Manipulator-Free Versus Manipulator-Assisted Total Laparoscopic Hysterectomy: Are Outcomes Comparable in Experienced Hands?

BACKGROUND Total laparoscopic hysterectomy (TLH) is a minimal invasive procedure for benign, premalignant and early-stage malignant uterine conditions. Uterine manipulators are commonly used to facilitate uterine mobilizations and improve surgical exposure, but their necessity and potential impact on intraoperative and postoperative complications remain debated. Despite conflicting findings, evidence from large retrospective cohorts comparing manipulator-assisted versus manipulator-free TLH remains limited. The aim of this study is to compare intraoperative and postoperative outcomes of TLH performed with and without using uterine manipulators. MATERIAL AND METHODS A retrospective cohort analysis of consecutive TLH for benign, premalignant, and early-stage endometrial cancer indications was conducted. Patients were categorized by uterine manipulator use (manipulator group, n=244; manipulator-free group, n=166). Demographics, uterine weight, operative time, hemoglobin change, intraoperative injuries, and postoperative complications were extracted from electronic records. Statistical comparisons were performed using chi-square or Mann-Whitney U tests (P<0.05). RESULTS Baseline characteristics were comparable between the groups. Mean uterine weight was 349.55±324.35 g (range 44-1354 g) in the manipulator group and 356±324.42 g (range 47-1440 g) in the non-manipulator group (P=0.842). Mean operative time did not differ significantly (79.6±26.07 vs 76.6±25.16 min; P=0.259). Intraoperative complications, vaginal lacerations, postoperative complications rates (13.9% vs 12.7%; P=0.708), hemoglobin changes, and hospital stay were comparable. Vaginal cuff hematomas were rare and similar between groups; no dehiscence occurred. CONCLUSIONS Expert laparoscopic surgeons can safely perform TLH without the use of a uterine manipulator. This approach does not appear to increase the risk of morbidity, compared with the use of a manipulator.