Abstract:
A cutting device, for example for use in a method for laparoscopic hysterectomy wherein final resection of a uterus is executed using a vaginal approach, i.e. cutting from the vaginal side inwards, instead of cutting from the abdominal side outwards of the uterus. A hysterectomy assembly for such a method is also disclosed.

Description:
TECHNICAL FIELD 
       [0001]    The present disclosure relates to a method and a device for removing a uterus. More particularly, the present disclosure relates to a method and a device for a novel total laparoscopic hysterectomy. 
       BACKGROUND 
       [0002]    About 70% of all hysterectomies are carried out through an abdominal incision (total abdominal hysterectomies, TAH). This requires a 2 day to 4 day hospital stay, and a 6 week to 8 week recovery time. It also produces a large, permanent abdominal scar. Only 10% of the procedures are performed with a minimally invasive approach (total laparoscopic hysterectomy, TLH). TLH has major advantages over TAH: most patients are able to return home the same or next day, with a much shorter recovery period than required for other types of hysterectomies. However, the TLH procedure is surgically more difficult to perform. 
         [0003]    The main problems in current TLH procedures are related to difficulties in reaching and visualizing parts of the uterus with the laparoscopic tools. As can be seen in  FIG. 1 , the uterus is approached through small incisions on the patient&#39;s belly. In order to provide access to the desired tissue layers, the uterus needs to be moved around. A uterus mobilizer, inserted through the vagina is often used to maneuver the uterus and to create space for the laparoscopic equipment. The mobilizer does facilitate most part of dissecting the uterus, but is still limited in its ability to create sufficient room for the instruments, especially in the final phase of separating the uterus. 
         [0004]    The location at which separation takes place is referred to as the fornix. The line of separation extends from the anterior fornix to the posterior fornix, in a 360° circular motion. The posterior side of the uterus is particularly difficult to reach. The visual feedback is poor and special caution is needed to prevent damaging surrounding structures like the bladder or intestines. These limitations lead to long procedure times. On average 15-20 minutes (up to 40 minutes) of the procedure time is spend on resolving difficulties in the actual separation of the uterus. 
         [0005]    The disclosure is directed to a method and a device for total laparoscopic hysterectomy in which the above described problems are alleviated. 
       BRIEF SUMMARY 
       [0006]    In a first aspect, a cutting device is disclosed that includes a knife assembly that can make the initial incision from the vaginal side inwards. The cutting device is suitable for use in a method for hysterectomy wherein final resection of a uterus is executed using a vaginal approach, i.e. cutting from the vaginal side inwards, instead of cutting from the abdominal side outwards of the uterus, the cutting device. However, other applications for the cutting device are feasible as well. 
         [0007]    In a second aspect, a manipulator device is disclosed with which the uterus may be moved in a desired direction. 
         [0008]    In a third aspect, a hysterectomy assembly is disclosed that includes a manipulator device and a cutting device and that is configured to automatically push the uterus to a direction opposite of a cutting position where the cutting device is performing a cutting operation, thereby creating as much space and visibility of the cutting position. 
         [0009]    In a fourth aspect a hysterectomy assembly is disclosed that is configured to execute a circular cutting action for the final resection. 
         [0010]    In a fifth aspect, a method for laparoscopic hysterectomy is disclosed wherein final resection of a uterus is executed using a vaginal approach thereby using a hysterectomy assembly according to the present disclosure. 
         [0011]    The vaginal approach using at least one of the disclosed devices or assemblies has major benefits. Since no other tissue layers and ligaments obstruct the separation equipment, it is easier to reach the desired location. Also, improved access and ease of navigating to the fornix decreases the procedure time considerably. 
         [0012]    This solves the problems associated with executing the resection from the abdominal cavity, i.e.:
       impaired view of the operation area;   impaired approach to the incision sites; and       
 
         [0015]    Additional benefits may be:
       improved manipulation by virtue of the new hysterectomy assembly with the integrated manipulator assembly and cutting assembly;   reduced operation time;   reduced risk of damaging other tissue.       
