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Tips and tricks for laparoscopic interval transabdominal cervical cerclage; a simplified technique

DOI:10.4274/jtgga.galenos.2019.2019.0028
Authors:
Yavuz Emre Sükür at Ankara University
Yavuz Emre Sükür
Ertan Sarıdoğan
Ertan Sarıdoğan
Ertan Sarıdoğan
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Abstract

With the advance of laparoscopic surgery, several minimally invasive cervical cerclage techniques have been described and the outcome of those has been promising. With this video article we describe a simplified technique for laparoscopic interval transabdominal cervical cerclage. The suture material is a standard non-absorbable, braided polyester Mersilene tape which is also used for transvaginal cerclage. The straightened needle is passed medial to the uterine vessels and lateral to the cervico-isthmic junction in anteroposterior direction on both sides, and pulled out above the uterosacral ligament. The knot is tied posteriorly, just above the uterosacral plate. The advantages of straightened needles are easy insertion into the abdominal cavity through the 5 mm ports, and more accurate direction of the suture in anteroposterior direction. In addition, posterior knots can be removed via colpotomy in case of pregnancy failure in the second trimester and this allows vaginal delivery.
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Video Article
Tips and tricks for laparoscopic interval transabdominal cervical cerclage; a simplified technique
Şükür and Sarıdoğan. Laparoscopic interval cervical cerclage
Yavuz Emre Şükür1, Ertan Sarıdoğan2
1Department of Obstetrics and Gynecology, Ankara University School of Medicine, Ankara, Turkey
2Department of Obstetrics and Gynecology, University College London Hospitals, London, United Kingdom
Adress for Correspondence: Yavuz Emre Şükür
e-mail: yesukur@gmail.com Phone: +90 312 595 64 05
DOI: 10.4274/jtgga.2019.209.0028
Received: 11 February, 2018 Accepted: 8 May, 2019
Abstract
With the advance of laparoscopic surgery, several minimally invasive cervical cerclage techniques have been
described and the outcome of those has been promising. With this video article we describe a simplified
technique for laparoscopic interval transabdominal cervical cerclage. The suture material is a standard non-
absorbable, braided polyester Mersilene tape which is also used for transvaginal cerclage. The straightened
needle is passed medial to the uterine vessels and lateral to the cervico-isthmic junction in anteroposterior
direction on both sides, and pulled out above the uterosacral ligament. The knot is tied posteriorly, just above the
uterosacral plate. The advantages of straightened needles are easy insertion into the abdominal cavity through the
5 mm ports, and more accurate direction of the suture in anteroposterior direction. In addition, posterior knots
can be removed via colpotomy in case of pregnancy failure in the second trimester and this allows vaginal
delivery.
Keywords: Cervical cerclage, interval, laparoscopy, technique
Introduction
The two main indications for trans-abdominal cervical cerclage are grossly damaged cervical tissue due to
previous surgeries or absence of vaginal portion of cervix, and previously failed elective vaginal cerclage (1).
With the advance of laparoscopic surgery, several minimally invasive techniques have been described and the
outcome of those has been promising (2-4). With this video article we describe a simplified technique which
might reduce risk of complications such as uterine artery or lower urinary tract injuries (Video 1).
Technique
Under general anesthesia, the patient was positioned in a low dorsal lithotomy in booted support stirrups. Prior to
surgery urethral catheter is inserted. A uterine manipulated is placed into the endo-cervical canal to move the
uterus during surgery and avoid obstruction of the cervical canal. The suture material is a standard non-
absorbable, braided polyester Mersilene tape which is also used for trans-vaginal cervical cerclage (Ethicon US,
LCC, USA). First, the utero-vesical peritoneal fold is incised at the cervico-isthmic level and in order to identify
the uterine vessels the incision is extended laterally on both sides. Generally, bladder is not reflected downwards.
