The uterosacral ligaments are stretched and this eases the posterior dissection. During anterior dissection, the ends of the sutures were released, brought full article intraperitoneally, and then pulled cranially with a grasper. Cranial traction on the sutures facilitated dissection in the uterovesical or the prevesical space (Figure 4). Pulling on the sutures to the left or to right facilitated further lateral dissection. 3. Results We have used the laparoscopic uterine hitch technique in 23 patients. The procedure was easily accomplished in all patients. The average time required for hitching up the uterus was less than 5 minutes. In one of the patients, the round ligament was torn due to the suture cutting through the tissue.

In one of the obese patients, it was difficult to retrieve the needle through the abdomen, but it could be done by applying pressure on the abdomen when the needle was being removed. No other complication was noted. We did not need to use an extra uterine manipulator in any of the cases. 4. Discussion Various uterine manipulators are available for use in laparoscopic pelvic surgeries. Though each one has its own advantages and disadvantages, none of the manipulators has all the attributes of an ideal manipulator and can be universally used. Vaginal manipulators are being used successfully by some for laparoscopic pelvic oncosurgery. Ramirez et al. described the use of a modified vaginal manipulator in laparoscopic radical hysterectomy for cervical and endometrial cancer [2]. Similarly, Spirtos et al.

used the uterine sound steri stripped to the tenaculum as a uterine manipulator for laparoscopic radical hysterectomy [3]. The vaginal manipulators require an extra staff member to maintain the instrument in the correct position. Adjustments in the retraction are not in direct control of the operating surgeon, who has to instruct the assistant at the vaginal end as to what type of retraction is required. In patients with cervical stenoses, use of a uterine sound and cervical dilatation increases the risk of perforation [4]. In patients of cervical carcinoma, there is added risk of tearing of the cervix and bleeding or migration of the tissue into the endometrial cavity and thus into the peritoneal cavity. Lim et al. have described that the use of a uterine manipulator with an intrauterine balloon during laparoscopic surgery for endometrial cancer might be associated with positive cytological conversion [5].

Possible explanations were retrograde seeding of the tumor cells into the peritoneal cavity and the spillage of the preexisted tumor cells between the isthmus and the fimbriae. We have an extensive experience of Laparoscopic radical hysterectomy, Laparoscopic anterior exenteration, AV-951 and Laparoscopic total pelvic exenteration. We also have a high number of patients who undergo advanced laparoscopic pelvic colorectal and urological oncosurgeries.