Endometriosis
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Placement of a Laparoscopic Transabdominal Cerclage in a TCTA Pregnancy and Repair of Uterine Dehiscence with Omental Patch

Placement of a Laparoscopic Transabdominal Cerclage in a TCTA Pregnancy and Repair of Uterine Dehiscence with Omental Patch

Table of Contents

Video Description

To present a unique case presentation featuring the laparoscopic placement of a secondary cervico-isthmic abdominal cerclage during a trichorionic triamniotic (TCTA) pregnancy. Notably, the procedure reveals an incidental finding of uterine dehiscence, subsequently addressed through the placement of a uterine omental patch. This video provides a comprehensive overview of the pertinent anatomy and key surgical steps involved in placing a transabdominal cerclage during a 12 week TCTA pregnancy through narrated illustrations and video footage. Uterine dehiscence and extrusion of placenta from triplet A is identified and repaired. The procedure was uncomplicated and the patient delivered 3 healthy infants by cesarean-hysterectomy at 33 weeks gestation. The laparoscopic placement of a uterine omental patch represents a novel technique for repair of uterine dehiscence during pregnancy. Its consideration should be based on the patient’s reproductive history, and acknowledgment for the limited long-term studies regarding this technique.

Presented By

 

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Dr. E Skolnik
Dr. G Liu
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Dr. N Melamed
Dr. V Stratulat
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Dr. RC Kung
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Affiliations

University of Toronto

Sunnybrook

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What is a Placement of a Laparoscopic Transabdominal Cerclage in a TCTA Pregnancy and Repair of Uterine Dehiscence with Omental Patch?

The placement of a laparoscopic transabdominal cerclage in a trichorionic triamniotic (TCTA) pregnancy, combined with the repair of uterine dehiscence using an omental patch, is a specialized surgical intervention aimed at supporting the cervix and reinforcing the uterine wall in high-risk multiple pregnancies. Here’s a breakdown of this procedure:

  • Transabdominal Cerclage Placement: In TCTA pregnancies, which involve triplets with individual placentas and amniotic sacs, the cervix may be under increased strain due to the multiple fetuses. A transabdominal cerclage is a stitch placed at the upper part of the cervix, accessible only through an abdominal approach. This is often done laparoscopically, a minimally invasive method that allows the surgeon to place the cerclage with high precision to prevent premature cervical dilation, which is a risk factor for preterm labor.

  • Repair of Uterine Dehiscence: Uterine dehiscence refers to a partial thinning or separation in the uterine wall, which can increase the risk of uterine rupture as the pregnancy progresses. Repairing this dehiscence involves closing the defect, sometimes with the additional support of an omental patch. The omentum (a fatty tissue layer in the abdomen) is grafted onto the weakened area to provide reinforcement and promote healing.

  • Use of Laparoscopy and Omental Patch: Laparoscopic surgery allows for precise maneuvering with minimal incisions, reducing recovery time and the risk of infection. The omental patch adds an extra layer of tissue support, aiding in stabilizing the repaired area and reducing the risk of rupture as the pregnancy advances.

This combined approach is carefully designed to provide structural support to both the cervix and uterus, helping to manage the risks associated with TCTA pregnancies and prevent complications related to uterine integrity, particularly in a high-stress, multi-fetal pregnancy.

What are the Risks of a Placement of a Laparoscopic Transabdominal Cerclage in a TCTA Pregnancy and Repair of Uterine Dehiscence with Omental Patch? 

The placement of a laparoscopic transabdominal cerclage in a TCTA (transcervical tissue ablation) pregnancy and repair of uterine dehiscence with an omental patch involves several risks:

  • Surgical Complications: As with any laparoscopic procedure, there are risks of injury to surrounding organs such as the bladder, bowel, or blood vessels, which can lead to bleeding, infection, or the need for additional surgery.

  • Anesthesia Risks: General anesthesia carries risks such as allergic reactions, respiratory complications, and adverse effects on both the patient and the pregnancy.

  • Infection: Introducing surgical instruments into the abdominal cavity can lead to infection, including pelvic infections or abscess formation.

  • Uterine Injury: The process of placing a transabdominal cerclage and repairing uterine dehiscence can lead to further injury or weakening of the uterine wall, which might affect current or future pregnancies.

  • Preterm Labor: Manipulation of the uterus during pregnancy can stimulate contractions or cause preterm labor, which poses risks to both the mother and the fetus.

  • Cerclage-Related Complications: The cerclage itself can cause complications such as migration or erosion into surrounding tissues, and there is a risk of the stitch needing to be removed surgically, especially if complications arise during the current or subsequent pregnancies.

  • Omental Patch Complications: Using an omental patch to repair uterine dehiscence can lead to adhesions (scar tissue formation), which may cause chronic pain or complications in future abdominal surgeries.

Due to these risks, this procedure requires careful consideration and should be performed by an experienced surgical team with thorough preoperative planning and patient counseling.

Video Transcript: Placement of a Laparoscopic Transabdominal Cerclage in a TCTA Pregnancy and Repair of Uterine Dehiscence with Omental Patch

Placement of a laparoscopic transabdominal cerclage in a triplet pregnancy, and repair of uterine dehiscence with omental patch.

