Patent Publication Number: US-2020297385-A1

Title: Uterine manipulator

Description:
This application claims priority to U.S. Provisional Patent Application Ser. No. 61/777,350 filed on Mar. 12, 2013, the content of which is hereby incorporated by reference. This application also is a continuation of and claims a benefit under 35 U.S.C. § 120 of prior filed Non-Provisional application Ser. No. 14/204,766 filed on Mar. 11, 2014, the content of which is hereby incorporated by reference 
    
    
     BACKGROUND 
     Publication U.S. patent application Ser. No. 13/091,517, entitled FORNIX MANIPULATOR and filed on Apr. 21, 2011 (&#39;517 application), shares a common inventor with the present application. The &#39;517 application discloses a fornix manipulator including a collar and stabilizer to be attached to a uterine shaft. The fornix manipulator addresses several problems, including imprecise fornix delineation and deviation; vaginal shortening; abdominal deflation; blocked cervical access; unnecessary tissue damage from blind cervical retrieval, device insertion and retrieval, and lack of a platform for organ dissection. 
    
    
     
       BRIEF DESCRIPTION OF DRAWINGS 
       The accompanying drawings are included to provide a further understanding of the general inventive concept and are incorporated in and constitute a part of this specification. The drawings illustrate exemplary embodiments of the general inventive concept and, together with the description, serve to explain principles of the general inventive concept. Features and advantages of embodiments of the present invention will become apparent from the appended claims, the following detailed description of one or more example embodiments, and the corresponding figures: 
         FIG. 1  illustrates a conventional uterine manipulator from the 571′ application. 
         FIGS. 2A-2B  illustrate embodiments of a uterine manipulator containing a uterine shaft, tip, collar, stabilizer, and a pressing portion including an outer tube, fixing portion, and screw. 
         FIGS. 3A-3H  illustrate embodiments of a uterine manipulator, where either end of the collar is being employed as the receiving end. 
         FIGS. 4A-4F  illustrate three perspectives of an embodiment of a collar in addition to a cross-sectional view.  FIGS. 4E-4F  illustrate cross-sectional views of alternative embodiments of a collar. 
         FIGS. 5A-5D  illustrate an embodiment of a stabilizer fitted into either end of a collar. 
         FIGS. 6A-6E  illustrate an embodiment of a stabilizer with a delineating rim. 
         FIGS. 7A-7B  illustrate an embodiment of a reinforced stabilizer. 
         FIGS. 8A-8H  illustrate embodiments of a uterine shaft, embodiments of a dye delivery system, embodiments of an adolescent uterine manipulator system, and embodiments of an adult uterine manipulator system. 
         FIGS. 9A-9B  illustrate an embodiment of a tip in addition to a cross-section. 
         FIGS. 10A-10E  illustrate embodiments of a tip. 
         FIGS. 11A-11B  illustrate an embodiment of a tip and a cross-sectional view. 
         FIGS. 12A-12E  illustrate embodiments of a handle. 
         FIGS. 13A-13C  illustrate embodiments of a collar. 
         FIGS. 14A-14H  illustrate embodiments of a stabilizer. 
         FIGS. 15A-15C  illustrate embodiments of a stabilizer coupled to a collar. 
         FIGS. 16A-16F  illustrate an embodiment of a uterine manipulator system used in conjunction with a fulcrum and linkage to assist in articulation of the uterine manipulator. 
         FIG. 17  illustrates an embodiment including a uterine manipulator and fulcrum. 
         FIGS. 18A-18B  include embodiments of a fulcrum. 
     
    
    
     DETAILED DESCRIPTION 
     Preferred embodiments of the general inventive concept will be described below in more detail with reference to the accompanying drawings. These embodiments are provided so that this disclosure will be thorough and complete, and will convey the scope of the general inventive concept to those skilled in the art. The embodiments of the general inventive concept may, however, be embodied in different forms and should not be constructed as limited to the embodiments set forth herein. Although numerous specific details are set forth, embodiments of the invention may be practiced without these specific details. “An embodiment”, “various embodiments” and the like indicate embodiment(s) so described may include particular features, structures, or characteristics, but not every embodiment necessarily includes the particular features, structures, or characteristics. Some embodiments may have some, all, or none of the features described for other embodiments. “First”, “second”, “third” and the like describe a common object and indicate different instances of like objects are being referred to. Such adjectives do not imply objects so described must be in a given sequence, either temporally, spatially, in ranking, or in any other manner. Like numbers refer to like elements throughout. Well-known structures and techniques have not been shown in detail to avoid obscuring an understanding of this description. 
     An embodiment of the invention includes an improvement to uterine manipulators and dye delivery systems that addresses several issues, such as minimizing surgical error, facilitating dye delivery, fostering easy manipulation of a patient&#39;s anatomy, and/or reducing healthcare and hospital costs. An embodiment includes a uterine manipulator having a collar, stabilizer, uterine shaft, outer tube, pressing portion, handle, and/or special tip. Another embodiment includes a dye delivery system having a uterine shaft and special tip. However, embodiments are not limited to addressing these issues, and other benefits, features, and/or utilities may be apparent to one of ordinary skill in the art. 
       FIG. 1  shows a schematic of a uterine manipulator  30 , including a collar  10 , stabilizer  20 , and balloon tip  35  from the &#39;571 application. More specifically,  FIG. 1  shows a sagittal cross-section of a female pelvis. The cervix opens into the uterus  104 . On one side of the vagina  107 , toward the front of the body, is a bladder  112 . On another side of the vagina  107 , toward the rear of the body, is the rectum  109  between intestines  110  and the anus  108 , which opens from the rectum  109  to outside the body. Surgeons may access the uterus  104  and other organs from the abdominal cavity  111 . The fornix is a cylindrical ring of tissue encircling the cervix and lower uterus. The lowest cylindrical ring is the intra-vaginal fornix  101 , which encircles the cervix and is visible from the vaginal canal. The upper-most cylindrical ring of the fornix is the intra-abdominal fornix  113 . When viewed from the abdomen, the anterior half of the intra-abdominal fornix  113  may be visible, but it is neither demarcated nor obvious to the human eye. The ring of the intra-abdominal fornix  113  passes between the uterus  104  and rectum  109 , and also passes between the uterus  104  and bladder  112 , as indicated by  FIG. 1 . 
     Several problems and injuries may result when using conventional devices, known as uterine manipulators, to manipulate the fornix. These problems include imprecise fornix delineation and deviation; vaginal shortening; and abdominal deflation. Injury can also result from blocked cervical access and blind cervical retrieval; device insertion and retrieval; and lack of a platform while dissecting vital organs away from the fornix and vaginal wall. 
       FIGS. 2A-2B  illustrate an embodiment from two different angles. Uterine manipulator  30  includes a uterine shaft  31 , tip  70 , collar  10 , stabilizer  20 , an outer tube  61 , and a pressing portion  60 , comprising of a fixing portion  62  and screw  63  (e.g., set screw). In  FIG. 2A , smaller diameter end  11  of the collar  10  is the receiving end for the cervix. In  FIG. 2B , larger diameter end  12  of the collar  10  is the receiving end for the cervix. In other words, collar  10  is reversible. 
       FIGS. 3A-3D and 3E-3H  illustrate an embodiment of a uterine manipulator  30  from four perspectives including a handle  32 , inlet  40 , cap  34 , uterine shaft  31 , tip  70 , collar  10 , stabilizer  20 , an outer tube  61 , and a pressing portion  60 . In  FIGS. 3A-3D , end  11  of the collar  10  is the receiving end for the cervix. In  FIGS. 3E-3H , end  12  of the collar  10  is the receiving end for the cervix. In other words, collar  10  is reversible. 
       FIGS. 4A-4D  illustrate a shape of a collar  10  in an embodiment.  FIG. 4A  is a top view of an embodiment of the collar  10 ,  FIG. 4B  is a perspective view,  FIG. 4C  is a side view, and  FIG. 4D  is a cross-sectional view of  FIG. 4C . 
     The collar  10  includes two ends  11  and  12 , the diameter of end  12  exceeding the diameter of end  11 . A sidewall  14  defines a profile of the collar  10  with an inner surface  14   a  and outer surface  14   b . The sidewall also defines an opening  11   a  of the end  11  and another opening  12   a  of the opposite end  12 . Between the openings  11   a  and  12   a , the sidewall  14  also defines an inner cavity  19  and is ribbed with ridges  9 . The sidewall may be smooth, have even ridges, or uneven ridges of varying width and size. The sidewall may be of even or uneven density. 
     The opening of  11   a  is defined by a rim  13  having an outer edge  13   a , an inner edge  13   b , and a rim surface  13   c  between the outer and inner edges  13   a  and  13   b . The collar  10  may also include a second outer rim edge  13   f  separated by a trough or gully  13   g . Additional rim edges may be added as needed (e.g., 2, 3, 4, 5 or more). 
     In addition, the collar is dual-rimmed. Just as opening  11   a  is defined by a rim  13 , so is the opening  12   a  defined by a rim  15 . The rim has an outer edge  15   a , an inner edge  15   b , and a rim surface  15   c  between the outer and inner edges  15   a  and  15   b . It may also have a second outer rim edge  15   f  separated by a trough or gully  15   g . Additional rim edges may be added as needed (e.g., 2, 3, 4, 5 or more). The &#39;517 application describes a variety of rim shapes and configurations applicable to rim  13  of end  11 , depicted also in many of the figures. These shapes and configurations are also applicable to rim  15  of end  12 . In addition, although the collar is described as double-rimmed, it may also be single rimmed. The number of rims on one end of the collar need not correspond to the number of rims on the other end. 
     Cervixes have different lengths, diameter and shapes. Surgeons may delineate and manipulate the fornix using either rim  15  of end  12 , or rim  13  of end  11 , depending on which end more snuggly or appropriately fits around the cervix. In other words, end  12  or end  11  of collar  10  may serve as a receiving end of the collar that slides over the cervix and contacts the intra-vaginal fornix. 
