Manipulator-free technique for single-port laparoscopic hysterectomy avoids uterine perforation and reduces blood loss: a propensity score-matched study

Abstract Purpose To evaluate a novel manipulator-free technique for single-port laparoscopic hysterectomy. Methods A retrospective cohort study was conducted including patients who underwent single-port laparoscopic hysterectomy between January 2022 and July 2025. Surgical outcomes were compared between the manipulator-free and manipulator-assisted groups. Propensity score matching was performed based on surgical complexity, disease status, body mass index, and uterine size. Results Among 190 patients, 88 underwent manipulator-free and 102 manipulator-assisted surgery. No conversions occurred in the manipulator-free group. Proficiency in the manipulator-free procedure was achieved after 15 cases, with a mean operative time of 35.4 ± 13.7 min (range: 19 to 89). The manipulator-free group demonstrated significantly reduced blood loss (70.6 mL vs. 103.6 mL, P = 0.003) and hemoglobin decline (9.6 g/L vs. 14.5 g/L, P < 0.001) compared to the manipulator-assisted group. These differences remained consistent after propensity score matching (56.4 mL vs. 98.6 mL, P < 0.001) and multivariable adjustment (–39.1 mL, 95% CI: − 64.6 to − 13.6; P = 0.003). Uterine perforations occurred only in the manipulator-assisted group (9.8% vs. 0%, P = 0.002). There were no significant differences between groups in rates of peritoneal cytology positivity (16.4% vs. 9.7%, P = 0.24), lymphovascular space invasion (14.9% vs. 11.1%, P = 0.50). Conclusions Manipulator-free single-port laparoscopic hysterectomy is technically feasible with a short learning curve and was associated with reduced blood loss in this cohort. In short-term follow-up, the manipulator-free technique was not associated with increased rates of positive peritoneal cytology or lymphovascular space invasion; however, its impact on long-term oncologic outcomes remains to be validated.