upper quadrant. lifting the uterus by the outer parts of the suture. (Fig. 1B, 1C)
A total of 5 ports were used. Four ports were consistent with above mentioned, the extra was a 5-mm port 2cm above the symphysis pubis, which was used for insertion of the laparoscopic grasping forceps when traction of the uterus was applied (Fig. 2A). A 1-0 non-absorbable suture was placed through the fundus of uterus, tied this suture tightly to form the first knot and tied the second knot 2cm apart to create a ring in the middle, and a laparoscopic grasping forceps is inserted from the port above the symphysis pubis to pull the suture to manipulate the uterus. (Fig. 2B, 2C)
2. Enclosed colpotomy
2.1 Cable tie ligating
Before the resection of the upper third of the vagina, a sterilized cable tie was used to ligate the upper vagina (Fig. 3A).
2.2 Endoscopic stapler cutting
We also used the endoscopic stapler to close the vagina, the Fig. 3B showed the method of vaginal closure with an endoscopic linear cutting stapler with single use loading units.
2.3 transvaginal resection
Twenty three of 26 patients had transvaginal resection. Transvaginal resection was an alternative method that avoided tumor exposure in the abdominal cavity. We clamped the cervix with two forceps and dragged it out through the vagina (Fig. 3C, 3D).
3. pelvic cavity douche
To clear the potential residual tumor cells in the abdominal cavity thoroughly, we flushed the pelvic cavity with 2000 ml normal saline (NS) after the intraperitoneal procedures.
4. Bagging the resected lymph nodes
The resection of pelvic lymph nodes and para-aortic lymph nodes (if necessary) is an important part of cervical cancer surgery. Resected lymph nodes were immediately bagged when we do the laparoscopic lymphadenectomy and the specimen bag was removed from the vaginal stump after the operation.
To date we completed a total of 26 cases of this manipulator-free laparoscopic radical hysterectomy in early-stage cervical cancer. The procedures went well in all patients, with the difficulty similar to the conventional laparoscopic radical hysterectomy. The average estimated blood loss was 100 ± 80 ml, and the operative time was 220 ± 60 min in manipulator-free laparoscopic radical hysterectomy, similar to those in conventional group. There was no intra-operative transfusion, injury or conversion to open surgery in manipulator-free laparoscopic radical hysterectomy. In the short-term follow up, there was no post-operative transfusion, ileus, urinary tract injury or infection, vaginal cuff dehiscence, incisional infection or incisional hernia development. There were 4 cases of post-operative fever and 3 cases of deep venous thrombosis (DVT), who all got well after conventional management. Considering that the incidence of DVT after gynecologic surgery in our hospital is about 10%, we don’t think it’s an abnormal data.