Transabdominal Cerclage Placement Research Articles

Septic Abortion at 17 Weeks Gestation after Radical Trachelectomy and Transabdominal Cerclage: A Case Report

Septic abortion can lead to severe maternal morbidity and mortality. The management of septic abortion can be complicated by a history of radical trachelectomy and transabdominal cerclage placement. A 33-year-old G1P0 at 17 weeks and 6 days gestation presented in severe septic shock after being diagnosed 6 days prior with previable rupture of membranes at an outside hospital and managed expectantly. History was notable for cervical adenocarcinoma status post radical trachelectomy and transabdominal cerclage placement. Due to uterine occlusion from the cerclage, the patient underwent emergent uterine evacuation via an abdominal approach. The risks and benefits of expectant management of pre-viable rupture of membranes in patients with abdominal cerclage should be weighed very cautiously. Among women with abdominal cerclage for whom uterine evacuation is indicated, a transabdominal approach may be necessary.

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.

Longitudinal change in cervical length following vaginal or abdominal cervical cerclage: a randomized comparison

Cervical cerclage has been shown to reduce the risk of recurrent spontaneous preterm birth in a high-risk patient population; however, the mechanism is not well understood. Transabdominal cerclage is superior to low and high vaginal cerclage in reducing early spontaneous preterm birth and fetal loss in women with previous failed vaginal cerclage. Cervical length measurements are commonly used to monitor high-risk women and may explain the mechanism of success. This study aimed to evaluate the rate of change in longitudinal cervical length after randomized placement of low transvaginal, high transvaginal, or transabdominal cerclage in women with a previous failed vaginal cerclage. This was a planned analysis of longitudinal transvaginal ultrasound cervical length measurements from patients enrolled in the Vaginal Randomised Intervention of Cerclage trial, a randomized controlled trial comparing transabdominal cerclage or high transvaginal cerclage with low transvaginal cerclage. Cervical length measurements at specific gestational ages were compared over time and between groups, using generalized estimating equations fitted using the maximum-likelihood random-effects estimator. In addition, cervical length measurements were compared in women with transabdominal cerclage placed before and during pregnancy. The diagnostic accuracy of cervical length as a predictor of spontaneous preterm birth at <32 weeks of gestation was explored. This study included 78 women who underwent longitudinal cervical length assessment (70% of the analyzed cohort) with a history of failed cerclage, of whom 25 (32%) were randomized to low transvaginal cerclage, 26 (33%) to high transvaginal cerclage, and 27 (35%) to transabdominal cerclage. Abdominal cerclage was superior to low (P=.008) and high (P=.001) vaginal cerclage at maintaining cervical length over the surveillance period (14 to 26 weeks of gestation) (+0.08 mm/week, 95% confidence interval, -0.40 to 0.22; P=.580). On average, the cervical length was 1.8 mm longer by the end of the 12-week surveillance period in women with transabdominal cerclage (+1.8 mm; 95% confidence interval, -7.89 to 4.30; P=.564). High vaginal cerclage was no better than low cervical cerclage in the prevention of cervical shortening; the cervix shortened by 13.2 mm over 12 weeks in those with low vaginal cerclage (95% confidence interval, -21.7 to -4.7; P=.002) and by 20 mm over 12 weeks in those with high vaginal cerclage (95% confidence interval, -33.1 to -7.4; P=.002). Preconception transabdominal cerclage resulted in a longer cervix than those performed during pregnancy; this difference was significant after 22 weeks of gestation (48.5 mm vs 39.6 mm; P=.039). Overall, cervical length was an excellent predictor of spontaneous preterm birth at <32 weeks of gestation (receiver operating characteristic curve, 0.92; 95% confidence interval, 0.82-1.00). In women with a previous failed cervical cerclage, in the next pregnancy, the cervical length in women treated with vaginal cerclage funneled and shortened over time, whereas there was preservation of cervical length in women who receive transabdominal cerclage. Cervical length remained longer in transabdominal procedures performed before pregnancy than in transabdominal procedures performed during pregnancy. Overall, cervical length was an excellent predictor of spontaneous preterm birth in our cohort. Our findings may explain the mechanism of benefit for transabdominal cerclage, with its high placement better maintaining the structural integrity of the cervix at the level of the internal os.