 
         [0019]    The manipulator includes a manipulator element that is entered into the uterus and that may be fixated in the uterus using various fixation mechanisms. A simple fixation may be obtained by screwing the manipulator element into the uterus cavity. Once the manipulator element is in place and optionally fixated, the manipulator element may be freely rotated around a pivoting point near the entry of the uterus. The manipulation is performed manually by an operator or medical assistant during the operational procedures according to the instructions of the operating surgeon. With the hysterectomy assembly according to the invention, the manipulator element always moves the uterus away from the side of the uterus where the cutting device is active to cut the fornix. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0020]      FIG. 1  is a cross section of the female anatomy showing the location of the uterus with its surrounding organs; 
           [0021]      FIG. 2  is a transparent side elevation view of an example of an embodiment of a cutting assembly; 
           [0022]      FIG. 3  is a transparent side elevation view of the cutting housing of the cutting assembly of  FIG. 2 ; 
           [0023]      FIG. 4  is a transparent side elevation view of the cutting blade cover of the cutting assembly of  FIG. 2 ; 
           [0024]      FIG. 5  is a transparent side elevation view of the cutting blade and a lever of the cutting assembly of  FIG. 2 ; 
           [0025]      FIG. 6  is a side elevation view of a distal end of the cutting blade cover actuator and a distal end of the cutting blade actuator of the cutting assembly of  FIG. 2   
           [0026]      FIG. 7  shows perspective view of the example of the cutting assembly of  FIG. 2  with a transparent cutting front housing part in a condition in which the cutting blade and the cutting blade cover are accommodated in the cutting device housing; 
           [0027]      FIG. 8  shows a similar view as  FIG. 7  in which both the cutting blade and the cutting blade cover protrude distally from the cutting device housing, wherein the cutting blade protrudes distally from the cutting blade cover; 
           [0028]      FIG. 9  shows a similar view as  FIG. 7  in which both the cutting blade and the cutting blade cover protrude distally from the cutting device housing, wherein the cutting blade is completely accommodated within the cutting blade cover; 
           [0029]      FIG. 10  shows a similar view as  FIG. 7  in which the cutting blade protrudes proximally from the cutting blade cover; 
           [0030]      FIG. 11  shows a similar view as  FIG. 7  in which the cutting blade is pushed against the edge of the cutting device housing; 
           [0031]      FIGS. 12   a  and  12   b . show an example of an embodiment via which the cutting blade cover actuator and the cutting blade actuator may be operated; 
           [0032]      FIG. 13  shows a cross section view of a distal end of an example of an embodiment of a hysterectomy assembly in a first position; 
           [0033]      FIG. 14  shows a similar view of the example of  FIG. 13  in a second position; 
           [0034]      FIG. 15  shows a perspective view of the example in of  FIG. 13  in that position; 
           [0035]      FIG. 16  shows a perspective view of the example of  FIG. 14  in that position; and 
           [0036]      FIG. 17   a - 17   c  show perspective views of the complete hysterectomy assembly in various positions; 
           [0037]      FIGS. 18   a - 18   c  show the distal parts of the hysterectomy assembly shown in  FIGS. 17   a - 17   c  in more detail; 
           [0038]      FIGS. 19   a  and  19   b  shows a cross section view of a distal end of an example of a second embodiment of a hysterectomy assembly in a first and second position; and 
           [0039]      FIG. 20   a - 20   e  show schematically an example of an embodiment of the operation assembly for the cutting device in various positions. 
       
    
    
     DETAILED DESCRIPTION 
       [0040]      FIG. 1  shows, as stated in the background section, a cross section of the female anatomy at the location of the uterus with its surrounding organs.  FIG. 1  also shows the endoscope directed to the uterus. 
         [0041]      FIG. 2  is a transparent side elevation view of an example of an embodiment of a cutting assembly. The reference numbers of  FIG. 2  relate to the following:
         1 . Cutting device housing     13 . Cutting blade cover     23 . Cutting blade     28 . Lever     31 . Cutting blade actuator;     34 . Cutting blade cover actuator;       
 
         [0048]      FIG. 3  is a transparent side elevation view of the cutting housing of the cutting assembly of  FIG. 2 . The reference numbers of  FIG. 3  relate to the following:
         1 . Cutting device housing configured to accommodate the cutting blade cover, the cutting blade, the cutting blade cover actuator and the cutting blade actuator     2 . Opening in the cutting device housing  1  to allow protrusion of the cutting blade cover  13  and the cutting blade  23 .     3 . Opening in the cutting device housing  1  to allow passage of the cutting blade cover actuator  34 .     4 . Opening in the cutting device housing  1  to allow passage of the cutting blade actuator  31 .     5 . Partition wall forming one side of the guiding groove  6  of the cutting blade cover actuator  34  and one side of the guiding groove  7  for the cutting blade actuator  31 .     6 . Guiding groove for cutting blade cover actuator  34 .     7 . Guiding groove for cutting blade actuator  31 .     8 . Rounded corner serving as a hinge for the cutting blade cover  13 .     9 ,  10 . Sides of the space in the cutting device housing  1  that serve as a guiding groove for the cutting blade cover  13 .     11 . Area of the cutting device housing  1  toward which the cutting blade  23  cuts.     12 . Guiding groove for the notch  18  of the cutting blade cover  13 .       
