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.
Problem
Cervical insufficiency (also known as cervical incompetence) occurs in 0.5% to 1% of all pregnancies, and it is a major risk factor for second-trimester pregnancy loss and spontaneous preterm birth. Transabdominal cervicoisthmic cerclage is generally reserved for patients with cervical insufficiency in whom transvaginal cervical cerclage procedure cannot be performed or has failed previously with second-trimester pregnancy loss. With transabdominal cervicoisthmic cerclage, a suture is placed around the cervical isthmus in the avascular space above the cardinal and uterosacral ligaments through laparotomy or laparoscopy. The American College of Obstetricians and Gynecologists recommends that history-indicated cerclage should typically be placed at 13 to 14 weeks of gestation. During pregnancy, transabdominal cervicoisthmic cerclage can be difficult because of the enlarging uterus and increasing vasculature. To minimize complications, most authors describing transabdominal cervicoisthmic cerclage during pregnancy advocate localization of the uterine artery and ureter, , which can be challenging and time consuming. Here, we have detailed an easy and effective surgical procedure as needle-free laparoscopic trans–broad-ligament cervicoisthmic cerclage during early second trimester.
Our Solution
Step 1: establishing laparoscopic artificial pneumoperitoneum
After fetal viability was confirmed, the procedure was performed under general anesthesia with the patient in supine position after insertion of Foley catheter. Laparoscopy was performed by Veress needle insertion through the umbilicus and CO 2 insufflation. The 30-degree laparoscope was then introduced through 11-mm trocar at umbilical incision, and 3 5.5-mm trocars were inserted under visualization (2 placed through both lower quadrants and 1 placed in lower left abdomen). Intraabdominal pressure of no more than 12 mm Hg was maintained.
Step 2: establishing the trigonum area of the broad ligament and needleless Mersilene tape penetration
The needles of a 5-mm nonabsorbable Mersilene tape (RS22; Ethicon, Inc., Raritan, NJ) were cutoff. The uterus and bilateral appendages were observed carefully under laparoscopy, and adhesions separated when needed. With the patient was in Trendelenburg position, the assistant used a grasping forceps to grasp the proximal part of the contralateral round ligament, gently pulling it cephalad and in their own direction to partly move the gravid uterus out of the pelvis. Then, the broad ligament was extended, and the trigonum of ureter and ovarian vascular and ascending branch of the uterine artery expanded. The needleless Mersilene tape was introduced into the abdominal cavity through the 5.5-mm trocar, and the surgeon grasped 1 end of the tape with a separation clamp and guided it from posterior to anterior of the broad ligament in the center of the trigonum. During this step, the surgeon must be very cautious and precise because the vessels are tortuous. After electrocoagulation of the broad ligament at the cusp of the separation clamp with a bipolar coagulation forceps, the ligament was scissored, making the separation clamp pass through partly, and the end of the tape grasp through the broad ligament. We applied the same method with the other end of the tape, grasping it through the contralateral broad ligament. This was done using a posterior-to-anterior method at the level of center broad ligaments ( Figure 1 ).
Step 3: tying anteriorly at the cervico-isthmic junction
Both ends of the Mersilene tape were gently pulled, and the loop of tape pushed behind the uterus toward the cervix, making sure that the bowels and adnexal tissues were not encumbered. As the surgeon tightened the knot toward the vesicouterine reflection, the assistant pushed the loop behind the uterus, directing it to the cervix progressively. With this procedure, the placement of the tape reaches the level of the internal cervical os, above the uterosacral ligament. After the first square knot was temporarily clamped, transvaginal Doppler ultrasound was used to assess the systolic velocity of the uterine artery. Immediately after this, the tape was tied anteriorly at the cervico-isthmic junction with 5 to 6 intracorporeal square knots. The Mersilene tape was trimmed to approximately 2 cm in length bilaterally ( Figure 2 ).
Step 4: completing the procedure
After carefully checking for any bleeding or abnormalities in the state of the uterus and bilateral appendages, we expelled air from the abdominal cavity and removed the surgical instruments.
The difference between this modified laparoscopic transabdominal cervicoisthmic cerclage and the traditional one is that, the tape was inserted centrally from the broad ligaments, laterally to the uterine vessels, and finally tied above the uterosacral ligament at the level of the uterine isthmus without dissecting the bladder off the lower uterine segment and without separating the uterine vessels from the lateral wall of the cervix ( Video ).
Magnesium sulfate was used intravenously during operation. The whole procedure took approximately 15 to 30 minutes, and fetal exposure to drugs and other intraoperative adverse effects was minimized because of the short duration. There was very little intraoperative bleeding. We had considered that the tightness of the cerclage tape could be loosened after surgery and only assessed systolic velocity of the uterine artery at cerclage. Given that only a rough Doppler assessment was performed at the time of surgery, we made a detailed uterine artery Doppler assessment in the following days after surgery before discharge. The placement of the Mersilene tape and fetal growth were also assessed. Normal blood flow of uterine arteries was observed in most cases and proper cerclage placement was confirmed in all cases ( Figure 3 ). We observed bilateral increases in the resistance index of uterine arterial blood flow (>0.8) in 2 instances and unilaterally absent end-diastolic velocity in other 2 cases. All cases returned to normal blood flow of uterine arteries within 2 weeks after surgery.
