Laparoscopic Abdominal Cerclage Research Articles

11554 Laparoscopic Emergency Abdominal Cerclage During Pregnancy (23 weeks)

11554 Laparoscopic Emergency Abdominal Cerclage During Pregnancy (23 weeks)

Surgical Tips for Robotic Assisted Laparoscopic Abdominal Cerclage: A Minimally Invasive Approach.

Preterm birth is the leading cause of perinatal and neonatal morbidity and mortality in the developed world. An important cause of preterm birth is cervical insufficiency, leading to membrane prolapse, premature rupture of membranes, and mid-trimester pregnancy loss. A cerclage can be placed vaginally or abdominally to treat cervical insufficiency. In cases of failed prior transvaginal cerclage (TVC), transabdominal cerclage (TAC) is the alternative. The procedure can be completed via laparoscopy or open approach. The suture is placed at the internal os giving greater structural support.1 In this article, we review the definition of cervical incompetence, we present the indications for TAC, we discuss the outcomes of minimally invasive TAC compared to open approach, and we review surgical tips and tricks for robotic assisted (RA) TAC placement that can be used prior to pregnancy or in early gestation. The included images delineate the surgical technique for safe placement of robotic assisted laparoscopic abdominal cerclage in the management of cervical insufficiency.

Laparoscopic prepregnancy transabdominal cerclage: operative and pregnancy outcomes for a novel technique of suture placement using port closure device

Trans-abdominal cerclage (TAC) is an effective surgical intervention for preterm birth prevention. Placement of cervical suture using port closure device for pre-pregnancy laparoscopic abdominal cerclage has been used at our unit in recent years. We report operative and pregnancy outcomes for pre-pregnancy laparoscopic abdominal cerclage using the port closure device compared to traditional approach.For pre-pregnancy laparoscopic TAC(n=52), the port closure device approach is associated with lower blood loss at surgery and hospital length of stay (0.95+-4.4 mls vs 5.4+-15.7mls, p=0.007; 0.0(0.0-0.0) days vs 1.0(0.0-1.0) days, p<0.001). There were also trends towards shorter operating times (41.4+-15.3 minutes versus 50.1+-18.0, p=0.167) and lower peri-operative complications (0.0%, 0/21 vs 16.1%, 5/31, p=0.065) compared to traditional technique. There was no significant difference between the port closure device technique and traditional approach in rates of preterm birth rate in subsequent pregnancy (0.0%,0/9 vs 22.6%,7/39, p=0.248).Novel use of the port closure device for suture placement at pre-pregnancy laparoscopic cerclage for preterm birth prevention. This technique is associated with lower blood loss and length of stay, has trends in shorter operating times and peri-operative complications and similar rates of preterm birth.

Favorable surgical and obstetrical outcomes in pre- and postconceptional laparoscopic abdominal cerclage: a large multicenter cohort study