 
         [0060]      FIG. 4  is a transparent side elevation view of the cutting blade cover  13  of the cutting assembly of  FIG. 2 . The reference numbers of  FIG. 4  relate to the following:
         13 . Cutting blade cover having a front part and a rear part between which the cutting blade  23  is accommodated     14 . Rounded outer edge of the cutting blade cover  13 .     15 . Rounded inner edge of the cutting blade cover  13 .     16 . Elevated bulges reducing friction of the sliding movement of the cutting blade cover  13  within the cutting device housing  1 . Additionally, the elevated bulges create a distance between the cutting blade cover  13  and the cutting device housing  1  to form a space in which the cutting blade actuator  31  and cutting blade cover actuator  34  extend.     17 . Elevated ridge reducing friction of the sliding movement of the cutting blade cover  13  within the cutting device housing  1 .     18 . Notch that moves within guiding groove  12  of the cutting device housing  1  and together with rounded outer and inner edge  14 ,  15  limits the freedom of movement of the cutting blade cover  13  within the cutting device housing  1  to one path and related angle. Notch  18  is also engaged by the cutting blade cover actuator  34 .     19 . Guiding groove in a front part of the cutting blade cover  13  for co-operation with a notch  30  of the lever  28  of the cutting blade  23 .     20 . Guiding groove in the rear part of the cutting blade cover  13  for co-operation with one of the notches  27  of the blade  23 .     21 . Opening in the cutting blade cover  13  allowing protrusion of the cutting blade  23  for the stabbing function     22 . Opening in the cutting blade cover  13  allowing for protrusion of the cutting blade  23  for the cutting function       
 
         [0071]      FIG. 5  is a transparent side elevation view of the cutting blade  23  and a lever  28  of the cutting assembly of  FIG. 2 . The reference numbers of  FIG. 5  relate to the following:
         23 . Cutting blade.     24 . Sharp edge of the cutting blade for the stabbing function.     25 . Sharp edge of the cutting blade  23  for the cutting function.     26 . Notch that fits in the lever  28 .     27 . Notch that moves within the guiding groove  20  for the cutting blade  23 .     28 . Lever.     29 . Hole in the lever  28  for the notch  26  of the cutting blade  23       30 . Notch that moves in the guiding groove  20  of the cutting blade cover  13  and is engaged by the cutting blade actuator  31 .       
 
         [0080]      FIG. 6  is a side elevation view of a distal end of the cutting blade cover actuator  34  and a distal end of the cutting blade actuator  31  of the cutting assembly of  FIG. 2 . The reference numbers of  FIG. 6  relate to the following:
         31 . Cutting blade actuator.     32 . Slot for notch of the lever  28 .     33 . Handle of the cutting blade actuator  31  that slides in the blade handle guiding groove  7  of the cutting device housing  1 .     34 . Cutting blade cover actuator.     35 . Slot for the notch  18  of the cutting blade cover  13 .     36 . Handle of the cutting blade cover actuator  34  that slides in the cover handle guiding groove  6  of the cutting device housing  1 .       
 
         [0087]      FIG. 7  shows perspective view of the example of the cutting assembly of  FIG. 2  with a transparent cutting front housing part in a condition in which the cutting blade  23  and the cutting blade cover  13  are accommodated in the cutting device housing  1 ; 
         [0088]    In  FIG. 8  the cutting blade  23  and the cutting blade cover  13  both protrude distally from the cutting device housing  1  and wherein the cutting blade  23  protrudes distally from the cutting blade cover  13 . 
         [0089]    In  FIG. 9  the cutting blade  23  and the cutting blade cover  13  both protrude distally from the cutting device housing  1  and cutting blade  23  is fully accommodated within the cutting blade cover  13 . 
         [0090]    In  FIG. 10  the cutting blade  23  protrudes proximally from the cutting blade cover  13 . 
         [0091]    In  FIG. 11  the cutting blade  23  is pushed against the edge  11  of the cutting housing  1 . 
         [0092]    The cutting assembly includes a stabbing and cutting blade  23  within a protecting cutting blade cover  13 . The cutting blade  23  is moveable within the cutting blade cover  13 . The cutting blade cover  13  is moveably positioned in a cutting device housing  1  or  43  (see  FIGS. 2 ,  13 ,  14 ). The possible movement of the cutting blade  23  with respect to the cutting blade cover  13  is uniquely determined by two notches  26  and  27  on the blade  23 . Notch  27  engages in a guiding groove  20  in the cover  13  and notch  26  engages in a hole  29  in a lever  28 . Lever  28  in turn engages in a guiding groove  19  in the cutting blade cover  13  thus limiting the movement of notch  27  to the middle of the guiding groove  19  in the cutting blade cover  13 . The guiding grooves  19  and  20  are located on respectively the front and the rear part of the cutting blade cover  13  thus allowing trajectories of the guiding grooves  19 ,  20  to overlap. The possible movement of the cutting blade  23  is thus uniquely determined by the contour or shape of the guiding grooves  19 ,  20 . A cutting blade actuator  31  is engaged to the notch  30  on the lever  28  by a slot  32  and is used to move the cutting blade  23  to different positions with respect to the cutting blade cover  13  within the range of positions that is determined by the guiding grooves. A guiding groove  7  in the cutting device housing  1  prevents rotation of the cutting blade actuator  31  with respect to the cutting device housing  1  and limits the movement of the cutting blade actuator  31  to the distal and proximal direction. 
