The laparoscopic approach of the transabdominal cerclage of the uterine cervix in case of cervical incompetence

Abstract

Cervical incompetence is characterized by painless cervical dilation in the second or early in the third trimester, with prolapse or ballooning of membranes in the vagina and expulsion of an immature fetus. Unless effectively treated, this sequence tends to recur at each pregnancy. Usually a ‘purse-string’ cerclage as described by McDonald, using a vaginal approach, is effective. If the cervix is too short for this or even absent, a transabdominal cervicoisthmic cerclage (TCC) is indicated. After TCC an eventual pregnancy always culminates in a Caesarean section, as the cerclage cannot be removed vaginally. This is, in fact, the main drawback of this technique. Objective To present the laparoscopic approach to TCC. Case history The patient was a 34-year-old woman with a history of cervical intraepithelial neoplasia and electrosurgical excision of the transformation zone. The pregnancy following this operation ended with an immature delivery, which was attributed to cervical incompetence. Before the next pregnancy, TCC using a laparoscopic approach was carried out. Using one 12-mm port and two 5-mm ports, the cervix was laparoscopically freed from the bladder. The avascular space between the ascending and descending branch of the uterine artery was penetrated and a Mersilene band was guided through, just above the level of the sacrouterine ligaments and tied. The operation lasted 40 minutes and the patient was discharged from the hospital, in a good state of health, the next day. Some months later she had an uneventful pregnancy, and a healthy but growth-retarded son, weighing 1890 g, was delivered by Caesarean section at 37 weeks of gestational age. Conclusion The laparoscopic approach to TCC was successful. The growth retardation in the subsequent pregnancy seemed coincidental. The laparoscopic approach is to be preferred for a planned TCC.