However, previous caesarean section or other anterior uterine surgeries that result in adhesions may necessitate
dissection and bladder reflection. The straightened needle is passed medial to the uterine vessels and lateral to
the cervico-isthmic junction in anteroposterior direction with a right angle to cervix (Figure 1), and pulled out
from the posterior surface of broad ligament, 1 cm above the uterosacral ligament. Then, the same procedure is
repeated on the left side. The knot is tied on the posterior surface of cervico-isthmic junction, just above the
uterosacral plate (Figure 2). The Mersilene tape is carefully laid flat on the anterior surface of cervix (Figure 3).
The ends of tape are cut at least 1 cm beyond the knot after tying. It’s not essential to close the peritoneum on
anterior surface over the tape. After haemostasis, the bladder catheter is removed if there’s no contra-indication
and the patient is discharged on postoperative day 0/1.
Although the suture may be inserted in either direction, we believe in that placing the suture from anterior to
posterior has the advantages of better visualisation, lesser risks of bowel injury and bladder erosions. In addition,
posterior knots can be removed via colpotomy in case of pregnancy failure in the second trimester and this
allows vaginal delivery. Fibrosis can occur around and within the braided fibres of the Mersilene tape and make
removal more difficult. However, a posterior knot can make it easy to remove when necessary.
Uncorrected Proof
The procedure can be simplified further by straightening the needles before insertion to the abdominal cavity.
The two important advantages of straightened needles are easy insertion into the abdominal cavity through the 5
mm ports, and more accurate direction of the suture from anterior to posterior direction at cervico-isthmic level.
An anterior knot may be beneficial to avoid adhesions in the Douglas pouch, and also can be easily removed at
laparoscopy. However, it has the disadvantage of increased risk of bladder erosion.
References
1. Gibb D, Saridogan E. The role of transabdominal cervical cerclage techniques in maternity care. The
Obstetrician & Gynaecologist 2016; 18: 117-25.
2. Riiskjaer M, Petersen OB, Uldbjerg N, Hvidman L, Helmig RB, Forman A. Feasibility and clinical
effects of laparoscopic abdominal cerclage: an observational study. Acta Obstet Gynecol Scand 2012;
91: 1314-8.
3. Burger NB, Einarsson JI, Brölmann HA, Vree FE, McElrath TF, Huirne JA. Preconceptional
laparoscopic abdominal cerclage: a multicenter cohort study. Am J Obstet Gynecol 2012; 207: 273.e1-
12.
4. Ades A, May J, Cade TJ, Umstad MP. Laparoscopic transabdominal cervical cerclage: a 6-year
experience. Aust N Z J Obstet Gynaecol 2014; 54: 117-20.
Video 1. A simplified technique for laparoscopic interval transabdominal cervical cerclage.
Uncorrected Proof
Figure 1. The needle passed between uterine vessels and cervico-isthmic junction with a right angle.
Figure 2. Knot tied posteriorly, just above the uterosacral plate.
Uncorrected Proof
Figure 3. The tape is laid flat on the anterior surface of uterus.
Uncorrected Proof
Removal of laparoscopic cerclage stitches via laparotomy and rivanol-induced labour: A case report and literature review
Article
  • Jan 2022
Background: Laparoscopic cervical cerclage is performed for patients with abnormal cervical anatomy and/or transvaginal cervical cerclage failure. However, the method of removing the stitches to allow labour induction remains controversial. According to published literature, stitches are removed through laparoscopic or transvaginal methods. Herein, we report, for the first time, a case of a patient who had undergone laparoscopic cerclage, and then underwent removal of stitches by laparotomy and labour induction in the third trimester of pregnancy. Case summary: A patient who underwent laparoscopic cervical cerclage due to cervical insufficiency became pregnant naturally following the operation. At 31 wk of pregnancy, severe foetal malformations were found. To successfully induce labour, cerclage stitches were removed via laparotomy, and rivanol was injected directly into the uterus. Following successful induction of labour, the patient delivered a dead foetus. Conclusion: This report provides a reliable scheme of removing cerclage stitches for patients who have undergone laparoscopic cerclage but experience severe foetal malformations.