         [0093]    The lever  28  only functions to offset the engagement of the attachment of the cutting blade actuator  31  to a more proximal position to prevent this engagement position to protrude from the cutting device housing  1  when performing the stabbing and cutting actions. 
         [0094]    The movement of the cutting blade cover  13  within the cutting device housing  1  is limited by the shape of the cover  13  and the shape of the inner space of the cutting device housing  1 . 
         [0095]    The rounded outer side  14  of the cutting blade cover  13  is concentric with the rounded inner side  15  of the cutting blade cover  13 . The width of the inner space of the cutting device housing  1  is equal to the sum of the radii of the rounded inner side  15  and the rounded outer side  14  of the cutting blade cover  13 . This configuration laterally limits the movement of the cutting blade cover  13  relative to the cutting device housing  1 . The movement of the cutting blade cover  13  in the distal and proximal direction within the cutting device housing  1  as well as the rotation of the cutting blade cover  13  within the cutting device housing  1  is determined by a notch  18  on the cutting blade cover  13  which can slide within a guiding groove  12  in the cutting device housing  1 . Any specific position of notch  18  within the guiding groove  12  determines the position in the distal and proximal direction as well as the angle of the cutting blade cover  13  with respect to the cutting device housing  1 . A cutting blade cover actuator  34  is in engagement with notch  18  via a slot  35 . By moving the handle  36  of the cutting blade cover actuator  34 , the cutting blade cover  13  is moved to different positions with respect to the cutting device housing  1  within the range of positions that is determined by the guiding groove  12 . 
         [0096]    A guiding groove  6  in the cutting device housing  1  prevents rotation of the cutting blade cover actuator  34  with respect to the cutting device housing  1  and limits the movement of the cutting blade cover actuator  34  to the a distal and proximal direction relative to the cutting device housing  1 . 
         [0097]    The cutting blade cover  13  of the present example incorporates three bulges  16  and an elevated ridge  17  to allow smooth movement within the cutting device housing and to create space for the actuators  31  and  34 , thus compensating for any notches sticking outward of the surface of the cover and also reducing the friction of the cutting blade cover  13  within the cutting device housing  1 . 
         [0098]    The shapes of the guiding groove  12  and the slots  32  and  35  are chosen such that if the handles  33  and  36  are each moved with the same distance, the position of the cutting blade  23  does not change with respect to the cutting blade cover  13 . 
         [0099]    The combination of the position and contour of the guiding grooves  19  and  20  allow the cutting blade  23  to be positioned in a safe position within the cutting blade cover  13 , protrude outwards through opening  21  of the cutting blade cover  13  for a stabbing position or to move in a cutting action through opening  22  in the cutting blade cover  13 . A distal tip of the rear and the front part of the cutting blade cover  13  may be connected to each other to provide structural strength to the cutting blade cover  13 . This interconnection that may be formed by a spot weld, forms an obstacle for a simple movement of the cutting blade  23  relative to the cutting blade cover  13 . The notches and guiding grooves as discussed above and shown in the figures may provide a path of movement of the cutting blade  23  relative to the cutting blade cover  13  so that the distal end of the cutting blade  23  is steered around the spot weld. 
         [0100]    Normal operation of the system: The cutting blade  23  is set in the stabbing position protruding outward of opening  21  by moving the handle  33  of the cutting blade actuator  31  in the most distal position with respect to the handle  36  of the cutting blade cover actuator  34 . With the blade  23  in the stabbing position the handles of the cutting blade actuator  31  and the cutting blade cover actuator  34  are simultaneously moved in the distal direction thus pushing the cutting blade cover  13  with the protruding cutting blade  23  outward and slightly rotating until the cutting blade cover  13  has reached its maximum position. The protruding cutting blade  23  will make the initial cut through the tissue and the cutting blade cover  13  will dilate the initial cut by its wedge shape. When the cutting blade cover  13  has reached its maximum position, the cutting blade  23  will be pulled back to its safe position by moving the handle of the cutting blade actuator  31  with respect to the handle of the cutting blade cover actuator  34 . The cutting device assembly is now ready to make the first cut by moving the handle of the cutting blade actuator  31  further proximally with respect to the handle of the cutting blade cover actuator  34  until the blade  23  has completed the full movement toward and onto the area  11  of the cutting device housing  1  that limits the movement of the cutting blade  23 . The surgeon may now choose to rotate the whole system and make a second cutting action by moving the cutting blade  23  upwards or to first move the cutting blade  23  upwards into the safe position before rotating the system and repeating the initial cutting movement. This procedure is repeated until the full 360° has been cut and the uterus is fully resected. 
