What are the steps to move the vaginal tube in Total Laparoscopic Hysterectomy (TLH)?

Technique for Moving the Vaginal Tube in Total Laparoscopic Hysterectomy

The vaginal tube (colpotomizer or uterine manipulator) should be placed initially to expose the cervico-vaginal junction and stretch the vaginal fornices, then repositioned as needed during the procedure to facilitate safe colpotomy by guiding the incision line and protecting adjacent structures. 1

Initial Placement and Purpose

• Use a wide-bore plastic tube (4-5 cm external diameter) made from smooth, electrically-inert plastic to expose the cervico-vaginal junction and stretch the vaginal fornices 1
• The tube should have a valve at the distal end to maintain pneumoperitoneum during the procedure 1
• Modern systems include the KOH Colpotomizer System and RUMI Uterine Manipulator, which have become standard equipment for TLH 2

Sequential Steps for Tube Manipulation During TLH

Step 1: Early Procedure Positioning

• After entering the retroperitoneum and identifying the ureter, the vaginal tube remains in initial position to maintain uterine anteversion and exposure 3
• The tube provides consistent anatomic landmarks while dissecting pararectal spaces and identifying uterine vessels 3

Step 2: During Vascular Dissection

• Keep the tube stable while ligating uterine arteries (either at their origin from internal iliac vessels or at the level of the cardinal ligaments) to maintain consistent anatomic relationships 3
• The tube's position helps identify the proper plane between bladder and cervix during this phase 2

Step 3: Colpotomy Phase (Critical Repositioning)

• Advance or adjust the tube to maximally stretch the vaginal fornices as you approach the cervico-vaginal junction 1
• The stretched vagina falls away from the cervix as diathermy cuts over the tube rim, creating a clear surgical plane 1
• The tube guides the circumferential incision and the plastic material protects bladder, rectum, and ureters from thermal injury 1
• Rotate the tube as needed to maintain optimal tension on each quadrant of the vaginal fornix during the 360-degree colpotomy 1

Step 4: Specimen Removal

• After completing colpotomy, the tube may be partially withdrawn to allow specimen extraction through the vaginal opening 2
• The valve mechanism maintains pneumoperitoneum even during specimen manipulation 1

Step 5: Vaginal Cuff Closure

• Reposition or remove the tube as needed to visualize the vaginal cuff edges for laparoscopic suturing 3
• Some surgeons prefer keeping a smaller caliber tube in place to maintain vaginal distension during cuff closure 2

Safety Considerations

• The primary complication associated with vaginal tube use is vault hematoma (reported in <1% of cases), which is significantly lower than complication rates without the device 1
• The tube's smooth plastic surface prevents inadvertent thermal injury to adjacent structures during electrosurgical dissection 1
• Proper tube sizing (4-5 cm diameter) is essential—too small provides inadequate exposure, too large risks vaginal laceration 1

Technical Pearls

• The tube transforms the technically difficult cervico-vaginal separation into a straightforward procedure by providing tactile and visual guidance 1
• This technique contributed to TLH success rates of 98.2% in experienced hands 2
• The device addresses the main technical difficulty that previously limited adoption of total laparoscopic approaches 1