     In the embodiment shown in  FIG. 4A-4D , the surgeon has two alternative diameters to fit onto the cervix—the diameter of end  11  defined by rim element  13   c  or alternatively, the larger diameter of end  12  defined by rim element  15   c . Because there is variation in cervical size across patients, both ends being the possible receiving end saves hospitals and surgeons substantial time and cost. Instead of trials with multiple collars, surgeons need only experiment with either side of one collar. 
     In addition to reducing surgical time and cost, the dual-rimmed collar reduces the risk of surgical error resulting from over-estimating the cervical size. Surgeons may over-estimate the size of the cervix due to optical illusions. In particular, the vaginal wall and tissue surrounding the cervix may mislead the surgeon to believe the cervix is larger than it is. However, with a dual-rimmed collar, a surgeon who believes the cervix is large in diameter may apply the larger end  12  as the receiving end. She may also test her assumption by trying the reverse smaller end (end  11 ) to determine if she overestimated the cervical diameter. If over-estimated, she may use the smaller end. 
     The dual-rimmed collar does not complicate insertion or retrieval. Even if the larger diameter end  12  is to be used as the receiving end, the smaller diameter end  11  may be inserted in the vaginal canal first, allowing the vaginal opening to expand to the larger diameter as the device is inserted. Once the collar is within the vaginal canal, the surgeon may rotate the device within the vaginal canal and slide the appropriate end over the cervix. If the end is too large or too small in diameter for the cervix, the surgeon may slide the collar  10  off the cervix, rotate the device, and slide the other end onto the cervix. Alternatively, the device may be inserted sideways, so the sidewall  14  is inserted first. 
     Repeated trials indicate that in some embodiments, the distances  17   a  and  17   b  between the rim edges  13   c  and  13   f , and  15   c  and  15   f , respectively, may be 0-2 mm, 2-4 mm, 4-6 mm, or 6-8 mm. In some embodiments, the distances  17   c  and  17   d  between the rim edges  13   a  and  13   b , and  15   a  and  15   b , respectively, may be 0-2 mm or 2-4 mm. In some embodiments, the diameter  17   e  of end  11  may be between 15-20 mm, 20-25 mm, or 25-30 mm, 30-35 mm, or 35-40 mm, or 40-45 mm. In some embodiments, the diameter  17   f  of end  12  may be between 20-25 mm, 25-30 mm, 30-35 mm, 35-40 mm, or 40-45 mm. In some embodiments, the distance  17   g  between end  11  and end  12  may be between 5-10 mm, 10-15 mm, 15-20 mm, 20-25 mm, 25-30 mm, 30-35 mm, or 35-40 mm. The diameter may be 40 mm or more for women who have undergone natural childbirth. 
     A string, mesh, or strap (hereinafter “strap”)  64  may connect between the collar  10  and the outer tube  61 , pressing portion  60 , shaft  31 , handle  32  or any part of the uterine manipulator  30  to allow easy removal of the collar  10  along with the uterine manipulator  30 , as shown in  FIGS. 3E and 3G . The collar  10  may include a hole  14   e  along the side wall  14  or either collar end  11  or end  12 , as shown in  FIG. 13B . The strap  64  may be connected to the hole  14   e  via a ring, knot, a tie, glue, or any other means. Alternatively, the strap may be tied around the diameter of the collar&#39;s sidewalls  14 , as shown in  FIG. 3G . In another embodiment, the strap  64  is connected to the collar  10  but does not connect to any other portion of the uterine manipulator system and instead hangs loosely, inside our outside the vaginal canal, as shown in  FIG. 3F . 
     Dual-Use Collar for Universal Stabilizer 
     Each collar  10  may use a stabilizer  20  in some embodiments to further delineate the fornix. When the end  26  of stabilizer  20  is pressed against an end or rim of collar  10 , the collar  10  delineates the fornix intra-abdominally. However, if the collar is dual-use and the diameters of the collar end  12  and collar end  11  are different, then the stabilizer must be made in two different sizes, with two diameters corresponding to the respective diameters of collar ends  11  and  12 , or alternatively rim  13  and  15  if the stabilizer is configured to press against the collar&#39;s rim. This is costly and cumbersome. 
       FIGS. 5A-5D  illustrate an embodiment wherein a single universal stabilizer  20  may be used to stabilize either end of the collar  10 . In this embodiment, the collar  10  contains an inner ridge, ledge, shelf, abutment, rim, ring, protrusion, or shelf (hereinafter “shelf”)  14   c  located between collar end  12  and collar end  11  and in communication with or coupled to wall  14 .  FIGS. 4B  and cross-section  4 D also show a shelf  14   c  placed at the midpoint of the collar  10 . 
       FIG. 5A  is a top-down view of an embodiment where the stabilizer end  26  is inserted into collar end  11  and pressed against the collar&#39;s inner shelf  14   c .  FIG. 5B  is a perspective view.  FIG. 5C  shows that an embodiment of stabilizer  20  may be inserted into either end  11  or end  12  of collar  10 . Specifically, rim  25  of stabilizer  20  may snap, slide, lock into or simply presses against either side of the shelf  14   c . In other embodiments, the arms  22  of the stabilizer-whether unified by a rim or not—may snap, fit or stop into or onto the inner shelf  14   c  from either end of the collar, depending on which end the surgeon chooses to use a receiving end to contact the cervix. 
       FIG. 5D  shows a cross-section of  FIG. 5C  wherein one stabilizer  20  abuts one face of shelf  14   c  while another stabilizer  20  abuts the opposite face of shelf  14   c . The illustration of two stabilizers at once abutting either face of the shelf  14   c  in  FIGS. 5C and 5D  is only to illustrate how a single stabilizer end  26  may press against shelf  14   c  from either end  11  or end  12  of collar  10 , not to show that two stabilizers are used simultaneously. Thus, only one stabilizer is needed, instead of two, which reduces hospital and surgical costs. 
     As shown in  FIG. 5D , shelf  14   c  may be located at any point between the ends  11  and  12 , including but not limited to the midpoint of the side wall  14 . When the shelf  14   c  is located near or at the midpoint of wall  14  as shown in  FIGS. 5A-5D , the rim  25  or prongs  22  of the stabilizer  20 , whether unified by a rim  25  or not, may fit into, contact, or press against either side of the shelf  14   c  on the interior sidewall  14   a.    
     In some embodiments, the collar&#39;s wall  14  may have one or more sets of shelves lining two or more different locations of the wall  14 . In other words, the interior of sidewall  14  of collar  10  may contain a series of evenly or unevenly spaced parallel shelves. For example, a shelf  14   c  may be positioned away from the midpoint and closer to collar end  11 , and another shelf  14   c  may be positioned closer to collar end  12 , as shown in  FIG. 4F . In such an embodiment, when the stabilizer end  26  abuts the shelf  14   c , the distance between the stabilizer base portion  21  and the receiving end of the collar is greater than if the shelf  14   c  were placed at the midpoint of the inner wall  14 . This embodiment creates a longer inner cavity  19  to accommodate longer cervixes, which slide through the length of the collar (e.g.,  FIG. 13B ). The shelf sets may have identical designs, or may have different designs according to the possibilities described below. 
     In another embodiment, the collar&#39;s wall  14  may have more than two sets of shelves to accommodate stabilizers of different depths and diameters. For example, a collar may contain one or more shelves  14   c  located on either side of the inner wall  14 &#39;s midpoint, as shown in  FIG. 4E . Thus, a stabilizer with a larger diameter may abut a shelf located closer to end  11  or end  12  of the collar, whereas a stabilizer of smaller diameter may be designed to slide past the first shelf and press against a second shelf closer to or at the midpoint of collar wall  14 . Multiple shelves of different diameters would accommodate cervixes of different lengths. The shelf sets may have identical designs, or may have different designs according to the possible embodiments described below. 
     In an embodiment, a shelf  14   c  may be comprised of one or more continuous circular rings, protrusions, or ledges which the prongs  22 , rim  25 , or end  26  of the stabilizer snaps, slides, locks into or simply presses against. In another embodiment, the shelf  14   c  may be one or more discontinuous shelf tabs, protrusions, abutments, which the prongs  22 , rim  25  (which may or may not be continuous in different embodiments), or end  26  of the stabilizer snaps, slides, locks into or simply presses against. The discontinuous shelf tabs may be evenly or unevenly spaced, polygonal, curved, or mixed. The discontinuous shelf tabs have the same or different shapes and be smooth, jagged or mixed. In another embodiment, the shelf  14   c  may be comprised of a subset of both continuous and discontinuous shelves. Mixed shelves would facilitate a locking mechanism of stabilizer rim  25  to collar  10 . In other embodiments, when a collar contains multiple sets of shelves, one set may be continuous while the other set is discontinuous. One set may also include both continuous and discontinuous sub-shelves to facilitate a locking function. 
     In other embodiments, a shelf  14   c  may be angled against the sidewall  14 , be rounded, have a trapezoidal or polygonal surface, or the like to further facilitate security and stability of the stabilizer end or rim  25 . In addition, a shelf  14   c  may have an angled or perpendicular shelf  14   d  to reduce slide or slippage of the stabilizer rim and hold it in place. The angled shelf  14   d  may be continuous or discontinuous as a series of shelf tabs, with possible configurations described in the preceding paragraph. An angled shelf or shelf tabs is/are particularly useful on the side of the shelf facing end  12 , which may have a greater surface area because of the increasing diameter of the sidewall  14  from end  11  to end  12 . Alternatively, the inner sidewalls may have varying thickness to achieve the same effect as shelves or to support a shelf or multiple shelves. 