Robotic-Assisted vs Conventional Laparoscopic Transabdominal Cerclage Placement

<h3>Study Objective</h3> To compare and contrast robotic-assisted versus laparoscopic transabdominal cerclage placement. <h3>Design</h3> Video. <h3>Setting</h3> Tertiary academic medical center with two minimally-invasive gynecologists. <h3>Patients or Participants</h3> Two patients at approximately 13 weeks gestation with cervical insufficiency. <h3>Interventions</h3> Transabdominal cerclage. <h3>Measurements and Main Results</h3> It is important to know useful tools in placement of minimally invasive transabdominal cerclage. These include the 30-degree laparoscope, sacrocolpopexy cup, uterine manipulators, and laparoscopic paddle retractor. Consider use of a suprapubic port for laparoscopic cerclage placement for more ideal angle for dissection of the avascular tunnel and passage of the Mersilene tape. Tying the Mersilene tape anteriorly laparoscopically can be helpful so that no additional port is used for manipulation of the uterus. <h3>Conclusion</h3> Transabdominal cerclage may be placed safely in a minimally invasive fashion both with robotic-assisted and conventional laparoscopic approach.

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.

Retro cervical tunneling to ensure correct placement for robotic-assisted transabdominal cerclage

To demonstrate the step-by-step surgical technique of robotic-assisted transabdominal cerclage, highlighting a new posterior compartment approach. Stepwise explanation of a surgical technique using surgical video. The procedure was performed at the Obstetrics and Gynecology Department, Hospital Vall d'Hebron in Barcelona, Spain, a tertiary medical center. The local institutional review board considers that case reports are exempt from research approval. A 26-year-old non-pregnant patient, with a history of cervical incompetence, three second-trimester losses, and vaginal cerclage failure during her previous pregnancy. Robotic-assisted transabdominal cerclage placement was performed. An 8-mm, 30° scope; monopolar scissors; and Maryland bipolar graspers were used. A uterine manipulator was used for better exposure. First, a bladder flap was created, and the uterine vessels were identified and skeletonized. Next, a window between the uterine vessels and the uterine cervix at the level of the cervical-isthmic junction was created bilaterally. At the posterior compartment, the dissection of the root of the uterosacral ligaments was carefully performed. A retrocervical pocket was created with monopolar scissors and sharp dissection. The procedure was finished with the Mersilene tape placement. First, the tape was passed through the window created in the right broad ligament, with a posterior-to-anterior direction, the retro cervical pocket, and finally through the left broad ligament. The knot was placed anteriorly and reperitonization was performed. In addition to this operation, robotic-assisted transabdominal cerclage was successfully performed in another six patients with good surgical and obstetrics outcomes. Intraoperative technique to ensure successful robot-assisted abdominal cerclage placement. The patient became pregnant six months following the robotic-assisted transabdominal cerclage. Her pregnancy was closely followed up at the High-Risk Obstetric Unit, and she had no complications during pregnancy. An elective cesarean section was performed at 36 weeks with a healthy newborn baby that was discharged with the mother three days after delivery. The development of a retro cervical pocket during robotic-assisted transabdominal cerclage can be performed safely and effectively. It may help prevent displacement of the Mersilene tape during endoscopic knotting.

Transabdominal Cerclage and Timing of Removal: Cesarean Vs. Interval Laparoscopic

Study Objective To demonstrate the steps of transabdominal cerclage (TAC) placement and removal. The video addresses timing of removal at time of cesarean section versus interval laparoscopic removal and reviews tips and tricks for both approaches. Design The video describes a needle-less technique to TAC placement which avoids penetration into the cervical stroma, prevents scarring, and facilitates removal. Additionally, we describe tips and tricks to utilize while performing cerclage removal and highlight the advantages and disadvantages of TAC removal at the time of cesarean section. Setting The patient was placed in either dorsal lithotomy and/or supine position for the videos. Patients or Participants In this surgical video we present a case of a gravid woman with cervical insufficiency who required placement of a TAC. The pregnancy was uncomplicated and she had a scheduled cesarean section, tubal ligation, and TAC removal. Interventions Robotic-assisted TAC placement for cervical insufficiency followed by removal at time of cesarean section. Interval laparoscopic removal is also demonstrated. Measurements and Main Results Successful removal of TAC during cesarean section delivery was accomplished. If TAC removal at the time of cesarean section is precluded, it can be deferred to interval laparoscopic removal. Conclusion In placement of transabdominal cerclage, a minimally invasive approach is safe and effective. Removal of TAC at either time of cesarean delivery or with an interval laparoscopic removal is possible utilizing these surgical tips and tricks.

