Gravid Laparoscopic Abdominal Cerclage

Abstract

Study Objective Step-by-step tutorial for placement of laparoscopic abdominal cerclage during second trimester of pregnancy demonstrating two different suturing techniques. Design N/A. Setting Operating room in a large private not-for-profit hospital. Patients or Participants 31-year-old G5P0130 at 16w2d with a history of recurrent pregnancy loss in first trimester and one second trimester loss. Patient had a transvaginal McDonald cerclage placed at 13 weeks of gestation. However, the McDonald cerclage became displaced 2 weeks later leading to a cervical laceration and arterial bleed and was subsequently removed. Patient elected for laparoscopic abdominal cerclage placement at 16 weeks of gestation. Interventions First, the peritoneal bladder reflection was dissected to expose the cervicoisthmic junction. The lateral aspect of the broad ligament was dissected bilaterally. A window was created in the posterior leaf of the broad ligaments with further dissection bilaterally, skeletonizing the uterine vessels. Two different suturing techniques can be used for cerclage placement including using a CTX needle and a Carter-Thomason suture closure device. Measurements and Main Results This patient underwent an uncomplicated laparoscopic abdominal cerclage. Total operating time was about 180 minutes. She was discharged from PACU and was doing well at her 2-week follow up visit. She had an uncomplicated delivery via scheduled cesarean section at 37 weeks of gestation. Conclusion In this video, we demonstrate a step-by-step procedure for the safe and successful performance of a minimally invasive approach to abdominal cerclage in a gravid uterus in a patient with poor obstetric history who failed a transvaginal cerclage earlier in the pregnancy. We demonstrate two different suturing techniques that can be used at the time of cerclage placement. We also show the benefits of pexing the ovaries, as well as the use of a laparoscopic liver retractor and a Rumi manipulator handle, in order to help mitigate the challenges of performing this procedure in a 16-week gravid uterus. Step-by-step tutorial for placement of laparoscopic abdominal cerclage during second trimester of pregnancy demonstrating two different suturing techniques. N/A. Operating room in a large private not-for-profit hospital. 31-year-old G5P0130 at 16w2d with a history of recurrent pregnancy loss in first trimester and one second trimester loss. Patient had a transvaginal McDonald cerclage placed at 13 weeks of gestation. However, the McDonald cerclage became displaced 2 weeks later leading to a cervical laceration and arterial bleed and was subsequently removed. Patient elected for laparoscopic abdominal cerclage placement at 16 weeks of gestation. First, the peritoneal bladder reflection was dissected to expose the cervicoisthmic junction. The lateral aspect of the broad ligament was dissected bilaterally. A window was created in the posterior leaf of the broad ligaments with further dissection bilaterally, skeletonizing the uterine vessels. Two different suturing techniques can be used for cerclage placement including using a CTX needle and a Carter-Thomason suture closure device. This patient underwent an uncomplicated laparoscopic abdominal cerclage. Total operating time was about 180 minutes. She was discharged from PACU and was doing well at her 2-week follow up visit. She had an uncomplicated delivery via scheduled cesarean section at 37 weeks of gestation. In this video, we demonstrate a step-by-step procedure for the safe and successful performance of a minimally invasive approach to abdominal cerclage in a gravid uterus in a patient with poor obstetric history who failed a transvaginal cerclage earlier in the pregnancy. We demonstrate two different suturing techniques that can be used at the time of cerclage placement. We also show the benefits of pexing the ovaries, as well as the use of a laparoscopic liver retractor and a Rumi manipulator handle, in order to help mitigate the challenges of performing this procedure in a 16-week gravid uterus.