     The surface area of the shelf  14   c  may be increased to the point where it creates a continuous disc or surface without holes. In such an embodiment, the disc creates a closed end of the collar so that the stabilizer end  25  presses against the closed end. This embodiment reduces the dual-use collar into a single use collar and limits intravaginal access to the cervix. 
     In some embodiments, the distance  17   h  between the shelf  14   c  and end  11  may be between 2-5 mm, 5-10 mm, 10-15 mm, 15-20 mm, 20-25 mm, or 25-30 mm. In some embodiments, the distance  17   i  between the shelf  14   c  and end  12  may be between 2-5 mm, 5-10 mm, 10-15 mm, 15-20 mm, 20-25 mm, or 25-30 mm. In some embodiments, the distance  17   j  between the inner edge of shelf  14   c  and the closest edge of shelf tab  14   d  may be between 0-1 mm, 1-2 mm, 2-4 mm, 4-6 mm, or 6-8 mm. In some embodiments, the shelf thickness  17   k  may be between 0-1 mm, 1-2 mm, 2-4 mm, 4-6 mm, 6-8 mm, or 8-10 mm. 
     Dual-Use Stabilizer 
       FIGS. 6A-6E  illustrate a stabilizer  20  according to an embodiment of the invention. As shown in  FIG. 6A , the stabilizer  20  includes a base portion  21 , prongs  22  extending from the base portion  21 , and a rim  25  unifying the prongs  22  (although other embodiments may forego a continuous rim and include one or more prongs). The base portion  21  includes walls  23  that define an opening  24  at a center portion of the base portion. The opening  24  is of sufficient size to pass a tube or shaft, such as a shaft  31  of a uterine manipulator (as shown in  FIG. 2A ). The opening may also include an extended guide hole with walls  33  to facilitate passage of the shaft, as shown in  FIG. 14C . In another embodiment, the stabilizer has a sidewall  29  without prongs or windows, as shown in  FIG. 14A . 
     As shown in  FIG. 6A , the stabilizer  20  contains a rim surface  25  having an outer edge  25   a , an inner edge  25   b , and a rim surface  25   c  between the outer and inner edges  25   a  and  25   b . The stabilizer  20  also includes a second outer rim edge  25   f  separated from surface  25   a  by a trough or gully  25   g.    
       FIGS. 14A through 14F  illustrate alternative embodiments of the stabilizer, containing features that may be mixed and matched.  FIG. 14A  shows a stabilizer with a sidewall  29 . This sidewall  29  may have one or more windows or holes  27 , as shown in  FIGS. 14E-14H .  FIG. 14B  shows an embodiment that is single-rimmed, whereas  FIG. 14C  shows a double-rimmed embodiment.  FIG. 14D  shows an embodiment of a stabilizer with ridged or ribbed sidewalls. 
       FIGS. 14E through 14F  illustrate four views of an embodiment of a stabilizer.  FIG. 14E  is a side-view,  14 F a cross-sectional view,  14 G a top-down view, and  14 H is an angled view. In this embodiment, the stabilizer  20  includes a base portion  21 , sidewall  29  extending from the base portion  21  with windows  27 , and a rim  25 . The opening  24  is of sufficient size to pass a tube or shaft, such as a shaft  31  of a uterine manipulator. The opening  24  also includes an extended guide hole with walls  33  to facilitate passage of the shaft. The holes  27  may be utilized to suture the cervix with the stabilizer  20  for easy removal of the cervix after a colpotomy or hysterectomy. In other words, a surgeon may pass a needle and thread through the hole to suture the cervix to the stabilizer&#39;s sidewall  29 . The sidewall  29  may be smooth, or alternatively ridged or ribbed as the stabilizer prongs shown in  FIG. 14D   
     The &#39;517 application describes a variety of rim shapes and configurations applicable to rim  13  of end  11 , depicted also in many of the figures. These and other shapes and configurations are also applicable to rim  25  of stabilizer  20 . The stabilizer may also serve as a delineator for abnormally small cervixes and may contain a gully  25   g  as shown in  FIG. 6B  to facilitate an incision. For example, for abnormally small cervixes that are smaller in diameter than end  11  of the collar  10 , the surgeon may slide the stabilizer over the cervix without the accompanying collar, and use stabilizer&#39;s rim  25  to delineate the fornix, as shown in  FIG. 8E . Small cervixes do not require the same support as a normal or large cervix; therefore the stabilizer is sufficient in serving as a fornix manipulator or delineator, further reducing the need for multiple collars and saving costs. 
     In some embodiments, the stabilizer may have a number of embodiments. In some embodiments, the height  171  between the base portion  21  and unifying rim  25  may be between 5-10 mm, 10-15 mm, 15-20 mm, 20-25 mm, or 25-30 mm. In some embodiments, the diameter  17   m  of the rim  25  may be between 10-15 mm, 15-20 mm, 20-25 mm, 25-30 mm, 30-35 mm, or 35-40 mm. In some embodiments, the diameter  17   n  of the base portion  21  may be between 5-10 mm, 10-15 mm, 15-20 mm, or 20-25 mm. In some embodiments, the diameter  17   o  of the opening  24  may be between 0-2 mm, 2-4 mm, 4-6 mm, 6-8 mm, or 8-10 mm. 
     Reinforced Stabilizer 
       FIGS. 7A-7B  shows a stabilizer  20  may be connected to an outer tube  61  made of plastic, metal, nanofibers or some other biocompatible material. The tube  61  slides over a portion of the uterine shaft  31 , as shown in  FIG. 2A , and therefore minimizes the risk of the stabilizer  20  falling into the vaginal canal upon removal from the vagina. The outer tube  61  also allows for more stable application of force against the stabilizer  20  and reduces slippage of the stabilizer against the collar and uterine shaft when the uterine manipulator system is in use against a cervix. The outer tube  61  may be connected to the stabilizer  20  or manufactured as one part. An outer tube  61  may completely surround the shaft  31 , as shown in  FIG. 2A , or may partially surround the shaft. The outer tube may partially surround the shaft and remain slidable along the shaft. The outer tube  61  may extend a partial or total length of the shaft, as shown in  FIG. 17 . 
     A disc or other object may intermediate the connection between outer  61  tube and stabilizer  20  in order to enable a more even distribution of pressure from the outer tube  61  against the stabilizer  20 , and to prevent abdominal air leaks from the stabilizer aperture when an incision is made during a colpotomy. 
     As illustrated in  FIG. 2B , the outer tube  61  may also be part of or in fluid communication with a pressing portion  60  that secures the outer tube  61  onto a desired portion of the uterine shaft  31 . The pressing portion  60  may be comprised of a fixing portion  62  connected to a screw  63  (e.g., set screw). When the pressing portion is moved to a desired point on the shaft  31 , the screw  63  (which is connected to the fixing portion  62 ) may be tightened to the shaft  31 . This fixes the pressing portion  60  on the shaft  31 . In another embodiment, the pressing portion may be comprised of a slidable clip or a spring based-clip that locks into place when released. In yet another embodiment, a fastener may include set screw or any other fastener such as, for example, a stop collar. A stop collar (also called a shaft collar) is a mechanical fastener that goes around a shaft or rod with a screw or clamp or other tightening mechanism to fix the collar in position. Stop collars may take the form of small rings. A user can clamp the collar into place by running a screw through the collar and into the shaft, or by clamping the collar to distribute the pressure more evenly and reduce the risk of damage to the shaft. A stop collar may use a threaded portion that, when tightened, drives a member against the inner shaft to lock the shaft into place. A stop collar is a mechanical stop, which can attach components (e.g., outer tube  61 ) to a shaft (e.g., shaft  31 ), and may be used for positioning, limiting, and spacing activities. 
     When the pressing portion  60  is pressed against the outer tube  61 , the fornix may be more precisely delineated. This is because the pressing portion applies pressure to the outer tube  61 , which in turn applies pressure to the stabilizer  20  (which may or may not be attached to the outer tube  61 ). The stabilizer  20  applies pressure against collar  10 , which causes the rim of the collar to press against the intra-vaginal fornix and distend the fornix. When the pressing portion  60  is connected to the outer tube  61 , there is less slippage between the two components and pressure is more directly applied to the fornix. 
     In some embodiments, the diameter  17   p  of the tube  61  may be between 2-4 mm, 4-6 mm, 6-8 mm, or 8-10 mm, 10-12 mm, or 12-14 mm. In some embodiments, the length  17   q  may be between 5-15 cm, 15-25 cm, 25-35 cm, or 35-45 cm. 
     Alternatively, the outer tube  61  may extend outside the vagina  107 , with or without a pressing portion  60  as shown in  FIG. 17 . An extended outer tube  61  allows a surgeon to adjust the length of the shaft  31  extended through the vaginal canal and uterus by holding fixed the portion of outer tube  61  outside the vaginal canal and then sliding the shaft  31  forward into the canal or backward outside the canal. Sliding the shaft  31  may be facilitated if the shaft  31  is affixed to a handle  32 . When the shaft  31  is affixed to handle  32 , a surgeon may adjust the length of the shaft  31  extended through the vaginal canal and uterus by holding fixed the outer tube  61  while pushing forward or pulling back the handle  32 . In this embodiment, the outer tube  61  operates as a slider or slidable element. The outer tube may extend a partial length of the shaft, or alternatively may exceed the length of the shaft. 
     The Uterine Shaft 
       FIGS. 8A-8C  show possible embodiments of a uterine shaft  31 , a tube made of plastic, metal, or any other biocompatible material, or combination thereof. For example, the shaft  31  may be a combination of metal or plastic encased by plastic or other nonconductive material. In an embodiment, the shaft  31  contains an inner conduit for passage of fluid. In another embodiment, the tube does not contain an inner conduit. 