Transabdominal Cerclage Placement in a Gravid Patient at Week 22 of Gestation Period: A Case Report and Review of the Literature

Cervical insufficiency [CI] describes the painless dilation and shortening of the cervix at the end of the first trimester or early in the second trimester of the pregnancy and may result to miscarriage or preterm labor. The usual treatment is transvaginal cerclage [TVC]. There are however patients which should not be submitted in TVC, since TVC cannot be technically performed or may not be effective. In these women, transabdominal cerclage [TAC] placement may be the optimal alternative. We present a case of a gravid patient at week 22 of gestation, who underwent an emergency TAC, due to CI. TAC took place two days after the diagnosis of CI successfully, without any complication. The pregnancy proceeded without any other complication and a healthy female infant was delivered in 34th week due to beginning of labor, by elective cesarean section. According to our knowledge, there are no other reports of TAC placement, in a pregnant patient at week 22; a short review of the literature is also presented.

Novel Approach to Robotic Transabdominal Cerclage Utilizing Hand Thrown Knots

Video Objective The objective of this video is to present a novel approach to robotic transabdominal cerclage with the goal of maintaining tactile feedback utilizing a gelport mini device in lieu of a 12 mm robotic assist port. Setting The patient presented is a 29 year old G2P0110 with a history of a prior 16 week loss and a 22 week loss after placement of a history indicated transvaginal cerclage at 13 weeks. Having failed a transvaginal cerclage, the patient desired placement of a transabdominal cerclage to improve pregnancy outcomes. The procedure was performed at a tertiary care center. Interventions Placement of a robotic transabdominal cerclage utilizing a suprapubic gel port mini. Conclusion We demonstrate a novel technique which utilizes a suprapubic gel port mini to allow for hand tied knots at the time of robotic transabdominal cerclage placement. The surgeon is able to utilize tactile feedback ensuring both proper cerclage placement and sufficiently tied knots.

Tips & Tricks: Minimally Invasive Removal of Transabdominal Cerclage

Video Objective To present surgical tips and tricks for the minimally invasive removal of transabdominal cerclage and surgical technique during transabdominal cerclage placement that facilitates easier removal. Setting Three patients are presented that underwent uncomplicated robotic transabdominal cerclage placements in pregnancy. The first patient subsequently had a laparotomy for cerclage removal due to second trimester preterm labor at an outside hospital. This case prompted this tips and tricks surgical video to educate surgeons regarding minimally invasive removal of transabdominal cerclage. The second patient underwent an uncomplicated laparoscopic removal of transabdominal cerclage in the setting of preterm labor at 18 weeks. The third case had a term cesarean delivery although her cerclage was not removed at that time. She underwent a robotic transabdominal cerclage removal without complication. Apart from the laparotomy, all placement and removal procedures were performed at an academic medical center by one primary surgeon. Interventions In this surgical video, we present surgical tips and tricks for placement and removal of transabdominal cerclage in a minimally invasive fashion using conventional laparoscopic and robotic approaches. Tips described in this video include the “needleless” approach with creation of an avascular tunnel for cerclage placement as well as considerations for anterior versus posterior knot placement. Regarding cerclage removal, we present techniques such as undermining the cerclage tape anteriorly and posteriorly as well as blunt dissection in the previously created avascular tunnel to facilitate removal. Additionally, we present tricks for improved visualization and to delineate anatomic borders around a gravid uterus during these cases. Conclusion The removal of transabdominal cerclage is often performed at time of cesarean delivery. However, in cases of intrapartum and postpartum removal, a minimally invasive approach is effective utilizing these surgical tips and tricks.

Robot-assisted transabdominal cerclage for the prevention of preterm birth: A multicenter experience

ObjectiveHigh-risk pregnancy stratification and the use of Progesterone and prophylactic cerclage based on prior obstetrical outcomes and cervical length screening have been successful in curbing the impact of preterm birth. However, a large number of women will still suffer from preterm delivery even with optimal management. Experts agree that a transabdominal cerclage is the next best option for women who fail a transvaginal cerclage in a prior pregnancy. Our primary objective with this study is to assess the obstetric benefits and feasibility of robotic-assisted transabdominal cerclage in high-risk women projected to have poor obstetric outcomes. Study designA multicenter retrospective cohort analysis of consecutive patients undergoing a robotic-assisted transabdominal cerclage (RA-TAC) for obstetric indications at two urban teaching university hospital and one academically affiliated community hospital. High-volume gynecologic surgeons performed all transabdominal cerclage procedures (N = 68). To assess whether the transabdominal cerclage had any effect on subsequent pregnancies, we categorized gestational age into ordinal variables and used a two-proportion z-test to compare pregnancy outcomes and neonatal survival pre (n = 200) and post (n = 59) abdominal cerclage placement. ResultsA total of 68 consecutive patients undergoing a RA-TAC for obstetric indications were selected. We compared 200 pregnancies pre-robot-assisted cerclage to 59 pregnancies post-robot-assisted cerclage. The odds of delivering after 34 and 37 weeks gestational age was 4.0 and 3.6 times greater post-robot-assisted cerclage, respectively (P < 0.001). The RA-TAC also had a significant effect on neonatal survival. The odds of neonatal survival was 12.6 times greater after RA-TAC placement when compared to prior pregnancy outcomes. Surgical outcomes were also favorable with no conversions to laparotomy or perioperative pregnancy loss. ConclusionThe RA-TAC influences an increase in gestational age and improves neonatal survival in women projected to have poor pregnancy outcomes. The robot-assisted transabdominal cerclages provide excellent obstetric outcomes without the morbidity of a laparotomy or the technical challenges associated with a conventional straight-stick laparoscopy. This procedure is not intended to replace any other minimally invasive modality for cerclage placement but rather increase awareness of a less technically challenging option for transabdominal cerclage placement to help propagate the procedure to more patients.