         [0101]      FIG. 12  shows an example of an embodiment via which the cutting blade cover actuator and the cutting blade actuator may be operated. Rotatable knob  100  may be positioned in a stabbing position in which the cutting blade  23  protrudes distally from the cutting blade cover  13  as shown in  FIG. 8 . Rotatable knob  100  may be positioned in a cutting position in which movement of handle  102 , relative to handle  104  is possible as indicated with arrow  106 . The rotatable knob  100  may also be positioned in a safe position in which the cutting blade is positioned entirely within the cutting blade cover  13 . The cutting blade cover may be moved in and out of the cutting device housing  1  by movement of inner tube  108  relative to outer tube  110  as indicated by arrow  112 . The cutting device housing  1  may be connected directly or indirectly to the outer tube  110 . The rotatable knob  100  may also be embodied as a shiftable knob  100  as shown in the exemplary embodiment of  FIGS. 20   a - 20   e.    
         [0102]      FIG. 13  shows a cross section view of a distal end of an example of an embodiment of a hystorectomy assembly in a first position and  FIG. 14  shows a similar view of the example of  FIG. 13  in a second position.  FIG. 15  shows a perspective view of the example in of  FIG. 13  in that position and  FIG. 16  shows a perspective view of the example of  FIG. 14  in that position. 
         [0103]    The reference numbers of  FIG. 13-16  relate to the following:
         37 . Mobilizer assembly.     38 . Outer tube.     39 . Inner tube.     40 . Mobilizer element frame.     41 . Mobilizer element. The mobilizer element is also named manipulator element in this application.     42 . Cutting device holder.     43 . Blade cutting device housing or cutting device housing.     44 . Gear wheel connection between outer tube and mobilizer element frame, consisting of gear wheel  44   a  and gear wheel  44   b        44   a . Gear wheel on the outer tube  38       44   b . Gear wheel on the mobiliser element frame  40       45 . Gear wheel connection between inner tube and blade holder, consisting of gear wheel  45   a  and gear wheel  45   b        45   a . Gear wheel on the inner tube  39       45   b . Gear wheel on the cutting device holder  42         
 
         [0117]    When rotating the system, the mobiliser element  41  is automatically moved in a direction which is optimal for the cutting procedure and allows optimal vision for the surgeon. 
         [0118]      FIG. 19   a  shows a cross section view of a distal end of a second embodiment of a hystorectomy assembly in a first position and  FIG. 19   b  shows a similar view of the example of  FIG. 19   a  in a second position. 
         [0119]    The reference numbers of  FIGS. 19   a  and  19   b  relate to the following:
         43 . Blade cutting device housing or cutting device housing.     137 . Mobilizer assembly.     138 . A second tube.     139 . A first tube.     141 . Mobilizer element that may include a mobilizer element frame  140 . The mobilizer element  141  is also named manipulator element in this application.     142 . A Cutting device holder.     143 . A gear wheel connection between first tube  139  and the cutting device holder  142 ,     144 . A gear wheel connection between a third tube  145  and a rotation ring  146 .     145 . A third tube     146 . A rotation ring     147 . A gear wheel connection between the rotation ring  146  and the mobilizer element  141  or the mobilizer element frame  140 .       
 
         [0131]    When rotating the first tube  139  relative to the second and third tubes  138 ,  145 , the mobiliser element  141  is automatically moved in a direction which is optimal for the cutting procedure and allows optimal vision for the surgeon. 
         [0132]    In a first embodiment, the cutting device  43  may be embodied as a cutting device  1  as described with reference to  FIGS. 1-12   
         [0133]    In an other embodiment, the cutting device  43  could be replaced by a different dissection mechanism, like thermal dissection, ultrasone dissection or any other technique or combination of techniques that can fit to this system. 
         [0134]    Explanation of the Mobiliser System. 
         [0135]    The system includes a handle having an inner tube  39  and an outer tube  38  which can rotate with respect to each other, but can not move in the longitudinal direction with respect to each other. 
