Steps for interval cerclage and during pregnancy
Our practice is to place transabdominal cerclage via conventional laparoscopy as an interval procedure when possible. We find no benefit in using robotic assistance.
For an interval procedure, the patient is placed in a dorsal lithotomy position, and we place a 10-mm umbilical port, 2 lateral 5-mm ports, 1 suprapubic 5-mm port, and a uterine manipulator. We use a flexible laparoscope to provide optimal visualization of the pelvis from any angle.
The first step of the surgery involves dissecting the vesicouterine peritoneum in order to move the bladder inferiorly (FIGURE 3A). Uterine arteries are then identified lateral to the cervix as part of this dissection, and a window is created in the inferior aspect of the broad ligament just anterior and lateral to the insertion of the uterosacral ligaments onto the uterus, with care taken to avoid the uterine vessels superiorly (FIGURE 3B). Two 5-mm Mersilene tape sutures are then tied together to create 1 suture with a needle at each end. This is then passed into the abdomen, and 1 needle is passed through the parametrial space at the level of the internal os inferior to the uterine vessels on 1 side of the uterus while the other needle is passed through the parametrial space on the opposite side.
Alternatively, rather than using the suture needles, a blunt dissector can be passed through this same space bilaterally (FIGURE 3C) via the suprapubic port and can pull the Mersilene tape through the parametrial space (FIGURE 3D). The suture is then tied anterior at the level of the internal os intracorporally (FIGURE 3E), and the needles are cut off the suture and removed from the abdomen.
To perform transabdominal cerclage when the patient is pregnant, a few modifications are needed to help with placement. First, the patient may be placed in supine position since a uterine manipulator cannot be used. Second, use of a flexible laparoscope becomes even more imperative in order to properly see around the gravid uterus. Lastly, a 5-mm laparoscopic liver retractor can be used to aid in blunt manipulation of the gravid uterus (FIGURE 3F). (The surgical video below highlights the steps to transabdominal cerclage placement in a pregnant patient.) All other port placements and steps to dissection and suture placement are the same as in interval placement.
CASE Continued: Patient pursues transabdominal cerclage
You explain to your patient that ideally the cerclage should be placed now in a laparoscopic fashion before she becomes pregnant. You then refer her to a local gynecologic surgeon who places many laparoscopic transabdominal cerclages. She undergoes the procedure, becomes pregnant, and after presenting in labor at 35 weeks’ gestation has a cesarean delivery. Her baby is born without any neonatal complications, and the patient is overjoyed with the outcome.
Management during and after pregnancy
Pregnant patients with a transabdominal cerclage are precluded from having a vaginal delivery and must deliver via cesarean. During the antepartum period, patients are managed in the same manner as those who have a transvaginal cerclage. Delivery via cesarean at the onset of regular contractions is recommended to reduce the risk of uterine rupture. In the absence of labor, scheduled cesarean is performed at term.
Our practice is to schedule cesarean delivery at 38 weeks’ gestation, although there are no data or consensus to support a specific gestational age between 37 and 39 weeks. Unlike a transvaginal cerclage, a transabdominal cerclage can be left in place for use in subsequent pregnancies. Data are limited on whether the transabdominal cerclage should be removed in women who no longer desire childbearing and whether there are long-term sequelae if the suture is left in situ.17
Continue to: Complications and risks of abdominal cerclage...