     In embodiments where the shaft has an inner conduit, the inlet end of the shaft  31  may contain an inlet  40  configured to receive fluid, as shown in  FIGS. 8D-8F . Once injected, fluid may travel to through an outlet  37  at the distal tip of the shaft and into the uterus, or through an outlet  71  on a special tip  70  and into the uterus, as shown in  FIGS. 8C &amp; 8D  respectively. Inlet  40  may include a cap  34  and lock, luer lock or other mechanism or valve to control fluid flow through shaft  31 . As shown in  FIGS. 3A-3B  and  FIG. 12E , the inlet  40  can be attached to either the shaft  31 , handle  32 , or both. Similarly, the cap  34  may screw on to inlet  40 , handle  32 , or both. 
       FIGS. 8D-8H  show a shaft in combination with various parts, which may or may not be employed depending on the intended use or patient characteristics. For example,  FIG. 8D  shows a shaft  31  coupled to a tip  70  and handle  32  to create a simple dye delivery system.  FIG. 8E  shows the addition of a stabilizer  20  and shaft  61  to create an adolescent uterine manipulator system suitable for smaller cervixes.  FIG. 8F  shows the addition of a collar  10  to create an adult uterine manipulator system for adult cervixes.  FIG. 8G  and  FIG. 8H  show the addition of a fulcrum  50  to create a pivot point for the uterine manipulator in the simple and complex uterine manipulator system, respectively. 
     The outlet end of the shaft  31  may contain a screw portion  36 , as shown in  FIG. 8A . As shown in  FIG. 8A , a screw portion  36  may be comprised of external threads, roots or flanks configured to allow a special tip (such as element  70  shown in  FIG. 8D ) or balloon to be screwed on for dye delivery, inflation or other medical purposes. Alternatively, the shaft may have one or more openings or holes  37  at its tip or along the shaft&#39;s distal sidewalls. The hole  37  may be circular, rectangular, oval, or any other polygonal or trapezoidal shape. 
     The shaft  31  may have various shapes, as illustrated in  FIGS. 8A-8C .  FIG. 8A  shows a curved shaft  31 .  FIG. 8B  shows a straight shaft  31 .  FIG. 8C  shows a shaft with three sections. The third section  49  is designed for complete or partial insertion into the uterine cavity. The second section  48  is designed to travel partially or completely through vaginal canal. The first section  47  is designed for partial or complete protrusion outside of the vaginal canal. First section  47  may contain a handle  32  and/or inlet  40  with cap  34 . As shown in  FIG. 8C , the third section  49  may be curved or sharply angled to facilitate manipulation and elevation of the uterus intra-abdominally from nearby vital organs such as the sigmoid colon. Here, the second section  48  includes a second long axis and the distal third section  49  includes a distal end long axis that intersects the second section  48  long axis at an intersection angle between 0 to 90 degrees. 
     The advantage of the straight shaft with a curved tip, as shown in  FIG. 8C , is that movements of the shaft correlate to movements or displacements of the uterus. For example, rotation of the handle leads to direct rotation of the uterus. Movement of the shaft along the horizontal axis leads to horizontal displacement of the uterus. Movement of the shaft along the vertical axis leads to vertical displacement of the uterus. This is not true for multiple curved embodiments of a shaft, such as a shaft shown  FIG. 8A . For example, clockwise rotation of an embodiment with a straight shaft with curved tip (e.g., a shaft shown in  FIG. 8C ) leads to corollary right or clockwise rotation of the uterus. However, in a multi-curved shaft embodiment—exposure of the right fornix requires rotation and a disproportional upward and rightward movement (diagonal movement) of the shaft in order to achieve the same desired orientation. This complex diagonal vector movement is required because of the multiple curvature architecture and lack of a fulcrum in the pelvic cavity. Complex vector movements lead to complex instructions of the surgeon towards the assistant holding the shaft or uterine manipulator system. In contrast, the straight shaft and curved tip as shown in  FIG. 8C  permits clear instructions of the surgeon to the assistant. Clearer instructions may be facilitated by use of a directional handle described more in detail below. 
     In an alternative embodiment, the entire shape of the shaft is malleable. In another embodiment, the second and third section is malleable. In another embodiment, the distal third section is malleable. In the latter embodiment, a malleable third section would allow for the distal section to be manipulated 360 degrees along the second section axis and 360 degrees along the axis orthogonal to the second section, or a combination of both. Malleable material includes rubber and other biocompatible materials referenced through this specification or otherwise used in industry. 
     In some embodiments, the length of the third section  49 , or uterine portion, is 4 cm to 15 cm, and may be adjustable. In another embodiment, the length of the uterine portion is approximately 6 cm to 10 cm. The second section  48  designed for the vaginal canal may be 4 cm to 18 cm, depending on the patient&#39;s age. Alternatively, it may be a narrow range between 6 cm to 14 cm. The third section  27  containing the handle may be 6 cm or more. In an embodiment, the total length of the uterine shaft from the proximal to the distal end is greater than 15 cm. In an embodiment for adults, this length may be between 25 c  m and 40 cm, or more or less. Alternatively, the uterine shaft may be malleable in shape and the outer tube may be employed to adjust the length, as described below. In addition, an acute angle Φ between the second section  48  and third section  49  facilitates uterine manipulation and elevation, as shown in  FIG. 8C . In an embodiment, this angle is curved and gradual, as shown in  FIG. 8C , though it may also be sharp. In an embodiment, this angle may be 20 degrees to 80 degrees, as shown in  FIGS. 8C-8F . The angle may be adjustable to achieve greater or lesser angle. 
     The Tip of the Uterine Shaft 
     The distal end of the shaft  31  intended for insertion into a uterus may include one or more holes  37  along the sidewall to facilitate release of dye delivered through the shaft&#39;s inner lumen, as shown in  FIG. 8A . In addition, a hole may be placed at the most distal portion of the shaft&#39;s end for release of dye at the most distal portion, as shown in  FIG. 8B . Alternatively, a tip  70  may be affixed to the distal end to reduce the risk of perforation of the uterine wall, as shown in  FIG. 8D-8F . In an embodiment, tip  70  may be considered a portion of the distal end of the shaft  31 . 
       FIG. 9A  shows an embodiment of a tip  70 , and  FIG. 9B  show a cross-sectional view. The outlet end of the uterine shaft  31  may be affixed to or screwed into a tip  70  made of plastic, rubber, polyurethane, balloon-like biocompatible material, or other biocompatible or combination material. The tip may be affixed by glue, welding or other mechanism. In addition, the tip and/or the shaft may contain outer ridges, threads, flanks or roots to facilitate a screw mechanism for assembly. The tip  70  is inserted through the cervical canal and into the uterus, as illustrated in  FIG. 17 . 
     As shown in  FIGS. 9A-9B , the tip  70  may include one or more holes or apertures  71  dispersed along the sidewalls  79 . The holes may be circular, oval, rectangular shape, or any other shape, including trapezoidal shape, polygonal or an irregular circle shape. The holes may be microscopic or visible to the human eye. The purpose of the holes is to deliver dye (e.g., blue dye or indigo-carmine dye) into the uterus for, as an example, a “fallopian tube patency” test—an examination carried out to determine whether the fallopian tubes are clear and whether there are any abnormalities in the uterine cavity. To perform the procedure, a surgeon opens the inlet  40  located on the inlet end of the uterine shaft  31  (as shown in  FIG. 8B ) or on the distal portion of handle  32  (as shown in  FIG. 8D ), and connects a syringe containing dye to the inlet. The dye is then injected into the uterine shaft  31  and travels along the inner lumen of the shaft  31  into the tip  70  (see  FIG. 17  showing anatomy references). The dye then escapes the tip  70  through the hole  71  (or holes) located on the sidewalls  79  into the uterus  104  for the test. If the fallopian tube contains an abnormality, the dye leaks out of the uterus and fallopian tube and is visible in the pelvic cavity  111 . 
     The hole or series of holes  71  may also be placed at the far end  75  of the tip  70 , rather than on the sidewalls  79  in an embodiment. However, if the tip  70  is pressed against the uterine wall, the dye does not fill the uterus or enter the fallopian tube but rather remains in the tip or is alternatively absorbed by the uterus tissue or muscle. This may generate a false negative test result, which the current state of the art balloon tip often generates. Hence, in an embodiment, holes are along the sidewalls of the tip  70  to minimize the risk of false negatives by increasing the likelihood that the dye enters the uterus. Alternatively, if a special tip is not employed, one or more holes  37  may exist along the sidewalls of the shaft  31 , as shown in  FIG. 8A . 
     As shown in  FIGS. 10A-10E , the tip  70  may have an hourglass, dumbbell, humped, or curved shape. Alternatively it may have less curvature, as shown  FIG. 10E , or no or very limited curvature (as shown in  FIG. 10B ). The curves or humps located at points  73  and/or  72  (shown in  FIGS. 9A &amp; 9B ) serve to create a back seal between the tip and cervical canal. This prevents the dye from leaking out. In addition the curvature at point  72  prevents the tip from slipping out of the uterus, through the cervix into the vaginal canal. The curve at point  73  provides a rounded, blunted and expanded surface to minimize the risk of perforation of the uterine wall, which may occur if the uterine manipulator is inserted too deeply into the uterus. However, the curvature or number of humps may vary. A tip may have one hump, as shown in  FIG. 10B , though it makes the device less efficacious as it is liable to easily slip out. Or the tip may have two or more multiple humps (e.g., 2, 3, 4, 5 and so on). Alternatively, the tip may have different shapes (as shown in  FIGS. 10A-10E ) at any point including its distal end, such as an oval shape, rectangular shape, oblong shape, arrow shape, and the like. In other embodiments, the tip may have a single rounded snake head, as shown in  FIG. 10E . 
