Laparoscopic cervico‐uterine cerclage using polypropylene mesh for the treatment of cervical incompetence

Abstract

Cervical incompetence is defined as the inability to retain an intrauterine pregnancy up to term due to a deficiency in the structure or function of the cervix (1). The condition is characterized by a painless dilatation and shortening of the cervix in the second or early third trimester, usually followed by midtrimester miscarriage or preterm delivery. This tends to repeat itself in subsequent pregnancies. Diagnosis of cervical insufficiency is based on past obstetric history. The incidence has been estimated to 0.05 and 0.1% of all pregnancies (1). The first operation to prevent preterm delivery with a cervical suture used a vaginal technique (1). The transabdominal cerclage is a more invasive approach and has mostly been used when the cervix has been extremely short, deformed or when previously transvaginal cerclage has failed (2). The transabdominal application of the cerclage has been associated with a lower incidence of preterm delivery when compared to the transvaginal technique (1,2). The advantages and success of the technique may derive from stronger circumferential support of the uterine isthmus and decreased slippage of the suture because of its abdominal placement above the cardinal and uterosacral ligaments. Laparoscopic placement of cervicoisthmic cerclage has previously been described using polyester tape (Mersilene, Johnson and Johnson, Hvalstad, Norway) (3,4). Our case report describes a technique for the laparoscopic placement of an internal cerclage using a polypropylene mesh. A 33-year-old woman (gravida 9, para 1) presented with a history of recurrent second trimester miscarriages. She had experienced a total of eight miscarriages all during the 20–24 weeks of gestation. She experienced miscarriages without any evidence of preterm premature rupture of the membranes, contractions or infections. During one occasion she had been treated with a vaginal cerclage. In her eighth pregnancy, she developed cervical incompetence at 24-weeks gestation and spent the rest of her pregnancy immobilized. She had a normal delivery at 37 weeks. The cervix was noted to be extremely short. We performed a prophylactic laparoscopic internal cerclage. Shortly afterwards, the patient became pregnant. She was able to maintain a normal level of activity during this pregnancy. The internal cerclage was easily identified by vaginal ultrasound. The cervical length remained 2 cm. Elective caesarean section was conducted at 37 weeks. At the time of the caesarean section the polypropylene mesh was easily palpable retroperitonealy at the level of the internal os. The bladder peritoneum was opened at the level of the uterine isthmus and a window was created through the broad ligament medially to the uterine vessels (in the avascular space) at the level of the internal os bilaterally. Posteriorly the peritoneum was opened at the level of the internal os above the sacrouterine ligaments. A polypropylene mesh (Prolene, Johnson and Johnson) was placed loosely through the window retroperitonealy around the isthmus uteri above the cardinal and sacrouterine ligaments. The mesh was thereafter fixated with a nonabsorbable suture (Etibond, Johnson and Johnson) anteriorly. The mesh was placed loosely to allow the cervix to be opened up to a diameter of 2 cm in case of miscarriage. Patients should be very carefully selected when performing a transabdominal cerclage. The reason is the potential of significant peroperative morbidity and difficulties in case of miscarriage (1,2). Other previously described complications include occlusion of the uterine vessels and erosion of the cerclage suture through the lower uterine segment and peroperative bleeding (1,2). Selection criteria for transabdominal cerclage would be a history consistent with an incompetent cervix, painless dilatation of the cervix in the second or early third trimester and previously failed vaginal cerclage or deformed cervix (impossible to apply a vaginal cerclage). The patient must be informed that caesarean section is the only way to deliver (1). The laparoscopic technique requires an experienced laparoscopic surgeon (3,4) and should be performed as an elective operation when not pregnant. The laparoscopic technique reduces the need for repeated laparotomy reducing postoperative pain, hospitalization and convalescence (5). It has also been shown to reduce the risk of pelvic adhesions that might affect fertility. We used polypropylene mesh instead of polyester tape. Polyester tape has been shown to cause erosion of the lower uterine segment when used for cerclage (1). The texture of the polypropylene mesh makes it easier to handle and thereby simplifies the procedure.