         [0136]    On the upper side of the inner tube a mobilizer element frame  40  is connected such that it can rotate around an axis A3 which has an angle of φ1 with respect to axis A1 of the inner tube  39 . The mobilizer element frame  40  can only rotate but it can not move in the direction of the axis of rotation with respect to the inner tube  39 . The mobilizer element frame  40  is engaged with the outer tube  38  through a gearwheel  44  or any other mechanism that ensures that the rotation of the outer tube  38  with respect to the inner tube  39  is passed on to a similar rotation of the mobilizer element frame  40 . The mobilizer element frame  40  contains a mobilizer element  41  with an axis that has an angle of φ2 with respect to the angle of the axis of rotation of the mobilizer element frame  40 . A cutting device holder  42  is place around the mobilizer element  41  such that it can rotate around the mobilizer element  41 , but it can not move in the direction of the axis of the mobilizer element  41  with respect to the mobilizer element  41 . The cutting device holder  42  engages with the inner tube  39  through a gearwheel  45  or any other mechanism that ensures that the rotation of the inner tube  39  with respect to the mobilizer element holder  40  is passed on to a similar rotation of the cutting device holder  42 . 
         [0137]    A cutting device housing  1  or  43  is fixedly attached to the cutting device holder  42  at a certain angle with respect to the axis of the mobilizer element  41 . 
         [0138]    A second embodiment of the system, of which an example is shown in  FIGS. 19   a  and  19   b , includes a handle having an first tube  139 , a second tube  138  and a third tube  145  which can rotate with respect to each other around an first axis A1. The respective tubes can not move in the longitudinal direction with respect to each other. 
         [0139]    On the upper side of the second tube  138  a cutting device holder  142  is connected such that it can rotate around an axis A3 which has an angle of φ1 with respect to axis A1 of the outer tube  138 . The cutting device holder  142  can only rotate but it can not move in the direction of the axis of rotation with respect to the outer tube  138 . The cutting device holder  142  is engaged with the first tube  139  through a gearwheel  143  or any other mechanism that ensures that the rotation of the inner tube  139  with respect to the outer tube  138  is passed on to a similar rotation of the cutting device holder  142 . A rotation ring  146  is connected such that it can rotate around axis A3, but it cannot move in the direction of the axis of rotation with respect to the cutting device holder  142 . The third tube  145  is engaged with the a proximal gear of rotating ring  146  through a gearwheel  144  or any other mechanism that ensures that the rotation of third tube  145  with respect to the first tube  139  is passed on to a similar rotation of the rotation ring  146 . A distal gear of the rotation ring  146  is engaged with a gear  147  that is part of the mobilizer element  141  or the mobilizer element frame  140  of the mobilizer element  141 . Any other mechanism that ensures that the rotation of the rotation ring  146  relative to the cutting device holder  142  is passed on to a similar rotation of the mobilizer element  141  or the mobilizer element frame  140 . The axis A2 of the mobilizer element  141  makes an angle of φ2 with the axis of rotation of the cutting device holder  142 . A mobilizer element  141  or the mobilizer element frame  140  is placed on the cutting device holder  142  such that it can rotate around its axis A2 on the cutting device holder  142 , but it can not move in the direction of the axis A2 relative to the cutting device holder  142 . The mobilizer element  141  or mobilizer element frame  140  engages the third tube  145  through the gearwheel  147 , the rotation ring  146  and the gearwheel  144  or any other mechanism that ensures that the rotation of the third tube  145  with respect to the first tube  139  is passed on to a similar rotation of the mobilizer element  141 . 
         [0140]    A cutting device housing  1  or  43  is fixedly attached to the cutting device holder  142  at a certain angle with respect to the axis of the mobilizer element  141 . 
         [0141]    Normal functioning of the system: When the outer tube  38  is held in a stable position and the inner tube  39  is rotated with respect to the outer tube  38 , the mobilizer element  41  moves in a cone shape, but the mobilizer element  41  does not rotate around its longitudinal axis with respect to the outer tube  38  because of the gear wheel engagement between the outer tube  38  and the mobilizer element frame  40 . The person operating the system can thus move the mobilizer element to any position on the cone shape by holding the outer tube  38  and rotating the inner tube  39  with respect to the outer tube  38  without the risk that the mobilizer element  41  will either dislocate from the uterus by rotating counter clockwise (and thus unscrewing from the uterus) or the risk that the mobilizer element  41  will unintentionally screw itself further into the uterus with the risk of protruding into the abdominal cavity. 
         [0142]    When the inner tube  39  is rotated with respect to the outer tube  38  the cutting device holder  42  rotates around the mobilizer element  41 . 