BackgroundCervical incompetence is an important cause of extreme preterm delivery. Without specialized treatment, cervical incompetence has a 30% chance of recurrence in a subsequent pregnancy. Recently the first randomized controlled trial showed significant superiority of the abdominal cerclage compared to both a high and low vaginal cerclage in preventing preterm delivery <32 weeks of gestational age and fetal loss in patients with a prior failed vaginal cerclage. Objective(s)To assess surgical and obstetric outcomes in patients with pre- and postconceptional laparoscopic abdominal cerclage placement. Furthermore, to perform subgroup analysis based on the indication for cerclage placement in order to identify patients that benefit the most from an abdominal cerclage. Study designA retrospective multicenter cohort study with consecutive inclusion of all eligible patients from 1997 onwards in the Dutch cohort (104 patients) and from 2007 onwards in the Boston cohort (169 patients) was conducted. Eligible patients suffered from at least one second- or third-trimester fetal loss because of cervical incompetence and/or a short or absent cervix after cervical surgery. This includes loop electrosurgical excision procedure (LEEP), conization or trachelectomy. Patients were divided into subgroups based on the indication for cerclage placement: 1) prior failed vaginal cerclage 2) prior cervical surgery 3) other indications. This third group consisted of patients with a history of multiple second- or early third-trimester fetal losses based on cervical incompetence (without a failed vaginal cerclage) and/or multiple dilation and curettage procedures. The primary outcome measure was delivery at ≥34 weeks of gestation with neonatal survival at hospital discharge. Secondary outcome measures included surgical and obstetric outcomes, such as pregnancy rates after preconceptional surgery, obstetric complications and fetal survival rates. ResultsA total of 273 patients were included; 250 patients in the preconceptional cohort and 23 patients in the postconceptional cohort. Surgical outcomes of 273 patients were favorable with six minor complications (2.2%). In the postconceptional cohort we had one patient (0.4%) with hemorrhage of 650 ml, resulting in conversion to laparotomy. After preconceptional laparoscopic abdominal cerclage (n=250) the pregnancy rate was 74.1% (n=137) with a minimal follow-up of 12 months. Delivery at ≥ 34 weeks of gestation occurred in 90.5% of all ongoing pregnancies. Four patients (3.3%) suffered from a second-trimester fetal loss. The indication for the cerclage in all four patients was a prior failed vaginal cerclage. The other subgroups showed fetal survival rates of 100% in ongoing pregnancies with a total fetal survival rate of 96%. After postconceptional placement, 94.1% of all patients with an ongoing pregnancy delivered at ≥ 34 weeks of gestation with a total fetal survival rate of 100%. Thus second-trimester fetal losses did not occur in this group. Conclusion(s)Pre- and postconceptional laparoscopic abdominal cerclage is a safe procedure with favorable obstetric outcomes in patients with an increased risk of cervical incompetence. All subgroups show high fetal survival rates. Second-trimester fetal loss only occurred in the group of patients with a cerclage placed for the indication prior failed vaginal cerclage, but also in this group the chance was low.

Emergency Cervical Cerclage Following Laparoscopic Abdominal Cerclage with Cervical Dilatation

Emergency Cervical Cerclage Following Laparoscopic Abdominal Cerclage with Cervical Dilatation

O-055 Efficacy of Laparoscopic Abdominal Cerclage in Women With Prior 2nd Trimester Losses/Preterm Birth: Perinatal Outcomes of Case Series

Abstract Study question What is the efficacy of laparoscopic abdominal cerclage (LAC) that placed during periconceptional period in singletons with prior 2nd trimester pregnancy losses/preterm deliveries (PTDs)? Summary answer LAC seems to prolong pregnancy duration and enhance perinatal outcomes in singletons prior 2nd trimester losses/PTDs. What is known already Cervical insufficiency (CI) is defined as the inability of the uterine cervix to retain a pregnancy till term without the signs and symptoms of clinical contractions ,with an incidence up to 1% (Berghella, 2011). Cervical cerclage (CC) has been proposed as an effective treatment for CI in terms of successfully prolonging the pregnancy period and improving the perinatal prognosis. The common clinical approach is transvaginal cervical cerclage (TVC), which is a feasible and relatively easy technique. However, some group of women may experience late abortions and/or PTD and LAC has been proposed to enhance pregnancy outcomes. Study design, size, duration Case series consisting of singletons with at least 2 prior PTDs and managed with LAC was reviewed between January 2019-November 2022. After placement of LAC, reproductive and perinatal outcomes of women were reviewed for 2 years. Participants/materials, setting, methods All women with at least 2 prior 2nd trimester losses and/or PTDs were offered to LAC procedure during the period. After having informed consents, total of 28 LAC procedures were performed. All surgeries were performed by a single experienced laparoscopist in the same center. Non-absorbable mersilene tape was placed during preconceptional period. Reproductive outcomes including spontaneous and assisted conception cycles and perinatal outcomes were reported. Main results and the role of chance A total of 28 LAC proceudres were performed during the period. Mean age of women was 34±2 and mean numbers of previous 2nd trimester losses/PTDs was 2.8±0.8, of which all of them were &amp;lt;24 weeks. Total of 8 women have had gynecologic surgery in their history. Less than 12 months interval, 19 out of 28 women got pregnent; 13/28 conceived spontaneously and 6/28 conceived with after IVF treatment. For the perinatal outcomes; there were no single case of 2nd trimester losses/PTDs &amp;lt;24 weeks in the entire cohort. 15 women delivered &amp;gt;34 weeks and remaining 4 delivered at term (&amp;gt;37 weeks). During the gestation, no additional medication was provided to pregnants such as progesterone treatment. The mean gestational age was 35 4/7 weeks. There were no remarkable adverse events during the pregnancy. All newborns were healthy without remarkable issues, only 2 infants required intensive care for less than 2 weeks. Limitations, reasons for caution Small sample size, lack of a control group and randomization and heterogenious patient population. Wider implications of the findings LAC appears to have favorable pregnancy outcomes in singletons with prior pregnacy losses and/or PTDs. To precisely conclude, randomized controlled trials are needed with different intervention arms in the same population. Trial registration number non applicable