     The wall thickness of the tip  70 &#39;s sidewalls  79  may vary to create an empty oval core  74 , as shown in  FIG. 9B . Alternatively, the wall may have uniform thickness as shown in  FIG. 11A . The tip  70  may also have a ridged exterior to prevent slippage outside of the uterus into the vaginal canal. The ridges may be in on a proximal or distal portion of the tip, as shown in  FIG. 11B , or the ridges may be on the entire length of the tip  70 . The ridges may be horizontal, vertical, crossed, or in any design. The tip  70  may also include inner ridges at its inner proximal end to facilitate screwing the tip onto the shaft&#39;s distal end. 
     In some embodiments, the length  17   r  of the tip may be between 10-15 mm, 15-20 mm, 20-25 mm, 25-30 mm, 30-35 mm, 35-40 mm, 40-45 mm, 45-50 mm, 50-55 mm, or 55-60 mm. In some embodiments, the distance between the two humps at point  73  and  72  may be 10 mm to 30 mm. The minimum diameter of the hole(s)  71  may be 0-2 mm, 2-4 mm, 4-6 mm, 6-8 mm, or 8-10 mm. In some embodiments, the diameter  17   t  at points  73  and  72  may be between 3-5 mm, 6-7 mm, and 8-10 mm. The diameter  17  of the narrow middle portion may be between 0-2 mm, 2-4 mm, 4-6 mm, 6-8 mm, or 8-10 mm. 
     A uterine manipulator system that is comprised of a shaft  31  and tip  70  may serve as a simple dye delivery system, as shown in  FIG. 8D . In addition, a modified uterine manipulator system for small cervixes may exist utilizing the stabilizer  20  without the collar  10 , as shown in  FIG. 8E . In a modified system, an outer tube  61  and pressing portion  60  may be utilized for additional support and stability. 
     Uterine Shaft Handle 
       FIG. 12A  shows an embodiment of the handle  32  of the uterine shaft  31  containing a marking, ridge, or compass at  42  to indicate the appropriate angle and direction at which to hold the handle  32 . Current uterine manipulators have no indication on the appropriate placement of the manipulator. Physical markers or language at  42 , such as “This Side Up” or “Top”, would indicate to the holder the appropriate placement of the manipulator and minimize the risk of twisting the manipulator in the wrong direction during surgery. The area with the physical area may be flat or recessed for embossing a label. 
     As previously discussed, the handle  32  may also have directional components to facilitate precise instructions from the surgeon and corresponding movements of the uterine manipulator from the assistant holding the manipulator. In particular, the handle may have a triangle, polygonal, curved, or mixed shaped base portion  45  with a distinct tip  46  along an axis orthogonal to the axis of the shaft. In other words, the handle may include a base portion  45  that projects orthogonally (or any other angle) to the proximal end of the shaft. This base portion  45  enables a person holding the uterine manipulator to know how many degrees the device is rotated. 
     This rotation of the shaft  31  is often obscured in current embodiments where a hand wraps entirely around the handle  32 , or where rotations of the wrist do not clearly translate to rotations of the device to the human eye. For example, when the base portion  45  is comprised of a triangle with a tip  46 , as shown in the embodiment in  FIG. 12D , the surgeon may instruct the holder of the device to point the triangle tip  46  to the left or to the right, alternatively at 9 o&#39;clock or 3 o&#39;clock, to achieve the desired configuration. In addition the words “9 o&#39;clock” or “3 o&#39;clock,” “left” or “right” or any other such directional language may be printed on either side of the handle. In addition, the tip  46  may also contain a dot or other marking to facilitate simple instructions, such as “dot right” or “dot left” to instruct the holder to rotate the handle appropriately. 
     The base portion  45  may also be comprised of a vertical stick, rod or bar  55  attached perpendicularly or at an angle to the handle  32 , as shown in  FIG. 12B , which allows for similar instruction and printed directional language. The bar  55  may have a triangle or pyramid structure appended to the base portion  45 , as shown in  FIG. 17 . The bar  55  may extend through both ends of the handle  32 , forming a T shape, as shown in  FIG. 12E . The bar  55  may be rectangular, triangular, or any other polygonal shape. It may be curved or a combination of curves and polygonal shapes. Alternatively, the bar  55  and handle  32  may form a vertical joystick-like grip, wherein fingers are intended to wrap around the face connecting to or proximal to the shaft and the thumb is intended to rest perpendicular to the fingers on the distal portion of the handle  32 , as shown in  FIG. 12E . When connected to a robotic arm, the grip may be comprised of a robotic arm attachment  220 . This attachment may allow allows for forward, vertical, horizontal, and rotational motion or six degrees of freedom of the robotic arm and uterine manipulator system. 
       FIGS. 13A-C ,  14 A-H and  15 A-C illustrate alternative embodiments of a stabilizer  20  and collar  10 . Each of the embodiments shown in  FIGS. 13A-13C  generally show opposing ends of a collar whereby one end has a larger diameter than the other end. Like the collar shown in  FIG. 2A , the collars  10  shown in  FIGS. 13B and 13C  include ridges on the outside wall to help guide a cutting surface.  FIG. 13B  shows an additional hole  14   e  to facilitate the attachment of a strap  64 .  FIG. 13B  also shows a shelf  14   c  located at a distal portion, whereas  FIG. 13C  shows a shelf  14   c  located at the midpoint of the collar wall  14 .  FIGS. 14A through 14D  show embodiments of a stabilizer configured for attachment to a collar  10 .  FIG. 14A  shows a stabilizer  20  without prongs and instead a sidewall  29 .  FIG. 14C  shows a stabilizer with a double-rim configured for delineating use on a small cervix.  FIG. 14D  shows a stabilizer with ribbed outer walls configured to reduce slippage within the vaginal canal.  FIGS. 14E-14F  illustrate an embodiment of a stabilizer with sidewalls  29  and small windows  27 .  FIGS. 15A-15C  show embodiments of a collar and stabilizer manufactured as one piece. 
     Fulcrum 
     To facilitate precise displacement of the uterus, the shaft may contain a fulcrum (hereinafter “fulcrum”)  50  or an attachment for positioning a fulcrum or fulcrum point, as shown in  FIG. 8G-8H . The fulcrum  50  may be placed intravaginally or exist external to vagina. When placed intravaginally, the fulcrum may be comprised of a disc, plate or sponge as shown in  FIG. 8G . Alternatively, the fulcrum may be spherical or rounded in shape as shown in  FIG. 8H . Alternatively, the fulcrum may be polygonal or trapezoidal in shape. The fulcrum  50  may be positioned or slidable along any portion of the shaft  31 . For example, the fulcrum  50  may surround the second section  48  or third section  49  of the shaft  31 , as shown in  FIG. 8G ; it may surround, be a affixed to or part of the outer tube  61 , as shown in  FIG. 17 ; or the fulcrum  50  may be positioned between components, such as the outer tube  61  and pressing portion  60 , or between the stabilizer  20  and outer tube  61 . 
       FIG. 18A  shows an embodiment of a fulcrum wherein it is a disk structure with one or more arms  134 , rim  130  and hole  132 . Space exists between arms to facilitate insertion of a tenaculum and provide access to the cervix. Alternatively, as shown in  FIG. 18B , the fulcrum may contain no arms and be comprised of a solid disc with one or more holes. When a solid object with a single hole to receive the shaft, the fulcrum has serves as a plug against intrabdominal air leaks after an incision made at the fornix. The rim  130  is adapted to contact the vaginal wall. The fulcrum  50  may also exist, in the alternative, as spherical, oval, trapezoidal, and polygonal shapes. The fulcrum may also be spherical or rounded in shape, or have extended depth into the vaginal canal. Hole  132  may be at the center point of the fulcrum, or another point. 
     In some embodiments, the fulcrum  50  may be a sponge which slides over the shaft  31  between the stabilizer and shaft handle. A sponge prevents the escape of CO 2  from the abdominal area when the fornix is incised. This sponge may be configured to expand into and fill the vaginal cavity. Alternatively, the sponge may be located between the stabilizer  20  and collar  10 , and fill any extra space between in cavity  19  of the collar not filled by the cervix. The sponge may be made of gauze or the like. It may be comprised of natural or synthetic sponge material, foam, or any material that naturally expands into the vaginal cavity. 
     In addition, a plate, tube, speculum or retractor (hereinafter “retractor”)  82  may be placed intravaginally to provide resistance against or fixed support for the fulcrum  50 .  FIG. 17  illustrates an embodiment of a uterine manipulator having a collar  10 , stabilizer  20 , uterine shaft  31 , outer tube  61 , pressing portion  60 , handle  32 , tip  70 , and fulcrum  50 , used in conjunction with a vaginal retractor  82 . 
     The vaginal retractor  82  is placed within a vaginal canal and used to expand the upper and lower walls of the vagina. A uterine manipulator shaft travels between the retractor and is inserted into the cervix. The retractor plates provide a fixed platform against which the fulcrum  50  operates. 
     The retractor  82  may be comprised of a spoon like structure with an elongated body and concave distal portion of greater diameter than the elongated body. Alternatively, the retractor  82  may be a speculum, or be comprised of a plate, which may have concave curvature or one or more protrusions perpendicular to the elongated plate, as in a “Sims Retractor.” Or the retractor  82  may be comprised of a simple elongated body, which may be concave or convex. The retractor  82  may also be comprised of a hollow tube with two open ends, or a speculum structure with a diameter larger than the uterine manipulator system to permit horizontal and vertical movement of the shaft within the tube. Or the retractor  82  may be any tool or surface that provides a fixed plane. The material may be metal, plastic, or any other biocompatible material. 
