Video Transcript: Approach to Laparoscopic Cerclage
This is an educational video outlining an approach to laparoscopic cerclage. The objectives of this video include the demonstration of our five-step surgical approach and providing a video example.
Cervical incompetence is known to affect 0.5 to 1% of all pregnancies, with a recurrence risk of 30%. Candidates for abdominal cerclage, or laparoscopic cerclage, may include those with a history of mechanical cervical incompetence, previous large cone procedures, history of failed vaginal cerclage, or deep cervical lacerations.
The patient is placed in the dorsal lithotomy position with a urinary catheter. A standard four-port laparoscopic entry and set-up is completed. During gestation, we choose to use Palmer’s point left upper quadrant entry. And otherwise, we use a Hassan entry at the umbilicus.
A five-step surgical approach is used. The paravesical and vesicouterine spaces are developed, allowing the creation of a bladder flap. This exposes the lower uterine segment and cervix. Broad ligament peritoneal windows are created to allow for the visualization of the uterine vessels. The sutures pass through one of the broad ligament windows. The cerclage is placed at the cervical-isthmic junction. This figure shows ideal cerclage placement, with the suture passing in the avascular space medial to the uterine vessels. Finally, the knot is secured.
The patient in this video demonstration has some adhesions anteriorly between the bladder and uterus following a previous cesarean section at 32 weeks for painless cervical dilation. A Valtchev uterine manipulator is used to push the uterus cephalad. An atraumatic grasper is used to lift the peritoneum. The tips of monopolar scissors are used to open it. This opening is extended medially to open the paravesical and vesicouterine spaces.
Here the operator demonstrates the use of only the scissor tips. Using vaporization to accurately open the peritoneum with minimal thermal spread. Next, the paravesical spaces open with blunt dissection. The filmy leaflet of the postural broad ligament is visualized.
Superficial vessels are fulgurated, and a broad ligament peritoneal window is created with a push and spread technique. The window is enlarged by stretching the opening parallel and lateral to the uterine vessels. Creating this window allowed for a caudal displacement of the ureters and identified the uterine vessels at the cervico-isthmic junction.
Given the patient’s adhesions, the bladder flap was dissected further to give improved visualization of the cervico-isthmic junction. A push and spread technique is used. The uterus is then anteverted. The cerclage should be placed at the level of the internal OS. The Valtchev manipulator, the level of the external OS and the internal OS are all visible.
Polypropylene mesh, traditional Mersilene tap, and synthetic monofilament non-absorbable sutures have all been described. We choose to use a number one Prolene suture for ease of handling and removal. The suture on a curved CT-1 needle is passed through one of the previously created broad ligament windows. A trailing length of the suture is left for the final step.
We aim to place the cerclage medial to the branches of the uterine vessels at the cervico-isthmic junction. The needle tip is placed, a quarter turn of the needle is taken, and then direct anterior pressure is used to anchor the cerclage on the right side.
In a similar fashion, the needle is placed medial to the left side of the uterine vessels at the cervico-isthmic junction. The suture material and needle were passed anteriorly across the lower segment to the left side of the uterus. The needle is left in the cul-de-sac after the second bite is secured.
The uterus is anteverted, and an extracorporeal Roeder knot is used to secure the cerclage. The uterus is moved into a neutral position, and the final tension on the suture is adjusted over a 5 mm-sized transcervical dilator at the tip of the manipular in this non-pregnant patient. The suture placement should sit at the level of the internal cervical OS above the ureteral sacral ligaments. The knot at the posterior aspect of the uterus.
Two additional intra-corporeal knots are placed. The suture is trimmed to a 2 cm length to ease removal. The success rate of laparoscopic cerclage is estimated to be between 79 and 100%.
In conclusion, there’s a high reported success rate of laparoscopic cerclage. Our five-step approach has been demonstrated. Careful patient selection is key.