Effect of different surgical routes on pregnancy outcome of history-indicated cervical cerclage

ObjectiveTo study the guiding significance of medical history on laparoscopic and vaginal cervical cerclage in the treatment of cervical incompetence and its influence on pregnancy outcome.MethodsA total of 53 cases by laparoscopic abdominal cervical cerclage (LAC group) before pregnancy and 73 cases by transvaginal cervix cerclage (TVC group) at 12–14 weeks of pregnancy were collected. Multivariate logistic regression analysis was performed on the influencing factors of delivery gestational weeks. Furthermore, the gestational weeks after cervical cerclage were compared between the two groups with high- and low-risk grades.ResultsThe number of previous uterine cavity operations in LAC group was more than that TVC group, and the costs of operation were more than TVC group. At the same time, the hospitalization days and operation time were longer than those in TVC group, and the delivery rate of cesarean section was higher than TVC group, but the total hospitalization times were less than TVC group (P < 0.05). The rate of delivery before 34 weeks of pregnancy and the incidence of premature rupture of membranes or premature labor in LAC group were lower than those in TVC group (P < 0.05). In TVC group, the increased number of prior PTB or STL and the history of cervical cerclage failure would increase the risk of premature delivery before 34 weeks of pregnancy. There was no increased risk of preterm delivery before 34 weeks of pregnancy in LAC group (P > 0.05). According to the risk level, in the high-risk group, the delivery rate of LAC group at gestational weeks < 37 weeks, < 34 weeks and < 28 weeks was lower than that of TVC group.ConclusionLaparoscopic cervical cerclage might be more effective in preventing premature delivery before 34 weeks of gestation, and its influence on delivery gestational weeks was not affected by related medical history. For high-risk patients with the history of prior PTB or STL and failed cerclage, laparoscopic cervical cerclage might be more effective than vaginal cervical cerclage in preventing extremely preterm before 28 weeks, premature delivery before 34 weeks and premature delivery before 37 weeks. Therefore, our limited experience suggested that LAC can be a recommended option for patients with high-risk history.

Laparoscopic abdominal cerclage in a bicornuate uterus during pregnancy

Laparoscopic abdominal cerclage in a bicornuate uterus during pregnancy

Favorable surgical and obstetric outcomes in pre-and postconceptional laparoscopic abdominal cerclage: large multicenter cohort study

Favorable surgical and obstetric outcomes in pre-and postconceptional laparoscopic abdominal cerclage: large multicenter cohort study