     In another embodiment, the fulcrum  50  may be created by coupling an external arm  200  to a shaft  31 , handle  32  or outer tube  61  of a uterine manipulator system  30 , or dye delivery system, as shown in  FIGS. 16A-16F . As shown in  FIG. 16A and 16B , the arm  200  may attach at the second section  48  or first section  47  of shaft  31  to create a fulcrum  50  at the attachment point of the arm  90  to the shaft  31  (e.g., the second section  48  or first section  47  of shaft  31  as shown in  FIGS. 8C ). The arm may also attach to the third section  49 , however, this may be invasive in the vaginal canal. When the shaft  31 , or other component parts of a uterine manipulator system (e.g., handle  32  or outer tube  61 ) attaches to an external arm, a fulcrum  50  is created at the attachment point. The fulcrum  50  enables movements of the external arm to correlate to movements of the uterine manipulator system  30  and, when inserted into the uterus, movements of the uterus  104 . A fulcrum is particularly well suited for the shaft shapes illustrated in  FIG. 8B  &amp;  FIG. 8C . 
     The arm  200  may be comprised of a robotic arm part of a robotic surgery platform. In robotic surgery, an automated arm leads to automated movements of the uterine manipulator system  30 , as shown in  FIGS. 16E-16D . 
     Alternatively, the arm may have an attachment point  202 , which clamps, screws or affixes onto an operating table, as shown in  FIG. 16A . Alternatively the attachment point  202  may attach to a patient&#39;s extremities, such as legs.  FIG. 16C  shows an arm  200  attached to a plate  95 , which the patient&#39;s body rests upon and is therefore immobile due to the gravitational force of the patient&#39;s body. The plate may be affixed to the operating table  98  via a strap(s)  99  or other fixing mechanism to ensure it is immobile. Alternatively, the strap may encircle the patient and be secured via a knot, velcro or other fixing mechanism. The plate  95  may be any circular, oval, rectangular, square, polygonal or other mixed shape.ARTICULATION SYSTEM 
     The uterine manipulator system  30  or dye delivery system may include a fulcrum  50  comprised of a linkage to assist in articulation of the uterine manipulator. The linkage may include, for example, a collection of rigid shafts interconnected by pivots and/or clamps to enable selected ranges of motion. The selected ranges of motion are adapted to extend within a three-space envelope needed or expected to be needed for the uterus undergoing the procedure. 
     The linkage, for example, may include an arm  200 , as shown in  FIG. 16A  and  FIG. 16B , such as a Martin&#39;s arm). The arm includes an attachment point  202  comprised of a clamp, a right angle shaft  204 , a secondary shaft  206 , a tertiary shaft  208  and an end clamp  210 . The attachment point  202  is configured to fix the arm  200  to a fixed surface in proximity to the patient, such as an operating table. 
     The attachment point  202  may connect to the right angle shaft at a first end and may have two degrees of freedom. The attachment point  202  may include a rotational component that can be freed or fixed with a locking knob. The attachment point  202  may also include a second locking knob that allows sliding translation of the right angle shaft  204 . 
     The right angle shaft  204  may have a long portion  204   a  configured to extend through a linear opening  202   a  defined in the attachment point  202 . The right angle shaft may include a short portion  204   b  extending at a right angle to the long portion  204   a  and supporting a ball at its free end. The long portion  204   a  of the right angle shaft  204  may be sized and shaped to extend vertically the anterior-posterior thickness of a patient reclined on the operating table. The short portion  204   b  of the right angle shaft  204  may be sized to partially close the distance between the table&#39;s edge and the patient&#39;s uterus. 
     The secondary shaft  206  may include a lockable socket  212  at a first end. The lockable socket  212  may be configured to receive the ball at the free end of the right angle shaft  204 . The lockable socket  212  may be configured to allow the secondary shaft  206  to move with three rotational degrees of freedom relative to the right angle shaft  204 . The lockable socket  212  may be configured for a friction fit with the ball of the right angle shaft  204 . The friction fit may be calibrated to allow the health care worker to move the secondary shaft  206  relative to the right angle shaft  204  but to remain relatively fixed when not under hand forces. 
     The secondary shaft  206  may be a linear shaft and relatively shorter than the long portion of the right angle shaft  204  and about the same length as the shorter portion of the right angle shaft. 
     The secondary shaft  206  may include a second end with a lockable pivot  214 . The lockable pivot  214  may connect the second end of the secondary shaft  206  to a first end of the tertiary shaft. The lockable pivot  214  may include a locking knob  214   b  configured to fix the single pivoting degree of freedom between the secondary and tertiary shafts. 
     The tertiary shaft  208  is a linear shaft that may be the same length as the secondary shaft  206 . The tertiary shaft  208  may include a second end  208 a with a socket similar to the socket of the secondary shaft  206 . 
     The end clamp  210  includes a ball configured to rotate with three degrees of rotational freedom within the socket of the tertiary shaft  208 . The end clamp  210  includes a C or U shaped body defining an opening configured to slidably receive a portion or shaft of the uterine manipulator. The end clamp  210  also includes a screw mechanism  216  having a lever at a free end and a locking face at an end extending into the opening of the C or U shaped body of the end clamp  210 . The lever may be gripped to rotate the screw and advance the locking face into the portion of the uterine manipulator extending through the opening of the body. The screw mechanism  216  is therefore configured to lock or fix the uterine manipulator into place relative to the end clamp  210 . 
     Once the uterine manipulator is fixed to the end clamp  210 , the intervening movable connections between the shafts enable a relatively full range of six degree of freedom motion relative to the patient. At the same time, the healthcare worker can selectively fix the various interconnecting joints to eliminate degrees of freedom and provide for a more controlled manipulation of the uterus. A modified arm  200  with fewer degrees of motion and fewer intervening shafts may be used, as illustrated in  FIG. 16F . 
     In another embodiment, an arm may be connected to a tripod-like structure, as shown in  FIG. 16F . In such an embodiment the tripod legs  200 , which may be two or more, would support a base portion  202  and have similar mechanics as a Martin&#39;s arm. For example, the height or vertical translation could be controlled by an attachment point  202  and the device could include a secondary shaft  206 , a tertiary shaft  208  and an end clamp  210 . The secondary shaft  206  may also include a lockable socket  212  at a first end configured to receive the ball at the free end. The lockable socket  212  may be configured to allow the secondary shaft  206  to move with three rotational degrees of freedom. The secondary shaft  206  may also include a second end with a lockable pivot  214 . The lockable pivot  214  may connect the second end of the secondary shaft  206  to a first end of the tertiary shaft. The lockable pivot  214  may include a locking knob  214   b  configured to fix the single pivoting degree of freedom between the secondary and tertiary shafts. The tertiary shaft  208  may include a second end  208 a with a socket similar to the socket of the secondary shaft  206 . And the end clamp  210  includes a ball configured to rotate with three degrees of rotational freedom within the socket of the tertiary shaft  208 . The end clamp  210  includes a C or U shaped body defining an opening configured to slidably receive a portion or shaft of the uterine manipulator. The end clamp  210  also includes a screw mechanism  216  having a lever at a free end and a locking face at an end extending into the opening of the C or U shaped body of the end clamp  210 . The lever may be gripped to rotate the screw and advance the locking face into the portion of the uterine manipulator extending through the opening of the body. The screw mechanism  216  is therefore configured to lock or fix the uterine manipulator into place relative to the end clamp  210 . 
     Rather than a hand-operated arm, the linkage  150  may include various motors to form a partial or full robotic system  240 .  FIG. 16D  illustrates a robotic arm  220  coupled to a uterine manipulator system  30  and  FIG. 16E  illustrates a robotic arm  220  and uterine manipulator system  30  as part of a robotic system. The robotic system may be configured to achieve the same full six degrees of freedom motion within the envelope needed to perform the uterine manipulation. The robotic system may be a generalized robotic arm  220  with an end effector  221  configured to grip or lock onto a portion of the uterine manipulator. The effector  221  also serves as a fulcrum  50 . A commercially available robotic arm system, for example, is the da Vinci surgical system sold by Intuitive Surgical. The linkage system need not be commercially available but instead could be selectively combine various dimensions and motorization to best fit the desired amount of precision, motion and control desired by the health care worker. 
     Not every embodiment of a uterine manipulator system necessarily includes the particular features, structures, or characteristics described in the specification. For example, a uterine manipulator system may be comprised of a shaft  31  and tip and may serve as a simple dye delivery system, as shown in  FIG. 8D . The tip  70  may be substituted with a balloon. In other embodiments, the system may also include a fulcrum  50  or fulcrum attachment. Alternatively, the system may also include a stabilizer  20  that may or may not be accompanied by an outer tube  61 . In other embodiments, the system may include additionally a collar  10 . 
     The uterine manipulator system and its various embodiments may be packed, sold or delivered as a kit with a surgical tool or device, such as an arm, linkage, robotic arm or any device the facilitates articulation. In addition, one more collars and stabilizers may be sold in a single uterine manipulator kit. For example, such a kit may include one or more collars and one or more stabilizers in addition to a shaft  31 , tip  70  and handle  32 . Alternatively, a kit may include a shaft  31 , tip  70  and handle  32 , but the collars and stabilizers are sold separately. The device may come pre-assembled or separately with the system. The kit may include other materials including appropriate labeling, one or more sterile barriers (e.g., 2 barriers), trays, bags, and a box. These other components may be sterile. 
     All parts may be constructed from a variety of materials, including but not limited to plastic, metal, cloth, textiles, synthetic fibers, nylon, rubber, Silicone (Polydimethylsiloxane), Polyurethane (e.g., Aliphatic Aromatic), Polycarbonate Urethane, Polyvinyl Chloride (PVC), Polyethylene Mesh or Film (e.g, LLDPE, LDPE, HDPE), Polypropylene Mesh or Film, Nylon, Pebax, Polycarbonate, or other materials with other appropriate or similar properties. 
     Various examples of embodiments are now discussed. 
     Example A includes a uterine manipulator, comprising a uterine shaft, collar, and stabilizer; wherein the collar has a first end having a first opening with a rim to encircle the first opening, and a second end having a second opening with a rim to encircle the second opening; the second end having a diameter greater than the first end, and the collar having an inner surface and outer surface to define an inner cavity; and a stabilizer comprising a base portion and a plurality of prongs extending from the base portion; wherein the uterine shaft slides through the base portion of the stabilizer, and the ends of the prongs of the stabilizer contact the collar. 