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A Four Step Strategy for Robot Assisted Abdominal Cerclage Placement Prior to Pregnancy
Article
Full-text available
  • Sep 2020
Objective To demonstrate a simple, stepwise strategy for robot-assisted abdominal cerclage placement before pregnancy. Design Demonstrative video presentation. Surgical footage surrounding a case report is used to describe a four-step technique for robot-assisted abdominal cerclage placement in women with recurrent pregnancy loss or other anatomic variants before pregnancy. This video article was reviewed by the Investigational Review Board and further investigation was waived because the study was “not considered human subject research.” Setting Tertiary medical center. Patient(s) A 38-year-old G4P0220 (Gestations: 4, Term deliveries: 0, Preterm deliveries: 2, Abortions: 2, Living children: 0) with a history of two second trimester losses who had failed a prior history-indicated transvaginal cerclage (Fig. 1). Intervention(s) The patient underwent an uncomplicated robot-assisted abdominal cerclage using a four-step strategy: Step 1, create the bladder flap; Step 2, identify pertinent anatomy; Step 3, place the cerclage; and Step 4, hysteroscopy. Main Outcome Measure(s) Intraoperative technique presenting a four-step method to ensure successful robot-assisted abdominal cerclage placement. Result(s) Robot-assisted abdominal cerclage is a safe, viable alternative to traditional abdominal cerclage placed via laparotomy. This video outlines four critical steps to facilitate placement and decrease patient morbidity. This patient did well operatively without increased blood loss or operative time and was discharged home on postoperative day 1. She went on to have a successful future pregnancy and currently is scheduled for an elective cesarean section at term. Conclusion(s) Abdominal cerclages significantly improve pregnancy and neonatal outcomes in women who previously have failed transvaginal cerclage. Robot-assisted abdominal cerclage placement allows a minimally invasive approach with enhanced dexterity and better visualization for the surgeon compared with conventional laparoscopy or laparotomy, as well as decreased pain and shorter recovery time for patients. This video demonstrates placement of a robot-assisted abdominal cerclage in a patient with recurrent pregnancy loss using a simple four-step strategy to ensure successful, correct, and easy placement. To our knowledge, this is the first video demonstrating a stepwise approach to robot-assisted abdominal cerclage placement.
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The role of transabdominal cervical cerclage techniques in maternity care
Article
  • Apr 2016
The transabdominal cerclage procedure aims to strengthen the cervix by placing a suture at the level of the internal os. The main indications for transabdominal suture are a grossly disrupted cervix, an absent vaginal cervix, and previous failed elective vaginal cerclage. The transabdominal cerclage was first described in 1965 and the laparoscopic modification was first reported in 1998. Published reports suggest very high neonatal survival rates with both approaches. Laparoscopic cerclage has the general advantages of minimal access surgery, such as avoiding a large abdominal incision, short hospital stay and quick recovery. Potential complications include bleeding from uterine vessels and loss of pregnancy for non-interval procedures. The other reported complications, such as suture migration, rectouterine fistula, uterine rupture and intrauterine growth restriction, are rare. The place of transabdominal cerclage in preventing pregnancy loss and preterm birth remains a subject of debate and there is a need to audit the outcomes. To better understand the role of the cervix in miscarriage. To understand the indications for referral for transabdominal cervical cerclage. To understand the obstetric and neonatal outcomes of women after this procedure. To consider the place of this invasive procedure, with its consequent possible complications, in the management of cervical weakness in women who often have poor reproductive histories. To consider the lack of national and international availability of this potentially valuable procedure. To consider an effective system of assessment of this procedure in a referral context, and the future of this procedure.