The objectives include presenting a unique case involving the laparoscopic placement of the secondary cervico-isthmic abdominal cerclage during a trichorionic, triamniotic pregnancy, and demonstrating the surgical steps to identifying uterine dehiscence and placement of an omental patch in pregnancy.

A 38-year-old G5P2 patient presented at 12 weeks gestational age with a trichorionic, triamniotic pregnancy, following IUI with ovulation induction at an outside centre.

Previous pregnancies were complicated by recurrent loss and cervical insufficiency. This included a 19-week loss. Placement of a 14-week McDonald cerclage, followed by PPROM at 24 weeks, resulting in a caesarean section with classical incision and subsequent neonatal death.

A six-week loss and placement of a transabdominal cervical cerclage prior to a healthy term pregnancy, resulting in elective repeat caesarean section. The patient was otherwise healthy.

As seen on transvaginal ultrasound at 12 weeks gestation, there is an intact transabdominal cerclage that was placed previously and is seen in situ at 4.1 cm. There is funnelling of the cervix noted below and through the cerclage, with a closed length of 17 mm. Options were discussed, and the decision was made to proceed with a second transabdominal cerclage procedure.

Step one. Bladder Dissection. Initial inspection revealed a gravid uterus and significant adhesions between the lower uterine segment and bladder, likely due to the history of two previous caesarean sections. The bladder was carefully dissected off of the interior lower uterine segment. The adhesions were judiciously incised with the use of an energy sealing device and careful sharp dissection. The vesicouterine peritoneum was identified, grasped and incised.

At this time, a small uterine dehiscence was identified. A small amount of placenta could be seen extruding through a three-millimetre hole in the lower segment scar.

The bladder was insufflated with CO2 gas to identify its superior margin, and care was taken to try to avoid the placenta and exacerbation of bleeding. Seen here is the identification of the cervico-isthmic junction.

Step two. Identify Placement for Transabdominal Cerclage. A 5 mm articulating fan was used to gently antevert the uterus and a number two proline on a GS-26 needle was introduced. Hair was taken to identify the junction between the uterus and the cervix at the upper portion of the cervix posteriorly, medial to the patient’s right uterine artery.

Step three. Placement of Transabdominal Cerclage. The needle was placed posterior to anterior on the patient’s right side, brought across the upper cervix so that the needle could then be driven interior to posterior, again, at the level of the junction between the uterus and upper cervix.

The needle was brought out medial to the patient’s left uterine artery and lateral to the cervix on the patient’s left side. The suture was tied extracorporeally, using a Roeder’s Knot, and then placed inferior to the previous transabdominal cerclage, which is seen here, and also noted to be intact.

Once the cerclage was sufficiently tightened around the cervico-isthmic junction, cystoscopy was performed. The bladder mucosa and dome were normal and intact, and both ureteric jets were seen.

Step Four. Identification and Repair of Uterine Dehiscence. The area of uterine dehiscence was carefully examined. No bleeding was noted. However, a portion of the amniotic membranes of what was likely foetus A was noted to be extruding through this 3 mm gap in the patient’s scar.

Using a 2-O Biosyn, the stitch was placed through the subrosa [?] and underlying myometrium in an imbricated, interrupted fashion in order to close over the dehiscence. This was performed with extreme care, so as to not damage the placenta, and also not to rupture membranes of foetus A. A single intracorporeal tie was placed carefully, and the defect was uncovered without any complications.

Step Five. Omental Patch Placement. At this time, consideration was given as to whether or not anything further could be done in order to cover this area of dehiscence. To our knowledge, this case stands as the first to demonstrate use of an omental patch to reinforce the closure of an incidentally discovered uterine dehiscence, in the context of a triplet pregnancy.

The omentum was brought down to the level of the lower segment of the uterus, and gently placed overtop the area of repair dehiscence. The omentum was then stitched to the uterus and peritoneum in order to cover the area of dehiscence. Stitches were tied intracorporeally. MRI demonstrates the omental patch located over the placenta previa of triplet A, as the myometrium in that area is extremely thin, or absent.

The focal myometrial defect in the protrusion of the amniotic sac is demonstrated here.

Case Review. The pregnancy course was complicated by intrahepatic cholestasis of pregnancy, gestational diabetes on insulin and placenta accreta of triplet A. A repeat elective caesarean section, with hysterectomy was planned for 33 plus one week’s gestational age. However, the patient went into spontaneous labour one day prior, resulting in a stat caesarean section hysterectomy. The patient delivered three healthy infants. Final path confirmed placenta increta of triplet A.

In summary, we reviewed the approach to the laparoscopic placement of a secondary transabdominal cervical cerclage in pregnancy. Laparoscopic placement of a uterine omental patch represents a novel technique for repair of uterine dehiscence.

Patient selection is individualised, as counselling should include an in-depth discussion regarding the risks of the procedure in the context of a patient’s unique reproductive history and limited long-term studies. Future research is required to understand the long-term effects of uterine omental patches.