Laparoscopic Abdominal Cerclage after Prior Radical Trachelectomy

<h3>Study Objective</h3> To present a case and surgical video of laparoscopic abdominal cerclage placement after prior radical trachelectomy and demonstrate techniques in overcoming challenging dissections and an alternative surgical technique in placement of cerclage. <h3>Design</h3> Case report and surgical video. <h3>Setting</h3> In the operating room with a patient in dorsal lithotomy position with both arms tucked. A 10mm port was placed at the umbilicus and 3 additional 5mm ports were placed in the right and left lower quadrant and suprapubic region. A uterine manipulator, flexible laparoscopic, and bipolar sealing device were used. <h3>Patients or Participants</h3> One patient. <h3>Interventions</h3> A 34yo P2 with prior surgical history of exploratory laparotomy, radical trachelectomy, sentinel lymph node mapping, pelvic lymphadenectomy for stage 1B1 cervical squamous cell cancer. She had been disease free for two years and she had erosion of her vaginal cerclage that had been placed at the time of her original surgery. She had two prior cesarean deliveries prior to her cervical cancer diagnosis and desired future fertility. She underwent a laparoscopic abdominal cerclage with cystoscopy and ureteral catheter placement. <h3>Measurements and Main Results</h3> Laparoscopic placement of abdominal cerclage was successful. Surgical techniques in navigating difficult dissections are reviewed in the video. In the absence of a cervicouterine junction, placement a 5mm Mersilene tape cerclage at the neo-cervical region was successful. There were no intra or post-operative complications. Patient had a good surgical recovery. <h3>Conclusion</h3> This video demonstrates challenges in placement of an abdominal cerclage following a radical trachelectomy due to distortion of anatomy and dense post-surgical adhesions. The video demonstrates that laparoscopic placement at the neo-cervical junction can be accomplished successfully and safely.

Laparoscopic Cerclage during Pregnancy

<h3>Study Objective</h3> The objective of this study is to demonstrate techniques for successful placement of laparoscopic cerclage in pregnancy, highlighting ways to mitigate the challenges of operating on the gravid uterus, and differences from the procedure performed outside of pregnancy. <h3>Design</h3> Video case presentation illustrative of techniques for laparoscopic cerclage in pregnancy. <h3>Setting</h3> Quaternary care academic hospital <h3>Patients or Participants</h3> 34-year-old with two prior preterm deliveries in the setting of cervical insufficiency, a prior failed vaginal cerclage, and currently 13 weeks gestation. <h3>Interventions</h3> Laparoscopic abdominal cerclage placement. <h3>Measurements and Main Results</h3> The patient had an uncomplicated pregnancy following her laparoscopic cerclage, delivering at 37 weeks by cesarean following spontaneous rupture of membranes. <h3>Conclusion</h3> There are important differences between laparoscopic placement of a cerclage outside of pregnancy and during pregnancy. For the latter, the uterus is more difficult to manipulate, the vessels are larger and more fragile, and the risk of pregnancy loss exists. Creating windows in the broad ligaments helps identify the correct location for cerclage placement and avoid injury to the uterine vessels. An anterior-to-posterior on the left, followed by posterior-to-anterior approach on the right allows for ergonomic needle handling using two 5-mm right-sided ipsilateral ports.

Comparison of transvaginal cervical cerclage versus laparoscopic abdominal cervical cerclage in cervical insufficiency: a retrospective study from a single centre

BackgroundCervical cerclage has been proposed as an effective treatment for cervical insufficiency, but there has been controversy regarding the surgical options of cervical cerclage in singleton and twin pregnancies. This study aimed to compare the pregnancy outcomes between transvaginal cervical cerclage (TVC) and laparoscopic abdominal cervical cerclage (LAC) in patients with cervical insufficiency. We also aimed to evaluate the efficacy and safety, and provide more evidence to support the application of cervical cerclage in twin pregnancies.MethodsA retrospective study was carried out from January 2015 to December 2021. The primary outcomes were the incidence of spontaneous preterm birth (sPTB) < 24 weeks, < 28, < 32, < 34 weeks, and < 37weeks, gestational age at delivery, and the incidence of admission for threatened abortion or preterm birth after cervical cerclage. The secondary outcomes included admission to the Neonatal Intensive Care Unit, adverse neonatal outcomes and neonatal death. We also analysed the pregnancy outcomes of twin pregnancies after cervical cerclage.ResultsA total of 289 patients were identified as eligible for inclusion. The LAC group (n = 56) had a very low incidence of sPTB ˂ 34 weeks, and it was associated with a significant decrease in sPTB < 28 weeks, ˂32 weeks, ˂34 and < 37 weeks, and admission to the hospital during pregnancy for threatened abortion or preterm birth after cervical cerclage (0 vs.27%; 1.8% vs. 40.3%; 7.1% vs. 46.8%; 14% vs. 63.5%, 8.9% vs. 62.2%, respectively; P < 0.001), and high in gestational age at delivery compared with the TVC group (n = 233) (38.3 weeks vs.34.4 weeks,P < 0.001). Neonatal outcomes in the LAC group were significantly better than those in the TVC group. The mean gestational age at delivery was 34.3 ± 1.8 weeks, with a total foetal survival rate of 100% without serious neonatal complications in twin pregnancies with LAC.ConclusionIn patients with cervical insufficiency, LAC appears to have better pregnancy outcomes than TVC. For some patients, LAC is a recommended option and may be selected as the first choice. Even in twin pregnancies, cervical cerclage can improve pregnancy outcomes with a longer latency period, especially in the LAC group.

