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Laparoscopic Cervicoisthmic Cerclage in Pregnancy


 

UNIVERSAL CITY, CALIF. — A significant number of successful deliveries have occurred, and one patient has delivered two babies, following laparoscopic cervicoisthmic cerclage performed during pregnancy at the University of Illinois, Chicago.

Andrew I. Brill, M.D., professor of ob.gyn. and director of gynecologic endoscopy at the university, reported on more than a dozen cases at the annual meeting of the Obstetrical and Gynecological Assembly of Southern California.

The innovative laparoscopic procedure could offer hope of a minimally invasive alternative to a technically demanding and often complicated abdominal surgery during pregnancy, in patients for whom conventional vaginal cerclage has failed or is not possible.

“These are patients who are quite desperate, with a history of multiple losses despite repeated conventional procedures,” Dr. Brill said.

All the patients in his series had experienced failure of conventional vaginal cerclages for cervical incompetence, and many had suffered repeated second-trimester losses. In some patients, previous cervical procedures precluded placement of a vaginal cerclage.

If such patients desire children, “There really is no salvation but abdominal cervicoisthmic cerclage,” he explained.

Conventional abdominal cerclage typically requires an extended midline abdominal incision and a considerable hospital stay. Complications can include hemorrhage and pregnancy loss. Laparoscopic cervicoisthmic cerclage during pregnancy is a novel and technically challenging procedure. Ideally, it should be performed by 12 weeks' gestation, at a point when the risk of spontaneous first trimester loss is minimal but there is still enough space to safely manipulate and work around the gravid uterus, according to Dr. Brill.

Besides the threat of fetal loss, the risk of bleeding is considerable, so the surgical team must be prepared to quickly convert to conventional surgery. Morbid obesity and the risk of significant abdominal adhesions should be viewed with caution, according to Dr. Brill.

“This is a surgery where you know that if you make a mistake, it's over, and it's a very rapid over,” he said.

Nonetheless, the University of Illinois experience has been largely successful. Dr. Brill noted that the exact numbers are being compiled for publication but that at least 10 healthy babies have been born following the procedure.

Some patients have undergone the procedure as outpatients, while perinatologists have opted to observe others overnight. Some pregnancies are ongoing.

Fetal viability is carefully assessed before and after the procedure, which initially took about 4 hours but, with experience, has been reduced to about 90 minutes.

Two losses have occurred, one the day following the procedure and one at about 20 weeks' gestation in a patient with recurrent previous losses. In one early case, the laparoscopic procedure was converted to laparotomy to control bleeding when the underside of a harmonic scalpel abrupted a uterine vein. The procedure is performed under general anesthetic.

A cervical cup is placed into the vagina and up to the fornices to aid in lifting the uterus for skeletonization of the uterine vessels and placement of a Mersiline ligature between the uterine vessels and the lower segment at the isthmus.

A port is placed at the umbilicus for the laparoscope. Two right and two left paraumbilical ports are placed high and lateral, and one is placed at the midline suprapubic abutting the mons pubis. Bipolar dissection and sharp dissection are used to mobilize the uterine arteries well off the lower uterine segment.

Using a right-angle dissector placed through the suprapubic port, a Mersilene stitch is pulled from back to front through windows created in the broad ligament and tied snugly around the isthmus of the uterus, insuring the suture remains flat against the posterior lower segment.

Throughout the procedure, precautions are taken against over-manipulating the uterus or causing vascular injury. Cutting is performed with monopolar energy or blunt-tipped mechanical scissors.

The uterine vessels are skeletonized and isolated from the lower uterine segment.

The knotted Mersilene stitch has been placed, and the procedure is completed. Photos courtesy Dr. Andrew I. Brill

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