AH MANIPULATOR
by Dr Abhijit Halder

Overview

The AH manipulator is specially designed to make the uterine manipulation very easy, safe and smart. It is used in total laparoscopic hysterectomy (TLH), laparoscopic assisted vaginal hysterectomy and all other laparoscopic gynaecological operations. The device has several components- one rod with detatchable handle, one colpotomy tube with 2 different sizes of cup,  one colpotomy tube fixation screw, one cervical guard, and 3 sizes of cervical insert.
The special features are that the cervical insert of this manipulator is to be fixed at the tip of the rod by screwing movement. The insert is of 3 different length. After measuring the uterinocervical length appropriate insert can be fit at the tip of the instrument.
As there are threads on the rod, during TLH, threads can easily be negotiated through the external OS if the uterine size is more than the longest insert (9 mm). It is of greatest advantage as tip length can be increased by rotating back the lock over the rod. 
This manipulator can be used by any personnel with less experience of uterine manipulation without perforating the uterine fundus even with greatest force to lift it up. As because it is disigned with a guard of 2 cm diameter just below the insert it doesn’t allow the rod to be advanced more in the uterine cavity during forceful manipulation during TLH.
But in other cases where uterus is to be preservedbut manipulation is necessary like endometriosis surgery, diagnostic laparoscopy ,the cervical guard is to be fixed at the tip of the rod where the insert is attached. This is how the injury to the cervix by threads can be avoided though threads have minimal chance of injuring the cervix. So this manipulator can be used in all cases where uterus is to be preserved or uterus is to be resected out.
One colpotomy tube is there with an arm. It can be independently moved over the rod and the guard. So during TLH, if the operating surgeon wants to keep the cup inside the vagina for delineation of the fornices. It can be fixed over the rod by  fixing the arm with sctrewing movement. If  he or she doesn’t wish to keep the cup inside, the tube can be kept outside the vagina over the rod. With the in-out movement of the colpotomy tube uterine pedicle dissection becomes easier. The colpotomy tube even helps to delineate the utero-vescical fold in difficult cases like post-caesarean uterus or with bad adhesions. The uterine cup is also of different sizes to cater different sizes cervices.
Another extraordinary feature of this manipulator is that it has detachable handle. If the colpotomy tube needs to be changed to a different size , or surgeon willing to put the colpotomy tube over the rod in the middle of operation, the handle can be removed and tube can be pushed from behind over the rod and again the handle can be reattached with screwing movement.
The most important issue with this instrument is that it is very handy, light-weight, easy articulation and comfortable for use and cleaning compared to other popular manipulators.
TLH should be popular and should not only be done by selective surgeons but also by the new surgeons who are in trouble to perform the operation because of its inborn risk to injure the vital structures. What I found that if the uterine manipulation is of high standard the operation becomes easier with any type of energy source, and avoids its inborn risk of injuring the vital structures.
Many surgeons using the low-quality manipulator available in the market face the problem of uterine perforation, which makes the operation troublesome. None of the manipulators fulfill all the criteria to become the best manipulator. 
Clermond-Ferrand uterine manipulator popularized by Karl Storz is the most commonly used manipulator for last 3 decades. But it is an expensive device and it needs an trained personnel to articulate and clean. It is also too heavy.
Other manipulators like RUMI with KOH, Hourcabie, HOHL, V Care, Endopath etc. most of the manipulators are very much expensive and are not reusable (VCare, Endopath).
The Hourcabie is easy to use. Uterus handling efficiency (anteversion, retroversion).Precisely identify and present the vaginal fornix. Specific lengths of each hip are adapted to the fornix but doesn’t maintain the pneumoperitoneumvery well.
The Mangeshikar uterine manipulator is very popular now a days. It is of great advantage during TLH. But its use is not very simple and needs well training before its use. Articulation and cleaning of the instrument is cumbersome. 
 
The AH Uterine manipulator is reusable. The instrument is easy to assemble and clean and very much cost effective. 
Only drawback of this instrument compared to advanced type of manipulators is that
1.    It doesn’t have lever action at its tip. So vulva is the lever for its use. But it can have a great range of movement if the patient’s buttock is at the edge of the table. 
                                                                                           
It doesn’t catch hold the cervix compared to Other manipulator available in the market for which during specimen retrival another vulsellum like instrument is to be introduced for removing the uterus and adnexae. 

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