Outcomes of patients who have undergone laparoscopic abdominal cerclage: A retrospective study

ObjectiveThis study aims to evaluate the surgical morbidity and obstetric outcomes following in-pregnancy or pre-pregnancy laparoscopic abdominal cerclage (LAC) for patients who were diagnosed with refractory cervical insufficiency or had a short cervix. MethodsA retrospective study was conducted on patients undergoing LAC between May 2017 and May 2019 at the Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital. The patients were diagnosed with refractory cervical insufficiency based upon a previous failed transvaginal cervical cerclage (TVC), or had a short cervix who were considered unsuitable for a TVC after a previous cervical procedure. All patients were followed-up after surgery with transperineal ultrasonography until May 2020. Subsequently, surgical and obstetric data were collected and analyzed. ResultsIn total, 44 patients underwent LAC, with 8 patients in-pregnancy and 36 pre-pregnancy. For the patient with pre-pregancy LAC, the pregnancy rate was 80.6% (29/36), including 3 patients with first-trimester loss, 1 patient with an ectopic pregnancy, and 25 patients with a delivery. For the remaining 7 patients, 3 did not conceive, and another 4 had no pregnancy plans. All the patients with in-pregnancy LAC had a delivery. The “take-home baby” rate was 89.2% (33/37), with a live-birth rate of 100% and a neonatal survival rate of 100% for both patients with in-pregnancy and pre-pregnancy LAC. For patients with in-pregnancy LAC, 75.0% (6/8) patients delivered at ≥37 wk of gestation, 12.5% (1/8) delivered between 34 and 36+6 wk, and 12.5% (1/8) delivered between 28 and 33+6 wk. For patients with pre-pregnancy LAC, 80.0% (20/25) patients delivered at ≥37 wk of gestation, 16.0% (4/25) delivered between 34 and 36+6 wk, and 4.0% (1/25) delivered between 28 and 33+6 wk. No adverse-event intra-operative or post-operative sequelae were noted. ConclusionsLAC is an effective and safe procedure that results in remarkable obstetric outcomes for women with refractory cervical insufficiency, or with a short cervix who are considered unsuitable for a TVC. The success rate of in-pregnancy or pre-pregnancy LAC depends on a full evaluation of patients, a proper peri-operative management and close follow-up.