     Another example includes the uterine manipulator of Example A, wherein the collar has one of a trapezoid cross-section shape, a domed cross-section shape, polygonal or a combination of a polygonal and domed cross-section shape. 
     Another example includes the uterine manipulator of Example A, wherein the collar has a plurality of parallel ridges around an outer surface of the collar. 
     Another example includes the uterine manipulator of Example A, wherein the collar has one of a hole, ring, tab, or other shelf fixed to the collar to receive a strap. 
     Another example includes the uterine manipulator of Example A, wherein one or more rims include an outer edge, an inner edge, and a rim surface between the outer edge and the inner edge to define the opening, and the rim surface is angled with respect to a plane defined by the outer edge. 
     Another example includes the uterine manipulator of Example A, wherein one or more rims include a shelf extending inward toward a middle portion of the collar from the first end. 
     Another example includes the uterine manipulator of Example A, wherein one or more rims comprise a first outer rim edge adjacent to the first opening and a second outer rim edge separated from the first outer rim edge by a gully. 
     Another example includes the uterine manipulator of Example A, wherein the base portion of the stabilizer has a guide hole. Another example may include the subject matter of the immediately preceding example, wherein the ends of the prongs contact a gully on the inner surface between the second outer rim edge and collar wall. 
     Another example includes the uterine manipulator of Example A, wherein the ends of the prongs contact an inner surface of the collar. 
     Another example includes the uterine manipulator of Example A, wherein the ends of the prongs of the stabilizer contact a rim of the collar. 
     Example B includes the uterine manipulator of Example A, wherein the stabilizer includes a stabilizer rim connecting the ends of the prongs that are opposite the base portion. Another example includes the uterine manipulator of Example B, wherein the stabilizer rim contacts the inner surface of the collar. Another example includes the uterine manipulator of Example B, wherein the stabilizer rim contacts a rim of the collar. Another example includes the uterine manipulator of Example B, wherein the stabilizer rim contacts a gully on the inner surface between an outer rim edge and collar wall. 
     Example C includes the uterine manipulator of Example A, wherein the inner surface of the collar wall includes one or more shelves. Another example includes the uterine manipulator of Example C, wherein the stabilizer rim contacts a shelf on the inner surface of the collar wall. Another example includes the uterine manipulator of Example C, wherein the stabilizer prongs contacts a shelf on the inner surface of the collar wall. Another example includes the uterine manipulator of Example C, wherein the shelves contain additional angled shelves. Another example includes the uterine manipulator of Example C, wherein the shelf(s) constitutes a circular inner rim or edge along the inner surface of the collar wall. Another example includes the uterine manipulator of Example C, wherein the shelf(s) is located at the midpoint between the inner and outer end of the collar. 
     Another example includes the uterine manipulator of Example A, wherein the stabilizer rim includes an outer edge, an inner edge, and a rim surface between the outer edge and the inner edge to define the opening. 
     Another example includes the uterine manipulator of Example A, wherein the stabilizer rim comprises a first outer rim edge adjacent to the first opening and a second outer rim edge separated from the first outer rim edge by a gully. 
     Another example includes the uterine manipulator of Example A, wherein the stabilizer prongs extend from the base portion to form one of a “U” shape, a “V” shape, or a wishbone shape, with the base portion located at a center point of the “U,” the “V”, and the wishbone, respectively. 
     Another example includes the uterine manipulator of Example A, wherein ends of the plurality of prongs opposite the base portion of the stabilizer are not mechanically connected to each other. 
     Another example includes the uterine manipulator of Example A, wherein the base portion of the stabilizer is connected to a hollow tube. 
     Another example includes the uterine manipulator of Example A, wherein a pressing portion including a screw and fixing portion slide over the uterine shaft. 
     Example D includes the uterine manipulator of Example A, wherein the shaft includes an inlet at one end an outlet at the opposite end. Another example includes the uterine manipulator of Example D, wherein the inlet is a luer lock. Another example includes the uterine manipulator of Example D, wherein the inlet includes a cap. Another example includes the uterine manipulator of Example D, wherein the outlet is a hole on the sidewall of the shaft. Another example includes the uterine manipulator of Example D, wherein the end containing the outlet has a screw portion. Another example includes the uterine manipulator of Example D, wherein the outlet is a hole on the sidewall of the shaft. 
     Example E includes the uterine manipulator of Example D, wherein the outlet end of the shaft includes a tip. Another example includes the uterine manipulator of Example E, wherein the tip is detachable. Another example includes the uterine manipulator of Example E, wherein the tip includes one or more holes. Another example includes the uterine manipulator of the immediately preceding example, wherein the holes are on the sidewalls of the tip. Another example includes the uterine manipulator of Example E, wherein the tip has an hourglass, dumbbell, or curved shape. Another example includes the uterine manipulator of Example A, wherein the tip has a ribbed portion. 
     Another example includes the uterine manipulator of Example A, wherein the shaft includes a handle. Another example includes the uterine manipulator of the immediately preceding example, wherein the handle has a marking, ridge, compass, or shelf. 
     Example 1 includes a uterine manipulator system comprising: (1) a collar including (a)(i) a first end comprising a first opening, having a first diameter, surrounded by a first rim, (a)(ii) a second end, opposite the first end, having a second opening, having a second diameter that is larger than the first diameter, surrounded by a second rim, (a)(iii) an inner surface, coupling the first end to the second end, adapted to contact a cervix, (a)(iv) an outer surface adapted to contact a vaginal wall, (a)(v) a hollow tunnel, including the inner surface, the first opening, and the second opening wherein the hollow tunnel is adapted to receive the cervix; and (a)(vi) a first shelf connected to the inner surface and located between the first and second ends; and wherein the first shelf includes a first surface and a second surface opposite the first surface, the first surface being between the second surface and the first end and the second surface being between the second end and the first surface; (2) a stabilizer including (b)(i) a first stabilizer end comprised of a base portion with a stabilizer aperture, (b)(ii) a second stabilizer end, opposite the first stabilizer end, having a stabilizer rim adapted to couple to the first shelf or the second shelf, wherein a diameter of the first stabilizer end is less than a diameter of the second stabilizer end; (3) a shaft configured to pass through the stabilizer aperture; wherein the shaft contains a hollow inner channel coupling a distal end of the shaft to a proximal end of the shaft; and wherein the distal end of the shaft includes at least one of a distal shaft aperture in fluid communication with the hollow inner channel, and the proximal end of the shaft includes at least one of a proximal shaft aperture in fluid communication with the hollow inner channel; (4) a bulbous portion having a maximum bulbous diameter greater than a maximum diameter of the shaft; wherein the bulbous portion includes a first portion, a second portion, and a third portion; wherein the second portion is located between the first portion and the third portion; wherein the first portion is configured for coupling to the distal end of the shaft; wherein the first portion, the second portion, and the third portion respectively include a first diameter, a second diameter, and a third diameter; wherein the second diameter is smaller than the first diameter and the third diameter; and wherein at least one or more of a bulbous portion aperture is located on the second portion and is in fluid communication with the distal shaft aperture and the hollow inner channel. 
     In example 2, the subject matter of Example 1 can optionally include a first rim including a first inner edge, separated by a first gully from a first outer edge; wherein the second rim includes a second inner edge, separated by a second gully from a second outer edge; wherein the first outer edge is closer than the first inner edge to the second outer edge in a linear direction; wherein the second outer edge is closer than the second inner edge to the first outer edge in a linear direction; and wherein the first outer edge is farther from a center of the collar in a radial direction than the first inner edge; and the second outer edge is farther from the center of the collar in a radial direction than the second inner edge. 
     In example 3, the subject matter of Examples 1-2 can optionally include a first rim with a diameter between 25 mm and 40 mm; wherein the diameter of the second rim is between 25 mm and 45 mm; wherein the diameter of the stabilizer rim is between 15 mm and 35 mm; wherein the distance between the first end and second end is less than 40 mm; and wherein the first diameter and the third diameter is 5 mm to 10 mm. 
     Example 4 includes a uterine manipulator system comprising: a collar including (a)(i) a first end comprising a first opening, having a first diameter, surrounded by a first rim, (a)(ii) a second end, opposite the first end, having a second opening, having a second diameter that is larger than the first diameter, surrounded by a second rim, (a)(iii) an inner surface, coupling the first end to the second end, adapted to contact a cervix, (a)(iv) an outer surface adapted to contact a vaginal wall, (a)(v) a hollow tunnel, including the inner surface, the first opening, and the second opening wherein the hollow tunnel is adapted to receive the cervix; and (a)(vi) a first shelf connected to the inner surface and located between the first and second ends; wherein the first shelf includes a first surface and a second surface opposite the first surface, the first surface being between the second surface and the first end and the second surface being between the second end and the first surface; and a stabilizer including (b)(i) a first stabilizer end comprised of a base portion with a stabilizer aperture, (b)(ii) a second stabilizer end, opposite the first stabilizer end, having a stabilizer rim adapted to couple to the first shelf or the second shelf, wherein a diameter of the first stabilizer end is less than a diameter of the second stabilizer end. 
     In example 5, the subject matter of Example 4 can optionally include a shaft configured to pass through the stabilizer aperture; wherein the shaft contains a hollow inner channel coupling a distal end of the shaft to a proximal end of the shaft; wherein the proximal end of the shaft includes at least one of a proximal shaft aperture in fluid communication with the hollow inner channel; and wherein the shaft includes a middle portion between the proximal end of the shaft and the distal end of the shaft. 
     In example 6, the subject matter of Examples 4-5 can optionally include the middle portion with a middle portion long axis and the distal end with a distal end long axis that intersects the middle portion long axis at an intersection angle between 0 to 90 degrees. 
