Laparoscopy
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Laparoscopic Cerclage: Didelphys Uterus & Solitary Kidney

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Video Description

This video demonstrates the intricacies of performing a laparoscopic abdominal cerclage on a patient with a didelphys uterus and a solitary kidney, showcasing surgical adaptability.

Presented By

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Dr. Angela Johnston
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Dr. Neeraj Mehra

Affiliations

University of British Columbia

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What is Laparoscopic Cerclage: Didelphys Uterus & Solitary Kidney?

Laparoscopic cerclage in the context of a didelphys uterus and a solitary kidney is a surgical procedure aimed at reinforcing the cervix to prevent preterm birth in patients with cervical insufficiency. This approach is used when previous vaginal cerclage attempts have been unsuccessful, and is preferred due to its minimally invasive nature and effectiveness in complex anatomical conditions.

  • Didelphys Uterus: A didelphys uterus is a congenital anomaly where the uterus is divided into two separate cavities, each with its own cervix (bicollis). This condition presents unique challenges for cerclage placement, as both cervixes must be addressed during the procedure.

  • Solitary Kidney: The presence of a solitary kidney, as in this case, requires careful attention to avoid damage to the ureter during the procedure. Preoperative imaging and intraoperative techniques such as stent placement are crucial to prevent ureteric injury.

  • Procedure: The laparoscopic cerclage is placed around the cervical isthmus, medial to the uterine vessels, after creating windows in the broad ligament and reflecting the bladder. In a didelphys uterus, the cerclage must encircle both cervixes to ensure effective support.

  • Considerations: The surgical approach in patients with a didelphys uterus and solitary kidney must consider the unique anatomy to avoid complications such as ureteral injury, bladder damage, or improper placement of the cerclage.

This procedure is particularly valuable for women with cervical insufficiency and complex anatomical conditions, improving the chances of carrying a pregnancy to term.

What are the Risks of Laparoscopic Cerclage: Didelphys Uterus & Solitary Kidney?

The risks of laparoscopic cerclage in a patient with a didelphys uterus and a solitary kidney stem from the complexity of the anatomy and the surgical procedure itself. Key risks include:

  • Ureteric Injury: In a patient with a solitary kidney, any injury to the ureter could severely impact kidney function. Preoperative stenting helps mitigate this risk, but ureteral damage remains a possibility during dissection.

  • Bladder Injury: The procedure requires developing a bladder flap, which could lead to inadvertent bladder injury. This is especially concerning in patients with complex uterine anatomy, such as a didelphys uterus.

  • Cerclage Failure: Improper placement of the cerclage around both cervixes in a didelphys uterus may result in inadequate support, leading to continued cervical insufficiency and risk of preterm birth.

  • Adhesions and Scar Tissue: The creation of windows in the broad ligament and dissection around the cervixes can lead to postoperative adhesions, which could cause future pelvic pain or complications in subsequent surgeries.

  • Infection or Bleeding: As with any surgical procedure, there is a risk of infection or excessive bleeding during or after the operation, though these risks are generally low with minimally invasive laparoscopic techniques.

Given these risks, careful preoperative planning and meticulous surgical technique are crucial to minimizing complications and ensuring a successful outcome.

Video Transcript: Laparoscopic Cerclage: Didelphys Uterus & Solitary Kidney?

This is a video of a laparoscopic abdominal cerclage in a patient with a didelphys uterus and a solitary kidney. The authors have no disclosures. The objectives of this video are to demonstrate a technique for laparoscopic abdominal cerclage in a patient with a didelphys uterus and a solitary kidney, and to highlight key anatomy important during laparoscopic abdominal cerclage.

As per the SOGC Clinical Practice Guideline in women with a classic history of cervical insufficiency in whom a prior vaginal cerclage has been unsuccessful, abdominal cerclage placement can be considered in the absence of additional mitigating factors. The laparoscopic approach is generally preferred to open. To our knowledge, only a few case reports have described abdominal cerclage in patients with didelphys uterus.

This patient is a 33-year-old female. Her past obstetrical history includes her first pregnancy in 2017, which was complicated by a preterm birth at 26+4 weeks gestational age with a subsequent neonatal demise. In her second pregnancy, in 2019, she had an emergency high vaginal cerclage placed in pregnancy for an incompetent cervix, which resulted in caesarean section at 38 weeks gestational age. The cerclage was initially left in place after delivery but was later removed, given chronic vaginal discharge. Her third pregnancy resulted in a first trimester missed abortion, treated with a D&C.