Laparoscopic abdominal cerclage during pregnancy: a simplified approach

Cervical insufficiency is a major cause of second-trimester pregnancy loss and spontaneous preterm delivery. Transabdominal cervicoisthmic cerclage is usually performed before pregnancy for patients of cervical insufficiency, in whom transvaginal cervical cerclage procedure cannot be placed or has failed previously. Performing a transabdominal cerclage becomes a huge challenge owing to the enlargement of the pregnant uterus in patients who were indicated for transabdominal cervicoisthmic cerclage but were missed before pregnancy. Here, we have outlined an easy and effective surgical procedure as needle-free laparoscopic trans-broad-ligament cervicoisthmic cerclage during early second-trimester. Laparoscope with 4 trocars was established, after expanding the trigonum of ureter, ovarian vascular and ascending branch of uterine artery. The needleless Mersilene tape was inserted in a posterior-to-anterior direction of bilateral trigonums, tightening the knot toward the bladder uterine reflection and simultaneously pushing the loop behind the uterus, directed to the cervix progressively. The tape was then tied anteriorly at the cervico-isthmic junction with 5 to 6 intracorporeal square knots after transvaginal ultrasound determined the presence of systolic velocity of uterine artery with first knot. The primary feature of our procedure was that the needleless Mersilene tape was inserted centrally from the broad ligaments, lateral to the uterine vessels, and finally tied above the uterosacral ligament at the level of the uterine isthmus, without dissecting the bladder off from lower uterine segment and without separating the uterine vessels from the lateral wall of the cervix. We performed this procedure on 10 patients with pregnancy outcomes and there was no pregnancy loss. This procedure proved to be an accessible and effective surgical technique for transabdominal cerclage of the uterine cervix during early-second trimester, with affirmative prognosis.

Gravid Laparoscopic Abdominal Cerclage

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.

Laparoscopic Abdominal Cerclage: Ensuring the Best Fertility Outcome

Study Objective To present the case of a patient undergoing fertility treatment, who required a Laparoscopic Abdominal Cerclage to improve fertility outcome. Design Descriptive video of Laparoscopic placement of Benson Cerclage. Setting Patient was in lithotomy position during surgery. One umbilical 5 mm port was used for the camera. Two 5 mm accessory ports were placed on both lower quadrants, and a left lateral 5 mm port was placed. A 5 mm Mersilene suture was used and tied with a posterior knot to avoid friction with bladder. Patients or Participants Only one patient was selected for this video. Interventions A laparoscopic abdominal cerclage (Benson) was placed in a patient with history of cervical cone due to a low-grade intraepithelial lesion at 22 years old. She underwent an IVF cycle due to idiopathic infertility. A frozen embryo was programmed, knowing that a cerclage needed to be placed after 12 weeks gestation. The cerclage (McDonald) was placed on an extremely short cervix (1 cm). She suffered a 2nd trimester loss due to rupture of membranes with Klebsiella positive culture. In preparation for next frozen embryo transfer, we recommended placement of an abdominal cerclage via laparoscopy. Measurements and Main Results The patient was seen after the laparoscopic procedure, with a vaginal ultrasound confirming the adequate placement of the abdominal cerclage. The patient will undergo frozen embryo transfer in the next months. Conclusion Initially, we informed the patient that, due to her gynecologic history, a cerclage was to be placed once a pregnancy reached the first trimester. We explained that given her extremely short cervix, an abdominal cerclage was needed to improve the outcome of her next frozen embryo cycle. To present the case of a patient undergoing fertility treatment, who required a Laparoscopic Abdominal Cerclage to improve fertility outcome. Descriptive video of Laparoscopic placement of Benson Cerclage. Patient was in lithotomy position during surgery. One umbilical 5 mm port was used for the camera. Two 5 mm accessory ports were placed on both lower quadrants, and a left lateral 5 mm port was placed. A 5 mm Mersilene suture was used and tied with a posterior knot to avoid friction with bladder. Only one patient was selected for this video. A laparoscopic abdominal cerclage (Benson) was placed in a patient with history of cervical cone due to a low-grade intraepithelial lesion at 22 years old. She underwent an IVF cycle due to idiopathic infertility. A frozen embryo was programmed, knowing that a cerclage needed to be placed after 12 weeks gestation. The cerclage (McDonald) was placed on an extremely short cervix (1 cm). She suffered a 2nd trimester loss due to rupture of membranes with Klebsiella positive culture. In preparation for next frozen embryo transfer, we recommended placement of an abdominal cerclage via laparoscopy. The patient was seen after the laparoscopic procedure, with a vaginal ultrasound confirming the adequate placement of the abdominal cerclage. The patient will undergo frozen embryo transfer in the next months. Initially, we informed the patient that, due to her gynecologic history, a cerclage was to be placed once a pregnancy reached the first trimester. We explained that given her extremely short cervix, an abdominal cerclage was needed to improve the outcome of her next frozen embryo cycle.