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Laparoscopic transabdominal cervical cerclage: A 6-year experience
Article
Cervical cerclage has been used as a treatment for cervical insufficiency for over 60 years. Transabdominal cerclage is indicated for cervical insufficiency not amenable to a transvaginal procedure, or following previous failed vaginal cerclage. A laparoscopic approach to abdominal cerclage offers the potential to reduce the morbidity associated with laparotomy. To evaluate the obstetric outcome and surgical morbidity of laparoscopic transabdominal cerclage. An observational study of consecutive women undergoing laparoscopic transabdominal cerclage from 2007 to 2013 by a single surgeon (AA). Eligible women had a diagnosis of cervical insufficiency based on previous obstetric history and/or a short or absent cervix. The primary outcome was neonatal survival. Secondary outcomes were delivery of an infant at ≥34 weeks gestation. Surgical morbidity and complications were also evaluated. Sixty-four women underwent laparoscopic transabdominal cerclage during the study period. Three women underwent cerclage insertion during pregnancy; the remaining 61 were not pregnant at the time of surgery. Thirty-five pregnancies have been documented to date. Of those, 24 were evaluated for the study. The remaining cases were either early miscarriages, ectopic pregnancies or are still pregnant. The perinatal survival rate was 95.8% with a mean gestational age at delivery of 35.8 weeks. Eighty-three per cent of women delivered at ≥34 weeks gestation. There was one adverse intra-operative event (1.6%), with no postoperative sequelae. Laparoscopic transabdominal cerclage is a safe and effective procedure resulting in favourable obstetric outcomes in women with a poor obstetric history. Success rates compare favourably to the laparotomy approach.
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Feasibility and clinical effects of laparoscopic abdominal cerclage: An observational study
Article
Objective: To evaluate the effect of laparoscopic abdominal cerclage performed as an interval procedure in non-pregnant women at high risk of second trimester spontaneous abortion and early preterm birth. Design: Observational study. Sample: Fifty-two consecutive patients at high risk of preterm birth. Setting: Department of Obstetrics and Gynecology, Aarhus University Hospital. Methods: Patients were registered prospectively. Indications for surgery included classical cervical insufficiency, preterm premature rupture of membranes (PPROM) or two conizations/cervical amputation. Outcome of subsequent pregnancies was registered. Main outcome measures: Gestational age in subsequent pregnancies. Results: No operative or postoperative complications were observed. A total of 45 pregnancies were registered during the observation period. Among 36 pregnancies lasting beyond the 16th week of gestation, 30 women (83.3%) gave birth by cesarean section after 36 weeks of gestation and the overall mean gestational age was 37.4 weeks compared with a mean gestational age of 25.2 weeks of the pregnancies prior to the cerclage. The cesarean sections were uncomplicated in all but one patient, where a re-laparotomy was needed six hours later due to atonic postpartum hemorrhage without evident bleeding through the cervix. Conclusion: Laparoscopic abdominal cerclage is a feasible and safe procedure. Obstetrical outcomes are encouraging but prospective studies are needed to define the effectiveness of the laparoscopic cerclage compared with the traditional transvaginal approach.
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Preconceptional laparoscopic abdominal cerclage: a multicenter cohort study REPLY
Article
  • Jul 2012
The purpose of this study was to evaluate the effectiveness of laparoscopic abdominal cerclage placement in the prevention of recurrent preterm birth. We conducted a multicenter cohort study with retrospective Dutch (32 patients) and Boston (34 patients) cohorts who had undergone preconceptional laparoscopic abdominal cerclage placement. Eligible patients had at least 1 second/third trimester fetal loss or delivered at <34 weeks of gestation because of cervical insufficiency and/or a short or absent cervix. Primary outcome was delivery of an infant at ≥34 weeks of gestation with neonatal survival. Secondary outcome measures included surgical and pregnancy outcomes and patients' satisfaction (Dutch cohort). Surgical outcomes of 66 patients were excellent, with 3 minor complications. After preconceptional laparoscopic abdominal cerclage, 35 pregnancies were evaluated. Twenty-five patients (71.4%) delivered at ≥34 weeks of gestation; 3 patients (8.6%) experienced a second-trimester fetal loss. The total fetal survival rate was 90.0%. Preconceptional laparoscopic abdominal cerclage shows encouraging and favorable perinatal outcomes in patients with a poor obstetric history.
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