06: A four step strategy for robot-assisted abdominal cerclage placement prior to pregnancy

Abstract

This video demonstrates a four step strategy for robot-assisted (RA) abdominal cerclage placement prior to pregnancy. Cerclages are used to treat cervical insufficiency that can affect 1% of all pregnancies. In women who failed transvaginal cerclage, or have anatomic variants, abdominal cerclage is recommended. This case demonstrates a four step strategy to place a RA abdominal cerclage in a 38yo G4P0220 who had a prior failed transvaginal cerclage and a history of two second trimester losses. Step one: Create the bladder flap. Careful attention must be paid during dissection to avoid lateral extension into the uterine arteries. Step two: Identify pertinent anatomy. This includes the uterosacral ligaments, uterine arteries, and the lateral edges of the cervical stroma at the level of the internal os; thus allowing correct placement of the cerclage. Step three: Place the cerclage. Depending on surgeon preference, the cerclage knot can be tied anteriorly or posteriorly. Step four: Perform confirmatory hysteroscopy. This allows for intraoperative evaluation confirming appropriate placement, ensuring cervical patency, and permitting intraoperative correction. Abdominal cerclages significantly improve pregnancy and neonatal outcomes in women who have previously failed transvaginal cerclage. This patient did well postoperatively without increased blood loss or operative time. RA abdominal cerclage placement allows a minimally invasive approach with enhanced dexterity and better visualization for the surgeon over conventional laparoscopy, as well as, decreased pain and shorter recovery time over laparotomy. RA abdominal cerclage is a safe, viable alternative to traditional abdominal cerclage placed with laparotomy. This video demonstrates placement of a history indicated RA abdominal cerclage utilizing a simple four step strategy to ensure successful, correct, easy placement.