Michael S. Baggish

Typically, cervical cerclage is performed via the vaginal route. The simple purse-string McDonald closure and the submucosal Shirodkar closure are accomplished with a low level of bleeding and relatively little pain, and within a short time.

When the cervix is extremely short as a result of obstetric injury, deep conization, multiple excisional/ablative procedures, or virtual amputation, vaginal placement of a constricting suture or band may be difficult or impossible to perform. In fact, anecdotal accounts about ureteral ligation have been reported in conjunction with McDonald suture placement.

Clearly, the observed lengthening of the cervix following cerclage cannot be accounted for by narrowing the cervical canal. It is obvious that the increased cervical length is attributable to inclusion of the uterine isthmus within the suture.

A laparotomy is required for this technique. Five steps are critical for the successful and safe performance of abdominal cerclage: (1) elevation of the uterus to expose the isthmus and cervix, (2) identification of the uterine vessels, (3) precise identification of the position of the ureters, and (4) placement of the cerclage band above the uterosacral ligaments by (5) location of an avascular plane between the uterine vessels and the isthmus.