     In example 7, the subject matter of Examples 4-6 can optionally include the stabilizer with at least one of a window between the stabilizer rim and the base portion. 
     In example 8, the subject matter of Examples 4-7 can optionally include a first configuration wherein the stabilizer rim couples to the first surface and not the second surface; and a second configuration wherein the stabilizer rim couples to the second surface and not the first surface. 
     In example 9, the subject matter of Examples 4-8 can optionally include a second shelf connected to the inner surface and located between the second end and the first shelf; wherein in a first configuration the stabilizer rim connects directly to the first shelf and not the second shelf; and wherein in a second configuration the stabilizer rim connects directly to the second shelf and not the first shelf. 
     In example 10, the subject matter of Examples 4-9 can optionally include the inner surface of the collar including two or more inner shelves; and wherein the stabilizer rim is configured to couple to at least one inner shelf. 
     In example 11, the subject matter of Examples 5-10 can optionally include the distal end of the shaft including a bulbous portion having a maximum bulbous diameter greater than a maximum diameter of the shaft; wherein the maximum bulbous diameter is adapted to resist withdrawal of the distal end from the cervix; and wherein at least one or more of a bulbous portion aperture is located on the bulbous portion and is in fluid communication with the proximal shaft aperture and the hollow inner channel. 
     In example 12, the subject matter of Examples 11 can optionally include the bulbous portion including a first portion, a second portion, and a third portion; wherein the second portion is located between the first portion and the third portion; 
     wherein the first portion is configured for coupling to the distal end of the shaft; wherein the first portion, the second portion, and the third portion respectively include a first diameter, a second diameter, and a third diameter; wherein the second diameter is smaller than the first diameter and the third diameter; and wherein the second portion includes at least one or more of the bulbous portion aperture. 
     In example 13, the subject matter of Examples 5-12 can optionally include a fulcrum configured to slidably couple to the shaft, wherein the shaft pivots about the fulcrum; wherein the fulcrum is selected from the group comprising a disc, a plate, a ball, a rim with prongs, and a sponge; and wherein the fulcrum is configured to fit within a vaginal canal that comprises the vaginal wall; and wherein the fulcrum contains a hole to receive the shaft. 
     In example 14, the subject matter of Examples 5-13 can optionally include a fulcrum configured to slidably couple to the shaft and wherein the shaft pivots about the fulcrum and a powered linkage configured to articulate the system; wherein the linkage is a robotic arm configured to articulate the system through six degrees of freedom; and wherein the powered linkage includes an end effector configured to interface with the system. 
     In example 15, the subject matter of Examples 12-14 can optionally include a conduit wherein the conduit is hollow with an inner diameter greater than the diameter of the stabilizer aperture and a diameter of the shaft; wherein the distal end of the conduit is configured couple to the base portion; wherein the conduit is configured to slide between the proximal end of the shaft and the distal end of the shaft; and wherein the base portion is distal to the conduit, and one or more of the bulbous portion aperture is distal to the stabilizer. 
     In example 16, the subject matter of Example 15 can optionally include a proximal end of the conduit adapted to couple to a fastener to fixedly fasten the conduit to the shaft. 
     In example 17, the subject matter of Examples 5-16 can optionally include the middle portion including a middle portion long axis and the distal end including a distal end long axis that intersects the middle portion long axis; and wherein the angle between the two axis is adjustable and the curvature of the shaft is malleable. 
     In example 18, the subject matter of Examples 12-17 can optionally include the diameter of the first rim being between 25 mm and 40 mm; wherein the diameter of the second rim is between 25 mm and 45 mm; the diameter of the stabilizer rim is between 15 mm and 35 mm; the distance between the first end and second end is less than 40 mm; and the first diameter and the third diameter is 5 mm to 10 mm. 
     Example 19 includes a uterine manipulator system comprising: (1) a shaft configured to pass through the stabilizer aperture; wherein the shaft contains a hollow inner channel coupling a distal end of the shaft to a proximal end of the shaft; and wherein the distal end of the shaft includes at least one of a distal shaft aperture in fluid communication with the hollow inner channel, and the proximal end of the shaft includes at least one of a proximal shaft aperture in fluid communication with the hollow inner channel; (2) a bulbous portion having a maximum bulbous diameter greater than a maximum diameter of the shaft; wherein the bulbous portion includes a first portion, a second portion, and a third portion; wherein the second portion is located between the first portion and the third portion; wherein the first portion is configured for coupling to the distal end of the shaft; wherein the first portion, the second portion, and the third portion respectively include a first diameter, a second diameter, and a third diameter; wherein the second diameter is smaller than the first diameter and the third diameter; wherein at least one or more of a bulbous portion aperture is located on the second portion and is in fluid communication with the distal shaft aperture and the hollow inner channel; and wherein the maximum first diameter and third diameter is 5 mm to 10 mm. 
     In example 20, the subject matter of Example 19 can optionally include (1) a stabilizer comprising (a)(i) a first stabilizer end comprised of a base portion with a stabilizer aperture, (a)(ii) a second stabilizer end, opposite the first stabilizer end; wherein a diameter of the first stabilizer end is less than a diameter of the second stabilizer end; wherein in a first configuration the stabilizer aperture is slidable along the shaft; wherein one or more of the bulbous portion aperture is distal to the stabilizer; and (2) a conduit wherein the conduit is hollow with an inner diameter greater than the diameter of the stabilizer aperture and a diameter of the shaft; wherein the distal end of the conduit is configured couple to the base portion; 
     wherein the conduit is configured to slide between the proximal end of the shaft and the distal end of the shaft; wherein the base portion is distal to the conduit, and one or more of the bulbous portion aperture is distal to the stabilizer; and wherein a proximal end of the conduit is adapted to couple to a fastener to fixedly fasten the conduit to the shaft. 
     In example 21, the subject matter of Examples 6-18 can optionally include the proximal end of the shaft being collinear with the middle portion and the intersection angle is adjustable. 
     In example 22, the subject matter of Examples 5-18 can optionally include the distal end of the shaft including a first portion, a second portion, and a third portion wherein the second portion is located between the first portion and the third portion, the first portion being proximal to the second portion; wherein the first portion, the second portion, and the third portion respectively include a first diameter, a second diameter, and a third diameter, and the second diameter is less than the first diameter and the third diameter; and wherein the first diameter is greater than a maximum diameter of the shaft. 
     In example 23, the subject matter of Examples 22 can optionally include one or more of the distal shaft aperture included in the second portion. 
     In example 24, the subject matter of Examples 23 can optionally include a first configuration wherein the stabilizer aperture is slidable along the shaft; and wherein one or more of the distal shaft aperture is distal to the collar, and the collar is distal to the stabilizer. 
     In example 25, the subject matter of Examples 4-18 can optionally include the stabilizer including at least one of a window between the stabilizer rim and the base portion, and between two or more prongs that couple the base portion to the stabilizer rim. 
     In example 26, the subject matter of Examples 11-18 can optionally include the bulbous portion including a first portion, a second portion, and a third portion; wherein the second portion is located between the first portion and the third portion; wherein the first portion is configured for coupling to the distal end of the shaft; wherein the first portion, the second portion, and the third portion respectively include a first diameter, a second diameter, and a third diameter; wherein the second diameter is smaller than the first diameter and the third diameter; and wherein a distal tip of the third portion includes at least one or more of the bulbous portion aperture. 
     In example 27, the subject matter of Examples 14-18 can optionally include the fulcrum adapted for use with a vaginal retractor or a speculum. 
     In example 28, the subject matter of Examples 17-18 can optionally include the fastener including at least one of a set screw or a stop collar. 
     In example 29, the subject matter of Examples 16-18 can optionally include a disc configured to couple to the distal end of the conduit and the base portion. 
     In example 30, the subject matter of Examples 5-18 can optionally include a strap or string configured for attachment to the collar. 
     In example 31, the subject matter of Example 30 can optionally include the collar having a hole, a ring or a protrusion to receive the strap or the string. 
     In example 32, the subject matter of Examples 5-18 can optionally include a handle coupled to the proximal end of the shaft, the handle including a projection that projects orthogonally to a long axis of the proximal end of the shaft. 
     In example 33, the subject matter of Examples 32 can optionally include the projection including a pointed end. 
     In example 34, the subject matter of Examples 13-18 can optionally include the fulcrum configured to connect to an arm with six degrees of freedom. 
     In example 35, the subject matter of Examples 34 can optionally include the arm configured to attach to a table, a robotic platform, a plate, a pad, a sled, or a fixed point. 
     In example 36, the subject matter of Examples 5-18 can optionally include a linkage configured to articulate the system. 
     In example 37, the subject matter of Example 36 can optionally include the linkage including at least one degree of freedom for articulating the system. 
     In example 38, the subject matter of Example 37 can optionally include the degree of freedom being rotation approximately within a sagittal plane of the patient. 
     In example 39, the subject matter of Example 38 can optionally include wherein approximately within the sagittal plane of the patient is within plus or minus 5 degrees of the sagittal plane. 
     In example 40, the subject matter of Example 39 can optionally include the linkage configured to articulate the system through six degrees of freedom. 
     In example 41, the subject matter of Example 40 can optionally include the linkage configured to selectively lock relative motion of its links. 
     In example 42, the subject matter of Example 37 can optionally include the linkage being a powered linkage configured to articulate the system. 
     In example 43, the subject matter of Example 42 can optionally include the powered linkage including an end effector configured to interface with the system. 
     In example 44, the subject matter of Example 43 can optionally include the powered linkage being a robotic arm having six degrees of freedom 
     In example 45, the subject matter of Example 5 can optionally include a sponge configured to slidably couple to the shaft. 
     While the present invention has been described with respect to a limited number of embodiments, those skilled in the art will appreciate numerous modifications and variations therefrom. It is intended that the appended claims cover all such modifications and variations as fall within the true spirit and scope of this present invention.