Achieving uterine manipulation with a newly developed adaptation of the classic rein technique (Modified rein technique–boztosun method) for uterine manipulation in laparoscopic hysterectomies

Aim: The aim of this study is to determine the effectiveness of a modified uterine rein technique (Boztosun method) used in hysterectomies that were performed in our clinic for benign reasons by examining the laboratory and clinical results of the procedures. Materials and Methods: From the patients who had laparoscopic hysterectomies for benign reasons in the Obstetrics and Gynecology Clinic at the Akdeniz University Medical Faculty Hospital between October 1, 2021 and July 1, 2022, our study examined the results for 40 patients who underwent surgery using the modified rein method (Boztosun method). The parameters by which the method was evaluated included the patients' demographic characteristics, duration of the operation, length of hospital stay, hemoglobin values at the beginning and end of the operation, whether the operation could be completed laparoscopically (transition to laparotomy), and the indications that determined the need for the operation. Whether a complication developed during or after the operation, an oophorectomy was added to the operation, an intraoperative drain was placed, a blood transfusion was needed, or the patient had previous abdominal surgery, and the outcome pathology of the hysterectomy materials, colpotomy time, and uterine weights were also considered as parameters. Results: The study evaluated the results for 40 patients aged between 40 and 78 who underwent a laparoscopic hysterectomy using the Boztosun method at Akdeniz University Medical Faculty Hospital between October 1, 2021 and July 1, 2022. The patients' mean age was 50.17; 24 of the patients (60%) were in menopause, and 17 patients (42.5%) had a history of abdominal surgery. The most common indications in the study's cases were treatment- resistant menometrorrhagia (47.5%), postmenopausal bleeding (17.5%), and myoma uteri (17.5%). The mean operation time was 78.5 minutes, and the colpotomy time was 8.05 minutes. For patients who had undergone previous abdominal surgery, the mean colpotomy time was 9.47 minutes, and for those who had not, it was 7.09 minutes, i.e., the colpotomy time was statistically longer in patients who had been operated on for abdominal issues. Similarly, patients with a history of abdominal surgery were found to have a longer mean operation time (85.88 minutes) than those without (73.04 minutes). In addition, it was necessary to complete the operation by laparotomy in three patients (7.5%). The patients' mean uterine weight was 151.77 grams, while the median uterus weight was 124.65 (min-max: 38-469) grams. A statistically significant and strong positive correlation was found between uterine weight and colpotomy time and a moderate positive correlation with operation time. While the median uterine weight of the patients who underwent a laparotomy was 169 (min-max: 128-469) grams, it was only 117 (min-max: 38-390) grams for those who did not. Although the uterus weight of the patients who needed a laparotomy was higher, it was not statistically significant. There was a history of previous abdominal surgery in 66.7% of the patient group who underwent a laparotomy and 40.5% of those who did not, which shows that there was no significant relationship between the status of transition to laparotomy and the history of previous abdominal surgery. Bladder damage, ureteral damage, bowel and vascular injury, preoperative, intraop- and postoperative blood transfusion need did not occur in any of the patients. In 90% of the patients, the bladder catheter was removed on the morning of the first postoperative day. All patients were given prophylactic antibiotics, and none of the patients presented with complications such as postoperative incision site or urinary tract infections. The pathology results of 36 patients (90%) were determined to be benign, and of these benign results, 29 patients (72.5%) had chronic cervicitis. The results also showed a premalignancy (EIN) in one patient (2.5%) and malignancies (ovarian granulosa cell tumors) in three patients (7.5%). Nineteen patients (47.5%) were hospitalized for one day and 21 patients (52.5%) for two days after their operations. Conclusion: The modified rein technique (Boztosun method), which we developed inspired by the classic rein technique, demonstrated great benefits in the manipulation of the uterus and during colpotomies. The most challenging situation for utilizing the classic rein technique was when the cotton tape is attached to and exits the uterus. Thanks to the method we have developed, the cotton tape is attached to the uterus much faster and easier, and it is simpler to reattach in case of possible dislocation. This advantage facilitated the applicability of the method. When the operation time, colpotomy time, postoperative hemogram reduction, discharge time, complications, and the success of the method were compared, the results were found to be significant compared to the classic rein technique, as well as the results reported in much of the relevant literature. We believe that prospective, randomized, larger case series studies conducted by surgeons with more laparoscopic experience and who are familiar with the method are needed in order to support and even improve our findings since the cases in the present study were performed by resident physicians who were trained in our clinic and possessed little laparoscopic experience. Key Words: Laparoscopy, Uterine Manipulator, Hysterectomy, Gynecology, Colpotomy, Rein, Boztosun