Cervical Procedures
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Laparoscopic Placement of Pre-Conception Cervical Cerclage

Laparoscopic Placement of Pre-Conception Cervical Cerclage
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Video Description

This video demonstrates an approach to laparoscopic cervical cerclage at the cervico-isthmic junction in a patient prior to conception. The risks and benefits of laparoscopic and vaginal cerclage are also compared.

Presented By

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Dr. Marielos Pineda Rivas
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Dr. Darrien Rattray
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Dr. John Thiel

Affiliations

University of Saskatchewan

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What is Laparoscopic Placement of Pre-Conception Cervical Cerclage?

Laparoscopic Placement of Pre-Conception Cervical Cerclage is a minimally invasive surgical procedure used to place a cerclage stitch around the cervix to provide support and prevent premature cervical dilation in women who have a history of cervical insufficiency. Here’s an overview:

  1. Procedure: Performed laparoscopically through small incisions in the abdomen. A cerclage stitch is placed around the cervix using specialized instruments to support the cervical tissue and reduce the risk of miscarriage or preterm birth.

  2. Indications: Typically recommended for women with a history of cervical incompetence or those who have experienced recurrent pregnancy loss due to cervical issues. It is often done before conception or in early pregnancy to offer support during the gestation period.

  3. Benefits: Laparoscopic placement is less invasive than traditional open surgery, resulting in reduced recovery time, less postoperative pain, and minimal scarring. It allows for precise placement of the cerclage and a quicker return to normal activities.

  4. Recovery: Patients usually experience a shorter hospital stay and faster recovery compared to open cerclage procedures, though they should follow post-operative care instructions and monitor for any complications.

The laparoscopic approach provides a less disruptive method for ensuring cervical support and improving the chances of a successful pregnancy for women with cervical insufficiency.

What are the Risks of Laparoscopic Placement of Pre-Conception Cervical Cerclage?

Laparoscopic placement of pre-conception cervical cerclage, while beneficial, carries certain risks:

  1. Infection: Risk of infection at the incision sites or within the pelvic area.
  2. Bleeding: Possibility of intraoperative or postoperative bleeding.
  3. Anesthesia Risks: Complications related to general anesthesia, such as allergic reactions or respiratory issues.
  4. Injury to Surrounding Organs: Potential for accidental injury to nearby structures like the bladder, intestines, or blood vessels.
  5. Preterm Labor: Although rare, the procedure itself might induce contractions or preterm labor.
  6. Cerclage Complications: Risk of cerclage displacement or failure, which may necessitate additional procedures.
  7. Scarring and Adhesions: Formation of scar tissue or adhesions, which can cause pain or affect future pregnancies.
  8. Postoperative Pain: Temporary pain or discomfort following the procedure.

Each risk requires careful consideration and monitoring to ensure the best possible outcome for the patient.

Video Transcript: Laparoscopic Placement of Pre-Conception Cervical Cerclage

The objectives of this video are to present the case of a patient requiring a transabdominal cerclage. Compare the risk and benefits of laparoscopic cerclage to vaginal cerclage. And demonstrate the laparoscopic placement of a cerclage at the cervico-isthmic junction.

 A 34-year-old woman was referred for a transabdominal cerclage. Her obstetrical history included a pregnancy loss at 21 weeks and a pre-term birth of a viable infant at 25 weeks. With her last pregnancy, she had a transvaginal cerclage placed at 12 weeks. The cerclage failed, and she required a rescue cerclage at 21 weeks. Fortunately, she had a viable infant by caesarean section at 35 weeks.

There is some variation in the exact definition of cervical insufficiency, but it is typically defined as painless progressive dilation of the cervix in the absence of labour. The incidence of cervical insufficiency is 0.5 to 1%. The recurrence risk is 30%. Transabdominal cerclage has traditionally been considered a more morbid procedure than transvaginal cerclage. Therefore, most guidelines recommend reserving a transabdominal cerclage for women who have either failed a transvaginal cerclage, or in whom a transvaginal cerclage is technically impossible to perform due to extreme shortening, scarring, or laceration of the cervix.

In this table, we have summarised the outcomes of the five largest studies of patients with a laparoscopic cerclage. The foetal survival rate ranged from 88 to 98%. The mean gestational age at delivery was 35 to 37 weeks. The complication rate ranged from 0 to 10.7%. Potential advantages of transabdominal cerclage over transvaginal cerclage are more proximal placement of the stitch at the level of the internal cervical os, decreased risk of suture migration, absence of a foreign body in the vagina that could promote infection, and the ability to leave the suture in place for future pregnancies.

Some disadvantages are that patients need to be delivered by caesarean section, and that patients may need to undergo another surgery to have their cerclage removed.

A 2015 study compared laparoscopic cerclage in the first trimester, laparoscopic cerclage pre-conception and transvaginal cerclage. There were no statistically significant differences between the laparoscopic cerclage groups. This finding is consistent with other studies. However, both laparoscopic cerclage groups were independently statistically significant from the vaginal cerclage group. Foetal survival rate and mean gestational age at delivery were higher in both laparoscopic cerclage groups. The complication rate was 0% for all three groups.

Our patient had a historical indication for a transabdominal cerclage, as she had failed the vaginal cerclage. The Leyland technique was used for cerclage placement. The uterus was small, mobile, and anteverted. A corner uterine manipulator was used to mobilise the uterus. We began the surgery by opening the vesico-uterine and paravesical spaces. Sharp dissection with monopolar scissors was used to develop these spaces.

At this point, we had good visualisation of the right uterine artery. There were some adhesions of the bladder to the uterus from the patient’s previous caesarean section. Once the vesico-uterine and paravesical spaces were opened, the uterus was anteverted so that we could make the windows in the broad ligament. Since we had good visualisation of the right uterine artery anteriorly, we used the grasper to gently push the broad ligament posteriorly to help delineate where the window should be made.

To obtain better haemostasias, we switched to a bipolar instrument. The broad ligament window should be lateral and parallel to the uterine artery as depicted here. This helps move the ureters caudal. The posterior sheath of the broad ligament was grasped. Sharp dissection with monopolar scissors was used to create the window.

Here again the broad ligament window is made lateral and parallel to the uterine artery. A number one proline suture was used to do the cerclage. The needle was passed medial to the right uterine artery, from posterior to anterior, at the level of the cervico-isthmic junction. We did not find it difficult to pull the proline suture through the uterine tissue. The needle was then passed from anterior to posterior on the left side, again staying medial to the uterine artery.

The suture was tied down, using an external knot pusher over the Kronner manipulator, which has a diameter of 5mm. The suture remnants were left long to facilitate removal of the cerclage at the time of caesarean section, or removal for a D&E or vaginal delivery, in case of pregnancy loss in the second or third trimester.

As you can see, the cerclage is correctly positioned at the level of the cervico-isthmic junction. Interceed was placed anteriorly and posteriorly to help prevent adhesions. The patient tolerated the procedure well. The estimated blood loss was 30ml. She was stable post-operatively, and was discharged home within 24 hours. The foetal survival rate for a laparoscopic cerclage is 88 to 98%. Given the advantages of laparoscopic cerclage over a vaginal cerclage, more studies are needed to determine if we should expand the indications for laparoscopic cerclages.