“HIGH UTEROSACRAL VAGINAL VAULT SUSPENSION TO REPAIR ENTEROCELE AND APICAL PROLAPSE”
MICKEY KARRAM, MD, AND CHRISTINE VACCARO, DO (JUNE 2011)
How to identify the uterosacral ligament
The technique described by Dr. Karram and Dr. Vaccaro is excellent—simple and effective. A similar procedure was described by Thomas M. Julian, MD, at the Pelvic Reconstructive and Vaginal Surgery Conference in 2002 in St. Louis, Missouri. He detailed a very helpful maneuver to identify the uterosacral ligament: “With the patient in the high dorsal lithotomy position, an Allis clamp is used to place firm traction on the posterior cul-de-sac on the side where the uterosacral ligament is to be located. The surgeon places a finger in the rectum and draws the finger from a far lateral position until the uterosacral ligament is felt….A second Allis clamp is placed directly on the palpated uterosacral ligament from the transperitoneal side as the ligament is elevated by the underlying rectal finger.”1
Joseph Capecchi, MD
St. Paul, Minn
“CAN CERCLAGE PREVENT PRETERM BIRTH IN WOMEN WHO HAVE A SHORT CERVIX?”
JOHN T. REPKE, MD
(EXAMINING THE EVIDENCE; JUNE 2011)
Cerclage is too complex for a one-size-fits-all approach
It was gratifying to read the comments by Dr. Repke about the problems with meta-analysis. The literature on cerclage often overlooks important clinical variables.
At one time, cerclage was not performed until three second-trimester preterm births had occurred. Thankfully, this approach is no longer considered valid; a single preterm birth is now a sufficient indication for cerclage.
A careful history is essential to determine whether the patient experienced labor in the previous pregnancy loss, to distinguish incompetent cervix from premature labor. A fair percentage of women who have an incompetent cervix do experience some labor—but usually not until the cervix has dilated 5 cm or more.
The timing of cerclage is critical. If it is performed at about 14 weeks’ gestation, the procedure usually does not precipitate labor. However, if the OB is timid and waits until changes occur, the placement of cerclage frequently makes the situation worse by irritating the lower uterine segment. Occasionally, if suture is used, the cervix may be effectively amputated by a late-placed cerclage. The cerclage should not unduly constrict the opening of the os; the tip of the little finger should be able to enter.
Proper placement of the tape or suture is also essential. If it is placed too high, the surgeon risks penetrating the uterine artery. If the tape is placed too low, the cervical neck is insufficiently supported.
In a successful cerclage, the anchoring knot remains successfully buried; it may be wise, in these cases, to consider elective cesarean so that the knot can be left in place for future pregnancies.
Another important consideration is whether to use tape or suture. Tape is difficult to insert properly but offers wider support, whereas suture is easier to use.
All of these variables—the patient’s history, timing and placement of cerclage, tape versus suture, and whether to leave the cerclage in place—should be addressed by the clinician. No single approach to cerclage fits all situations, including measurement of cervical length. Because so many variables go into the decision-making, meta-analysis yields questionable “conclusions,” as Dr. Repke pointed out.
Kenneth W. McHenry, MD
Dr. Repke responds:Both the art and science of medicine are critical in management of cervical insufficiency
I appreciate the comments of Dr. McHenry, who very nicely points out how, in addition to applying the science of medicine to the problem of cervical insufficiency, we must still continue to apply the art. Many of the interesting points that he raises remain unresolved scientifically. The type of cerclage, type of suture (or tape), optimal timing, and optimal placement have all been addressed, but not satisfactorily, from a truly scientific standpoint. This lack of definitive data underscores Dr. McHenry’s point that one size does not fit all when it comes to cerclage.