Open Versus Robotic-Assisted Transabdominal Cerclage Placement: A Comparison of Obstetric and Surgical Outcomes

Open Versus Robotic-Assisted Transabdominal Cerclage Placement: A Comparison of Obstetric and Surgical Outcomes

Surgical variance between postconceptional and preconceptional minimally invasive transabdominal cerclage placement

Recent data show that transabdominal cerclage placement via laparoscopy carries better obstetrical outcomes in comparison to transabdominal cerclage placement via laparotomy. In this surgical tutorial, we review the technique for minimally invasive abdominal cerclage and highlight the surgical differences between preconceptional and conceptional cerclage.

38: Robotic-assisted transabdominal cerclage placement in the pregnant patient: A case series

38: Robotic-assisted transabdominal cerclage placement in the pregnant patient: A case series

Robotic Cerclage in Advanced-stage Endometriosis

Study ObjectiveTo show a stepwise surgical technique of robotic-assisted transabdominal cerclage placement in a patient with deeply infiltrative endometriosis. DesignA step-by-step surgical tutorial using narrated video. SettingThe George Washington University Hospital. Local institutional review board approval is not required for case reports (Canadian Task Force Classification III). PatientsA 38-year-old woman with cervical incompetence and a history of infertility with 5 pregnancies accomplished by in vitro fertilization. Pregnancies were as follows: 3 first trimester losses, 1 second trimester loss, and another second trimester loss despite McDonald cerclage placement. InterventionsIndications for transabdominal cerclage placement include a congenital short or amputated cervix, cervical scarring that would prevent a transvaginal approach, and failed prior vaginal cerclage [1]. Robotic-assisted abdominal cerclage placement was performed in a case of advanced rectovaginal endometriosis. Normal anatomy was restored; however, no excision of endometriosis was performed because the patient was asymptomatic and already undergoing in vitro fertilization for infertility. The procedure used a 12-mm camera port through the umbilicus, 2 ancillary 8-mm robotic ports, and a 5-mm assistant port; ¼-inch-width Mersilene tape (Ethicon, Somerville, NJ) was preloaded in the abdomen through the 12-mm port before docking. Survey of the pelvis revealed the presence of advanced rectovaginal endometriosis hindering visualization of the cervicouterine isthmi on the posterior side of the uterus. The preloaded needle was parked on the right parietal peritoneum. Before cerclage placement, retroperitoneal spaces dissection bilaterally was necessary to lateralize the ureters and mobilize the rectum away from the cervicovaginal junction where the cerclage would be placed. Anteriorly, the vesicouterine peritoneum was dissected transversely, and the bladder was dissected off the lower uterine segment. A window was created in the posterior leaf of the right broad ligament lateral to the cervicouterine junction and medial to the ureter. The uterine vessels were then skeletonized, and the needle was placed through the lateral cervical isthmus medial to the vascular bundle going posterior to anterior. The procedure was repeated on the contralateral side with the needle going in the anteroposterior direction. The tape was pulled tightly against the anterior cervical isthmus. The tape ends were tied together posteriorly. There was minimal blood loss with no complications. ConclusionA robotic-assisted abdominal cerclage can be performed safely and effectively in patients with advanced-stage endometriosis.

