HOHL Uterine Manipulator

A member of the Reviews in Obstetrics & Gynecology editorial board reviewed the following devices. The views of the author are personal opinions and do not necessarily represent the views of Reviews in Obstetrics & Gynecology or MedReviews®, LLC.

Companies can submit a product for review by e-mailing Merilee Croft at mcroft@medreviews.com.

• Design/Functionality Scale

  • 1 = Poor design; many deficits
  • 2 = Solid design; many deficits
  • 3 = Good design; few flaws
  • 4 = Excellent design; few flaws
  • 5 = Excellent design; flaws not apparent
• Innovation Scale

  • 1 = Nothing new
  • 2 = Small twist on standard technology
  • 3 = Major twist on standard technology
  • 4 = Significant new technology
  • 5 = Game changer
• Value Scale

  • 1 = Added cost with limited benefit
  • 2 = Added cost with some benefit
  • 3 = Added cost but significant benefit
  • 4 = Marginal added cost but significant benefit
  • 5 = Significant cost savings
• Overall Scale

  • 1 = Don’t bother
  • 2 = Niche product
  • 3 = Worth a try
  • 4 = Must try
  • 5 = Must have

Design/Functionality: 4

Innovation: 3

Value: 2

Overall Score: 3

In the days when the forceps was king in obstetrics, the surest means of getting one’s name out there was to modify a pair of forceps and name the redesign after oneself. To that end, there are over 700 flavors of forceps in the world, although the pace of invention has slowed dramatically. Today, a similar phenomenon can be seen in the niche of laparoscopic uterine manipulators. This is not to imply that the raison d’être of invention is ego rather than function, but rather to highlight how subtle alterations in an instrument’s design can dramatically change its function. In our minimalist world of laparoscopic surgery, the uterine manipulator is our forceps and seeking the perfect design is, for many, the Holy Grail.

With the largest stable of uterine manipulator designs, KARL STORZ—Endoskope (KARL STORZ Endoscopy- America, Inc., El Segundo, CA) would seem to have something for everybody. The following review considers the HOHL Uterine Manipulator.

Design/Functionality

Compared with most of the other commercially available uterine manipulators, the HOHL has a simple but somewhat brutal appearance. The lines are straight and the forward end has a sharp, spiral-tread tip designed to be screwed into the endocervical canal to secure the device onto the cervix. The HOHL comes with several different-sized tips, screws, and cups to accommodate a wide range of anatomic variation and the manipulator is easy to assemble and disassemble. The cervical cups are ceramic, making them sturdy and electrocautery and harmonic compatible.

In clinical testing during a robotic total hysterectomy, the HOHL performed excellently. The device was easy to secure to the cervix and held the cup at the vaginal fornices with a tight seal that nicely delineated the anatomy during surgery. The ceramic cup was comfortable to cut against and the length of the cup was adequate to maintain a reasonable pneumoperitoneum after the colpotomy was made, although there was some air leakage.

On the downside, there were three issues: (1) Can someone at KARL STORZ please find a color for their cervical cups other than white? With the high-intensity lights of laparoscopes, the only color that is difficult to see straight-on is white (and “human tissue pink”)—pick another color. (2) Although the cervical screw does provide a supersecure grasp of the uterus, it does limit the HOHL to being a total hysterectomy-only manipulator. (3) The lack of an articulating mechanism slightly limits its ante/retroflexion capabilities, although for most total hysterectomies this is less of an issue as long as the surgeon has a good assistant.

Design/Functionality Score: 4

Innovation

The use of a cervical “screw” to secure the device to the endocervix is a major change. It looks scary, but it works as well if not better than anything else I have ever used in this regard. In addition to its superior grab on the tissue, it is the best method I have tested that withstands torque to twist the uterus without slipping. Unfortunately, this same innovation does limit the manipulator to total hysterectomy-only duty.

Innovation Score: 3

Value

As with most KARL STORZ products, the HOHL Uterine Manipulator is not cheap—in fact, it is really expensive. At ∼$8500, it is a significant upfront capital investment. However, it is 100% reusable and, thus, its amortized cost is reasonable if a center performs lots of total laparoscopic hysterectomies.

Value Score: 2

Summary

If your hospital or practice primarily performs total hysterectomies rather than supracervical hysterectomies, then you owe it to yourself to try the HOHL Uterine Manipulator. But with such a hefty purchase price, you had better love it and plan to use it a lot if you are going to ask your hospital to buy it.

Overall Score: 3

Figure 1.

HOHL Uterine Manipulator (KARL STORZ—Endoskope; KARL STORZ Endoscopy-America, Inc., El Segundo, CA). © 2011 Photo Courtesy of KARL STORZ Endoscopy-America, Inc..