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Four protective maneuvers in minimal invasive surgery of endometrial cancer
  1. Emad Matanes,
  2. Zainab Amajoud,
  3. Shannon Salvador,
  4. Susie Lau and
  5. Walter Gotlieb
  1. Department of Obstetrics and Gynecology, McGill University Jewish General Hospital, Montreal, Québec, Canada
  1. Correspondence to Dr Emad Matanes, Jewish General Hospital, Montreal, QC H3T 1E2, Canada; emad.matanes{at}

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While limited evidence about the uterine manipulator in endometrial cancer surgery, in which no impact of the uterine manipulator’s use on oncological outcome has been found,1 2 a recent large multicenter retrospective study suggests that the use of a uterine manipulator is associated with worse oncological outcomes in patients with endometrial cancer who undergo minimally invasive surgery.3 That is likely due to tumor spillage during the surgery, either to the vagina while manipulating the uterus, or intraperitoneally through the uterine walls (perforation) and the fallopian tubes.

This video demonstrates simple surgical maneuvers that can be considered and potentially help to reduce the risk of tumor spillage in minimally invasive surgery for endometrial cancer. This video report is part of an institutional, investigational board-approved study. Procedures shown in this video include: 1. closing the external os of the cervix with ethibond suture and then placing the vaginal cup of a HOHL manipulator (Karl Storz, El Segaundo, California, USA) without the intra-uterine component, while passing the suture through the manipulator using a laparoscopic grasper, and pulling on the suture to maintain the cervix into the ceramic cuff, making the colpotomy easier and safer; 2. sealing the fallopian tubes at the beginning of the surgery in order to reduce the risk of intraperitoneal spillage through the tubes while manipulating the uterus during the surgery; 3. placing the uterus and adnexa into an endobag that is introduced through the vagina while maintaining the suture on the cervix to keep it closed and avoid tumor cell contamination during extraction. Lastly, following the resection of the sentinel lymph node, and to avoid squeezing of the node, it is placed into either a laparoscopic spoon or, if the node is large, into a finger of a glove, avoiding tumor spillage. To conclude, avoiding spillage of the tumor during cancer surgery is crucial. The acts demonstrated in this video represent simple oncological safe adaptations of minimally invasive surgery for endometrial cancer.

Figure 1

Sealing of the fallopian tubes in order to reduce the risk of intraperitoneal spillage through the tubes.

Video 1

Disclaimer: this video summarises a scientific article published by BMJ Publishing Group Limited (BMJ). The content of this video has not been peer-reviewed and does not constitute medical advice. Any opinions expressed are solely those of the contributors. Viewers should be aware that professionals in the field may have different opinions. BMJ does not endorse any opinions expressed or recommendations discussed. Viewers should not use the content of the video as the basis for any medical treatment. BMJ disclaims all liability and responsibility arising from any reliance placed on the content.

Data availability statement

There are no data in this work.

Ethics statements

Patient consent for publication

Ethics approval

This study involves human participants and was approved by the ethics committee at the Jewish General Hospital. Approval number 2020-1904. Participants gave informed consent to participate in the study before taking part.


This video was made possible in part by a grant from the Israel Cancer Research Fund.



  • Contributors All authors have made a substantial contribution to the material submitted for publication and have watched the final video. EM is the guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.