Counseling a Patient on Laparoscopic Abdominal Cerclage Placement

Study Objective We examine a case in which a patient requests an abdominal cerclage and subsequently review cervical insufficiency and indications for transvaginal and transabdominal cerclage placement. We also share a video of laparoscopic abdominal cerclage placement in a gravid uterus. Design N/A. Setting N/A. Patients or Participants N/A. Interventions N/A. Measurements and Main Results Transvaginal cerclage placement is the standard treatment for cervical insufficiency. It can be exam-indicated, history-indicated, or ultrasound-indicated. In the setting of one prior second trimester loss or preterm birth prior to 34 weeks, cervical length screening with cerclage placement if the cervix shortens below 25mm avoids unnecessary history-indicated cerclages in over 50% of patients while maintaining similar perinatal outcomes. For women who fail an early transvaginal cerclage, abdominal cerclage decreases the rate of preterm delivery and preterm premature rupture of membranes (PPROM) compared to a second transvaginal cerclage. However, risks include those of general anesthesia, PPROM, bleeding with the possible need for blood transfusion, bladder or small bowel injury, conversion to laparotomy (which is associated with a constellation of additional risk), pain, infection, preterm labor, suture migration/erosion, rectovaginal fistula, fetal growth restriction, and fetal death. If a patient has a late second trimester or third trimester intrauterine fetal demise (IUFD), laparoscopic removal of the cerclage is needed prior to dilation and evaluation or induction of labor. Patients with an abdominal cerclage must be delivered by cesarean section, however the stitch may remain in situ for future pregnancies. Conclusion We must remain up-to-date on guidelines for management of cervical insufficiency. Abdominal cerclages have high success rates but are associated with increased risk, the need for cesarean section, and greater complexity in managing IUFDs. Despite our comfort with laparoscopic abdominal cerclage placement, we should continue to recommend transvaginal cerclage placement where appropriate. More data is needed before abdominal cerclage can be offered as a first line approach. We examine a case in which a patient requests an abdominal cerclage and subsequently review cervical insufficiency and indications for transvaginal and transabdominal cerclage placement. We also share a video of laparoscopic abdominal cerclage placement in a gravid uterus. N/A. N/A. N/A. N/A. Transvaginal cerclage placement is the standard treatment for cervical insufficiency. It can be exam-indicated, history-indicated, or ultrasound-indicated. In the setting of one prior second trimester loss or preterm birth prior to 34 weeks, cervical length screening with cerclage placement if the cervix shortens below 25mm avoids unnecessary history-indicated cerclages in over 50% of patients while maintaining similar perinatal outcomes. For women who fail an early transvaginal cerclage, abdominal cerclage decreases the rate of preterm delivery and preterm premature rupture of membranes (PPROM) compared to a second transvaginal cerclage. However, risks include those of general anesthesia, PPROM, bleeding with the possible need for blood transfusion, bladder or small bowel injury, conversion to laparotomy (which is associated with a constellation of additional risk), pain, infection, preterm labor, suture migration/erosion, rectovaginal fistula, fetal growth restriction, and fetal death. If a patient has a late second trimester or third trimester intrauterine fetal demise (IUFD), laparoscopic removal of the cerclage is needed prior to dilation and evaluation or induction of labor. Patients with an abdominal cerclage must be delivered by cesarean section, however the stitch may remain in situ for future pregnancies. We must remain up-to-date on guidelines for management of cervical insufficiency. Abdominal cerclages have high success rates but are associated with increased risk, the need for cesarean section, and greater complexity in managing IUFDs. Despite our comfort with laparoscopic abdominal cerclage placement, we should continue to recommend transvaginal cerclage placement where appropriate. More data is needed before abdominal cerclage can be offered as a first line approach.

A COMPLEX CASE OF LAPAROSCOPIC ABDOMINAL CERCLAGE PLACEMENT WITH STAGE IV ENDOMETRIOSIS

To present a systematic surgical approach to tackling the obliterated posterior cul-de-sac in severe endometriosis, as well as proper technique for laparoscopic abdominal cerclage placement in a patient with distorted anatomy.