         [0143]    In this embodiment, when both φ1 and φ2 are 45°, the axis of the mobilizer element  41  moves from parallel to the axis of the outer tube  38  (FIG.  12 ) to perpendicular to the axis of the outer tube  38  ( FIG. 13 ). The parallel position corresponds to positioning the uterus in a position whereby it is stretched towards the intestines, revealing the side of the uterus towards the bladder. The 90° angle pushes the uterus to a forward lying position towards the bladder, revealing the side of the uterus towards the intestines. An indicator on the outer tube  38  can show in which position the outer tube should be held to achieve these intended angles. 
         [0144]    In other embodiments the angles can be varied to allow for different shapes and axis of the cone movement of the mobilizer element  41 . 
         [0145]    In the second embodiment the third tube  145  can rotate around the second tube  138  or it can be rotationally fixed to the second tube  138 . When the second tube  138  and the third tube  145  are held in a stable position and the first tube  139  is rotated with respect to the second tube  138 , the axis A2 of the mobilizer element  141  moves in a cone shape, but the mobilizer element  141  does not rotate around its longitudinal axis with respect to the second tube  138  and the third tube  145  because of the gear wheel engagement between the third tube  145 , the rotation ring  146  and the mobilizer element  141  or the mobilizer element frame  140 . The person operating the system can thus move the mobilizer element  141  to any position on the cone shape by rotationally fixing the third tube  145  to the second tube  138 , holding the third tube  145  and rotating the first tube  139  with respect to the third tube  145  without the risk that the mobilizer element  141  will either dislocate from the uterus by rotating counter clockwise (and thus unscrewing from the uterus) or the risk that the mobilizer element  141  will unintentionally screw itself further into the uterus with the risk of protruding into the abdominal cavity. 
         [0146]    When the third tube  145  is rotationally fixed to the second tube  138  and the first tube  139  is rotated with respect to the third tube  145  the cutting device holder  142  rotates around the mobilizer element  141 . 
         [0147]    In this embodiment, when both φ1 and φ2 are 45°, the axis A2 of the mobilizer element  141  moves from parallel to the axis A1 of the second tube  138  ( FIG. 20   a ) to perpendicular to the axis A1 of the second tube  138  ( FIG. 20   b ). The parallel position corresponds to positioning the uterus in a position whereby it is stretched towards the intestines, revealing the side of the uterus towards the bladder. The 90° angle pushes the uterus to a forward lying position towards the bladder, revealing the side of the uterus towards the intestines. An indicator on the second tube  138  can show in which position the second tube  138  should be held to achieve these intended angles. 
         [0148]    In other embodiments the angles can be varied to allow for different shapes and axis of the cone movement of the mobilizer element  141 . 
         [0149]    When the first tube  139  is not rotated with respect to the second tube  138  and the third tube  145  is rotated with respect to the second tube  138 , the mobiliser element  141  will rotate around its own axis A2, without changing the direction of the axis A2, and without changing the position of the cone in the cone shape. That can be done when the mobilizer element  141  has to be screwed into the uterus. 
         [0150]    Normal operation of the system: The outer tube  38  or  138  is held in a position according to the indicator and the inner tube  39  or  139  is rotated until the axis A2 of the mobilizer element  41  or  141  is parallel to the axis A1 of the outer tube  38  or  138 . The system is then inserted into the vagina and in the first embodiment the mobilizer element  41  is screwed into the uterus by rotating the whole system, without allowing any rotation of the inner tube  39  with respect to the outer tube  38 , or by any other mechanism suited to attach the mobilising element  41  to the uterus. In the second embodiment the mobiliser element  141  is screwed into the uterus by rotating the third tube  145  with respect to the second tube  138  without allowing any rotation of the first tube  139  or the second tube  138 , The end position of the system should correspond with the optimal rotational position as revealed by the indicator. The system is now ready to be used as a manipulator, whereby the angle of the mobilizer element  41  or  141  is manipulated by rotating the inner tube  39  or the first tube  139  and holding the outer tube  38  or the second tube  138  in its optimal position as revealed by the indicator. In the second embodiment the third tube  145  should then be rotationally fixed relative to the second tube  138 , allowing a similar operation as in the first embodiment. 
         [0151]    When the final resection has to be performed and the surgeon elects to perform the final resection with the stabbing cutting mechanism of the cutting device  1 , the cutting device housing  1 ,  43  is moved to the optimal position for the initial cut using the stabbing mechanism. In order to aid the surgeon in selecting the optimal position, the top of the blade cutting device housing may contain a light source, which light can be seen from the abdominal side. The light allows the surgeon to double check that no major arteries or veins are still present in the cutting region. By rotating the inner tube  39  with respect to the outer tune  38 , the cutting device housing  43  is set in the optimal rotational position. The mobilizer element  41  automatically moves the uterus to a position whereby the tissue to be cut is stretched a little, the uterus is moved away from organs to avoid damage by the cutting action and the surgeon has optimal vision of the cutting site. The surgeon can now perform the stabbing action followed by the first cutting action. After the first cutting action the position of the blade cutting device housing  43  is rotated by rotating the inner tube  39  with respect to the outer tube  38 . This automatically moves the mobilizer element  41  to a new optimal position. The cutting action is again performed and this procedure is repeated until the full 360° has been cut and the final resection completed. The cutting blade  23  is set in the safe position and the cutting blade cover  13  together with the cutting blade  23  in safe position are moved back into the cutting device housing  1  by simultaneously pulling both handles of the cutting blade actuator  31  and cutting blade cover actuator  34 . 