Needleless Robotic-Assisted Abdominal Cerclage in Pregnant and Nonpregnant Patients

Study ObjectiveTo demonstrate the step-by-step surgical technique of “needle-free” robotic-assisted transabdominal cerclage placement. DesignThrough surgical video footage, presentation of a step-by-step demonstration of robotic-assisted laparoscopic placement of abdominal cerclage (Canadian Task Force classification III). SettingThe procedure was undertaken at Banner University Medical Center in Phoenix, Arizona. The local Institutional Review Board does not consider case reports research, and thus its approval was not required. PatientsThe patients had a history of cervical insufficiency. The first patient (case 1) was a nongravid 32-year-old woman with 2 late second trimester pregnancies delivered by cesarean section owing to cervical insufficiency. The second patient (case 2) was a 26-year-old woman in her sixth pregnancy with 4 previous second trimester losses due to cervical insufficiency, including a failed McDonald cerclage. InterventionsRobotic-assisted abdominal cerclage placement was performed in both patients. The procedure used an 8-mm, 0° scope; an 8-mm, 30° scope; monopolar scissors; and Maryland bipolar graspers. Following a complete survey of the pelvis and abdomen, the cervicouterine isthmus was identified bilaterally. The anterior leaflet of the right broad ligament was entered sharply, and the dissection was carried out in small increments to ensure safety and hemostasis. The right uterine artery was identified and skeletonized. The left broad ligament was entered in a similar fashion. Once a bladder flap was developed, a gentle wiping technique allowed for mobilization of the bladder from the vesicouterine junction with excellent hemostasis. In case 1, a uterine manipulator was used to flex the uterus. In case 2, a laparoscopic paddle device was introduced gently to allow for mobilization of the gravid uterus. An avascular tunnel was created on both sides of the cervicouterine isthmus, thereby eliminating the need for the Mersilene tape needle. Thus, a needleless Mersilene tape was introduced into the tunnel formed previously. In our opinion, the ideal knot placement is in the posterior cul-de-sac, as shown in the nongravid uterus. However, in the gravid uterus, owing to the difficulty of access, the knot was placed anteriorly, and reperitonization was performed. Four square knots were sufficient, with the snug (but not too tight) Mersilene tape at the cervicouterine isthmus. In both cases, there was minimal blood loss with no complications. In addition to these 2 operations, robotic-assisted transabdominal cerclage was successfully performed in another 21 patients. ConclusionA needle-less robotic-assisted laparoscopic technique can be performed safely and effectively in both gravid and nongravid patients.

“No Needle” Robotic Transabdominal Cerclage Placement at 13 Weeks Gestation

“No Needle” Robotic Transabdominal Cerclage Placement at 13 Weeks Gestation

Robotic-assisted abdominal cerclage: a case report and literature review.

We report a robotic-assisted, ultrasound-guided abdominal cerclage placement during pregnancy that resulted in term delivery, and review the current literature with respect to the efficacy of robotic-assisted transabdominal cerclage (RoboTAC) placement. The patient was a 25-year-old gravida 5 para 0-0-4-0 with cervical insufficiency who failed McDonald cerclage placement in two prior pregnancies, and presented at 13weeks with a shortened (1.66cm) cervical length. Placement of abdominal cerclage with robotic assistance under ultrasound guidance was performed at a teaching hospital. The main outcome measure was feasibility of RoboTAC placement in a gravid uterus under ultrasound guidance, and delivery of an infant ≥34weeks of gestation with neonatal survival. Abdominal cerclage was safely and successfully placed at 13weeks with robotic assistance. The patient had an otherwise uncomplicated antenatal course and was delivered via primary cesarean section at 38weeks. Robotic-assisted abdominal cerclage can be considered for patients who require abdominal cerclage placement by skilled robotic surgeons.

Transabdominal cerclage placement in patients with prior uterine incisions: Risk of scar disruption

The object of this study was to describe pregnancy outcomes in women who had a transabdominal cerclage (TAC) placed after a prior uterine incision due to caesarean section or hysterotomy. This is a retrospective observational study of 57 women referred to a maternal–fetal medicine specialist (JES) for TAC placement after a previous uterine incision from 1989–2012. Pregnancy outcomes post-TAC placement are reported, including gestational age at delivery, survival rate and complications directly related to labour and the previous uterine scar. Of 51 women who had a prior uterine incision and were pregnant at TAC, 49 (96.1%) delivered viable infants at a mean gestational age of 35.9 weeks. One patient had intrauterine fetal demise at 16 weeks for causes likely unrelated to TAC and another had uterine rupture associated with a unicornuate uterus and advancing labour at 31 weeks. This study includes women with low transverse incisions, classical uterine incisions and higher order multiples. It was concluded that in women with a prior uterine incision, placement of a TAC is associated with low risk (2%) of uterine rupture.

Robotic-assisted laparoscopic cerclage in a pregnant patient

A robotic-assisted laparoscopic technique for transabdominal cerclage placement could offer improvements over the traditional laparoscopic approach. A gravid female with no vaginal portion of the cervix underwent a robotic-assisted laparoscopic cerclage at 12 weeks' gestation and ultimately delivered a healthy infant at term.