Fertility outcomes after preconceptional laparoscopic abdominal cerclage for second-trimester pregnancy losses

Objective(s)Cervical incompetence is an important cause of recurrent pregnancy loss, typically presenting in the second trimester with silent cervical dilation and premature delivery of the fetus. We aimed to evaluate the conception rate and time to conception or failure to conceive after preconceptional laparoscopic abdominal cerclage (LAC). Study DesignWe conducted this retrospective observational cohort study at a tertiary referral center. Patients who underwent LAC in the nonpregnant state for a second-trimester pregnancy loss between June 2012 and February 2020 were included. ResultsThe subjects were 40 patients with a history of one or more second-trimester pregnancy losses despite the placement of vaginal cerclage, who had undergone LAC before contemplating a future pregnancy. The mean number of second-trimester pregnancy losses before LAC was two per woman. The ages of the women at the time of cerclage ranged from 21 to 42 years. The time to pregnancy, which was the primary outcome of the study, was determined as the number of menstrual cycles before the patient became pregnant after LAC and the number of cycles needed for the patient to achieve her latest pregnancy before LAC. Of the 40 women, 22.5 % were noted during the LAC operation to have a pelvic peritoneal pathology that might have affected fertility, and all such pathologies were treated concomitantly during the procedure. Spontaneous pregnancy rates before and after LAC were 96.4 % and 89.3 % (p = 0.299), and times to pregnancy before and after LAC were 6.3 ± 8.4 and 6.6 ± 8.1 cycles (p = 0.897). Neither difference was statistically significant. In more than 84 % of patients who became pregnant after LAC, pregnancy was sustained to the stage of viability. Conclusion(s)In patients with cervical incompetence, LAC is a very effective intervention to sustain pregnancy to the stage of viability. If placed during the preconceptional period, it does not delay achieving pregnancy and does not have a negative impact on the chances of conception. This may be reassuring to women undergoing this procedure before they achieve a pregnancy.

Comparison of laparoscopic abdominal cerclage and transvaginal cerclage for the treatment of cervical insufficiency: a retrospective study

To compare the pregnancy outcome of patients with cervical insufficiency (CI) underwent prophylactic laparoscopic abdominal cervical cerclage (LAC) and transvaginal cervical cerclage (TVC). A retrospective trial was carried out in the Department of Gynecology, Qingdao Women and Children's Hospital, Shandong Province, China. A total of 217 women with cervical insufficiency underwent the prophylactic cerclage, and the surgical approach was decided by the patients or depended on doctors' advice. The primary outcome measure was the fetal outcome. Secondary outcome measures were delivery of an infant at ≥ 34th gestational weeks, newborn birth weight, neonatal intensive care center (NICU) occupancy, and postoperative complications. Nonparametric variables were analyzed with the Mann-Whitney (U) test, and categorical type outcomes were analyzed with the Chi-square test or the Fisher's exact test. A P value < 0.05 was considered significant. Data analysis was performed using SPSS Statistics Version 19. As of follow-up date, 154 eligible patients were included in this study, with 74 (48.1%) women in the LAC group and 80 (51.9%) in the TVC group. The total fetal survival rate in the two groups was 90.3% (139/154), of which the rate significantly higher in the LAC group compared to the TVC group (97.3% vs. 83.8%, P < 0.01). The delivery of an infant at ≥ 34th gestational weeks was significantly higher in the LAC group compared to the TVC group (94.6% vs. 71.3%, P < 0.01). Compared to the TVC group, the mean newborn birth weight was higher, and the NICU occupancy rate was less in the LAC group (3293.4 ± 542.8g vs. 2953.6 ± 704.4g, P = 0.002; 2.8% vs. 17.9%, P = 0.003). No fatal surgical complications occurred in both groups. In patients with cervical insufficiency, the history-indicated conception of prophylactic LAC appears to have a better pregnancy outcome than TVC.