         [0152]    The activation of the various actions are performed by distinct movements of the handles  102  and  104 . The movement of the cutting blade  23  from a safe position to a stabbing position is done by rotating the knob  100  to the stabbing position (see  FIG. 11 ). The rotation of the knob  100  allows a movement of the two handles  102 ,  104  with respect to outer tube  110  and prevents any other movement of the handles  102 ,  104  with respect to each other. In the stabbing positions the handles  102 ,  104  can be moved towards the outer tube  110  to perform the stabbing action. When the knob  100  is set in the safe position, this results in freezing the position of the handles  102 ,  104  with respect to each other with the blade in the safe position. Also in the safe position the handles  102 ,  104  can be moved together with respect to the outer tube  110  in order to withdraw the cover  13  or push it outwards through an existing hole in the fornix. When the knob  100  is set in the cutting position, it enables movement of the handles  102 ,  104  with respect to each other moving the blade  23  from the safe position to a fully cut position and vice versa. This position of the knob  100  prevents movement of the handle  104  operating the cutting blade housing with respect to outer tube  110 . 
         [0153]      FIG. 20   a - 20   c  show an example of an embodiment of an operating assembly of the cutting device described above. The embodiment of the operating assembly of the cutting device may include a knob  100  that is slidably or rotatably connected with a part that includes the second handle  104 . The knob  100  may comprise a slot  116  that cooperates with a notch  114  on the first handle  102  or a part that is fixedly connected with the first handle  102 . The knob  100  may have three positions, i.e.:
       a first end position (shown in  FIGS. 20   a  and  20   b ) in which the first and the second handle  102 ,  104  are moveable relative to each other and in which the cutting blade  23  protrudes proximally from the cutting blade cover  13  and can make a cutting movement by moving the second handle  104  relative to the first handle  102 ;   an intermediate position (shown in  FIG. 20   c ) in which the first and the second handle  102 ,  104  are fixed relative to each other and in which the cutting blade  23  is completely covered by the cutting blade cover  13 ; and   a second end position (shown in  FIGS. 20   d  and  20   e ) in which the first and the second handle  102 ,  104  are fixed relative to each other and in which the cutting blade  23  is protruding distally from the cutting blade cover  13 . In the second end position both the first and the second handle  102 ,  104  may be move relative to the cutting device housing  1  to withdraw the cutting blade  23  with the cutting blade cover  13  into the cutting device housing  1  or to push the cutting blade  23  with the cutting blade cover  13  out of the cutting device housing  1  to protrude from that cutting device housing  1 . By that movement the cutting blade  23  may stab through the fornix of the uterus.       
 
         [0157]    Although illustrative embodiments of the present invention have been described above, in part with reference to the accompanying drawings, it is to be understood that the invention is not limited to these embodiments. The cutting device may also be used in other applications, for example removel of a part of the intestine. 
         [0158]    It should be noted that another invention is contemplated that is directed to a manipulator assembly without a cutting device. Such a manipulator assembly can be embodied as the hysterectomy assembly described in claims  11 - 29  but without the features that relate to the cutting device. Such a manipulator assembly may be the object of a divisional application. More particularly, the handle with an inner part and an outer tube that are rotatable relative to each other around a first axis A1 and a manipulator element that is connected with the handle so as to moveable along a cone without rotating around its own, second axis A2 may be beneficial relative to the known manipulators. Especially the gear assembly of the disclosed hysterectomy assembly may be used in such a manipulator assembly. 
         [0159]    Variations to the disclosed embodiments can be understood and effected by those skilled in the art in practicing the claimed invention, from a study of the drawings, the disclosure, and the appended claims. Reference throughout this specification to “one embodiment” or “an embodiment” means that a particular feature, structure or characteristic described in connection with the embodiment is included in at least one embodiment of the present invention. Thus, the appearances of the phrases “in one embodiment” or “in an embodiment” in various places throughout this specification are not necessarily all referring to the same embodiment. Furthermore, it is noted that particular features, structures, or characteristics of one or more embodiments may be combined in any suitable manner to form new, not explicitly described embodiments.