Cervical insufficiency resulting in preterm birth can have significant neonatal and maternal consequences.
Abdominal cerclage provides an advantage over transvaginal cerclage as it decreases the rates of fetal loss, and allows for greater average gestational age at delivery. The technique for laparoscopic cervico-isthmic cerclage (CIC) has been established. The objective of our video is to review the challenges of laparoscopic placement of CIC in pregnancy.
A CIC is most commonly placed prior to conception. However, if a patient presents pregnant and has an indication for CIC, a discussion regarding approach is needed. This video demonstrates the principles of laparoscopic placement of CIC using a case of a 27 yr old GO with a history of treated cervical cancer.
We demonstrate a stepwise approach to the procedure, some of the challenges that can be encountered in pregnancy and the strategies to mitigate these challenges.
Mount Sinai Hospital, University of Toronto
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Video Transcript: Laparoscopic Abdominal Cerclage in Pregnancy
Laparoscopic Abdominal Cerclage in Pregnancy. Our objectives for this video are to review the challenges of laparoscopic placement of cervico-isthmic cerclage in pregnancy.
The benefits of the abdominal cerclage over the transvaginal cerclage are increased neonatal survival rates, decreased fetal loss, greater average gestational age at delivery, reduced chance of slippage and significantly lower cervical length.
The cervico-isthmic cerclage is most commonly placed in patients prior to conception via a laparoscopic approach. When the patient presents pregnant, with an indication for a cervico-isthmic cerclage, a decision must be made regarding the best surgical approach, either laparoscopic or vaginal.
A full discussion of the vaginal cervico-isthmic cerclage is beyond the scope of this video, but in our institution, it is the preferred approach for cervico-isthmic cerclage in pregnancy. This is because it is not affected by the gestational age of the patient, allows her regional anesthesia and has outcomes equivalent to the laparoscopic approach.
A laparoscopic approach is preferred in pregnancy, where possible obliteration of the cul-de-sac may be present or in patients where bladder reflection and anterior colpotomy would be difficult.
Some of the challenges of a laparoscopic approach in pregnancy are the large gravid uterus that is challenging to mobilize, in addition to the fact that the gravid uterus fills the pelvis laterally. There is increased bleeding risk due to enhanced vascularity of the pregnant uterus. Overall, the complication rate is low. There are single case reports of suture migration, and erosion into the vagina.
We are going to demonstrate the principles of placement in pregnancy in the following case. A 32-year-old G1P0 presents to our centre at 12 weeks gestation. She has a history of Stage 1A2 cervical cancer, treated with a 3 cm cone excision procedure and pelvic lymphadenectomy. No adjuvant treatment was required, and she has been on routine surveillance for three years.
She was initially followed with serial cervical length and found to have a short cervix at 1.7 cm to 2.1 cm. On examination, the cervix was flush with the vagina. A multidisciplinary team recommendation was then to proceed with a laparoscopic cervico-isthmic cerclage. And this was placed at 13 weeks gestation, following a normal first trimester screen.
When completing this procedure in pregnancy, it is important to note the timing and gestational age, ideally pre-conception or before 16 weeks to allow for a laparoscopic approach. It is important to also consider the completion of first trimester screening prior to placement of the cervico-isthmic cerclage. We recommend consideration of Palmer’s point entry for port placement or supraumbilical and high accessory port placement.
The technique used in this video is similar to previously described techniques of laparoscopic cerclage. We will review the challenges in pregnancy and the needed adaptations to these five steps.
Upon abdominal survey, we see a bulky gravid uterus and a lack of uterine manipulation. We began our procedure with developing our paravesical spaces and opening up the vesico-uterine peritoneum.
The paravesical spaces are opened bilaterally. Our next step is to create windows in the broad ligament. We start by developing and clearing our spaces in the anterior broad ligament, as seen here. We now move posteriorly. And here, we demonstrate the challenge of manipulating a soft yet bulky gravid uterus.
Care is taken to minimize manipulation while being able to identify our landmarks, such as the ureter. The ureter is then followed from the level of the pelvic brim to where we would expect to make our avascular window. Here, we identify our ureter again and the avascular space where our window will be created.
The window is created with the use of electrosurgery and blunt dissection. Once this is done bilaterally, we proceed with planning our suture placement. The suture is brought into the abdomen and passed through the posterior window so the first bite is taken posterior to anterior.
Once the suture is loaded, it is important to note the position of where the suture will be placed at the cervico-isthmic junction. It is also important to note the uterine artery and its location so the suture can be placed medially to the uterine artery.
On the contralateral side, the suture is placed anterior to posterior, medial to the uterine artery, as seen here. The suture is then passed posteriorly and removed from the abdomen for an extracorporeal knot. A Roeder’s knot is made and then gently passed and pushed down to the level of the cervico-isthmic junction, with gentle traction on the uterus.
Once placed, the knot is tightened, and the location is confirmed. We then verify the location anteriorly, also to be at the anterior cervico-isthmic junction, well away from the bladder.
At our centre, the patients are monitored overnight. A fetal heart rate check or ultrasound are done in the morning prior to discharge. In conjunction with our MFM team, a 24-hour course of tocolytics is given postoperatively. Our patient in this case review had an uncomplicated postoperative course, routine obstetrical care for the remainder of the pregnancy, and an uncomplicated elective C-section at 36 weeks.
We’ve reviewed some of the challenges with the placement of a laparoscopic cerclage in pregnancy. We have discussed some strategies that include port placement, abdominal entry, the use of a 30 degree scope or a flexi-tip laparoscope, and position of the surgical bed. A multidisciplinary approach is important in determining the indication and timing of cervico-isthmic cerclage and postoperative care. Thank you for reading.