Her past medical history is significant for didelphys uterus with bicollis and previous vaginal septum, as well as a solitary left kidney. Here is an ultrasound showing the patient’s didelphys uterus with a missed abortion in the patient’s right uterus.

The patient was planning for a future pregnancy and cerclage options were considered. The patient’s previous high vaginal cerclage was a vaginally-placed cervicoisthmic cerclage. This placement level is at the cervical isthmus, the same level as for laparoscopic and open transabdominal cerclages. The vaginally-placed McDonald cerclage, which is more commonly used, is shown for comparison in the body of the cervix. The patient opted to proceed with a laparoscopically-placed transabdominal cerclage.

The surgical steps planned were a diagnostic hysteroscopy, followed by cystoscopy by urology, and last, laparoscopy, with placement of the transabdominal cerclage. First, a diagnostic hysteroscopy was done and both sides of the didelphys uterus were visualised. Next, cystoscopy was completed by urology. A solitary ureteric orifice was seen on the left side. Preoperative MRI had shown ureter dilation and so there was concern for possible stricture from previous high vaginal cerclage.

A retrograde pyelogram was done, given concern for anatomic distortion in the context of the patient’s known müllerian anomaly and to rule out stricture or stenosis. The retrograde pyelogram showed a patent but moderately distended left ureter with mild hydronephrosis. A left ureteric lighted stent was inserted to avoid ureteric injury in the context of the patient’s solitary kidney and bulky uterus. A Foley catheter was inserted into the bladder after completion of cystoscopy.

Last, we proceeded with laparoscopy, with placement of a transabdominal cerclage. After laparoscopic entry into the abdominal cavity, the uterine didelphys was visualised again. There were two normal and equal sized uteri, with a bulky cervix, where the uteri met. A uterine manipulator had been placed into the left uterus, and a Pratt dilator was placed in the right cervical os with a single-toothed tenaculum on the anterior lip. Together, there was good uterine manipulation.

Here is a transverse view of a cervix at the cervical isthmus, with the uterine arteries bilaterally. The general approach to an abdominal cerclage is placement of suture around the cervix at the cervical isthmus medial to the uterine vessels, as shown. This is done by creation of windows in the broad ligament bilaterally, followed by development of a bladder flap. This allows space to place the cerclage suture, as described. In a didelphys uterus, our plan was to similarly place the cerclage suture at the level of the cervical isthmus around both cervixes, medial to the uterine vessels.

There were adhesions of the rectosigmoid mesentery between the two uteri. This was taken down to allow the space to create windows into the broad ligament. The left ureter, with the lighted stent, was visualised and was found to be well away from any potential working area. The left broad ligament window was created with an ultrasonic scalpel and opened up in the anterior and posterior leaflets. Next, the right broad ligament window was created. The right uterine vessels were partially skeletonised, with sufficient space for cerclage placement. A bladder flap was developed and partially reflected inferiorly in order to help further delineate the anatomy and make room for cerclage placement.

Entry and exit points for the cerclage, both anteriorly and posteriorly, were identified at the level of the uterus cervical junction. A number one Prolene suture was passed through the umbilical port. First, the suture was placed on the right side, from posterior to anterior, medial to the uterine vessels.

Next, the suture was placed on the left side, anterior to posterior, exiting at the same level as the right-sided suture. The suture was brought out of the abdominal cavity through the umbilical port and a sliding knot was used to tie the cerclage down with knot placement posteriorly. Eight to ten additional intracorporeal knots were placed. The cerclage suture was trimmed. The pelvis was inspected for haemostasis. The location of the left ureter was again visualised and confirmed to be well away from the cerclage placement. This cerclage placement was reviewed and was in a satisfactory location. The cerclage was away from the bladder and ureters and medial to the uterine vessels at the level of the cervical isthmus.

The patient tolerated the procedure well. Estimated blood loss was less than 10 mL. The patient had a spontaneous conception soon after cerclage placement. She delivered via an emergency caesarean section at 33+3 weeks gestational age for preterm premature rupture of membranes, antepartum haemorrhage, and preterm labour for a live neonate.

In summary, we demonstrated a technique for laparoscopic abdominal cerclage in a patient with a didelphys uterus and a solitary kidney. We highlighted key anatomy important during laparoscopic abdominal cerclage. Thank you for watching.