Laparoscopic abdominal cerclage: An effective, patient-sought approach for cervical insufficiency

Our technique

Laparoscopic cerclages are much more easily placed – and with less risk of surgical complications or blood loss – in patients who are not pregnant. Postconception cerclage placement also carries a unique, small risk of fetal loss (estimated to occur in 1.2% of laparoscopic cases and 3% of open cases). ¹ We therefore prefer to perform the procedure before pregnancy, though we do place abdominal cerclages in early pregnancy as well. (Approximately 10% of the 137 patients in our analysis were pregnant at the time of cerclage placement. ¹ )

The procedure, described here for the nonpregnant patient, typically requires 3-4 ports. My preference is to use a 10-mm scope at the umbilicus, two 5-mm ipsilateral ports, and an additional 5-mm port for my assistant. We generally use a uterine manipulator to help with dissection and facilitate the correct angulation of the suture needle.

^{Dr. Jon I. Einarsson}

Fig 1. Dissection of the vesicouterine peritoneum. The uterine arteries are indicated by white arrows.

We start by opening the vesicouterine peritoneum to dissect the uterine arteries anteriorly and to move the bladder slightly caudad. It is not a significant dissection.

For suturing, we use 5-mm Mersilene polyester tape with blunt-tip needles – the same tape that is commonly used for vaginal cerclages. The needles (which probably are unnecessarily long for laparoscopic cerclages) are straightened out prior to insertion with robust needle holders.

^{Dr. Jon I. Einarsson}

Fig 2. Initial placement of the first needle on the right. The uterine artery is indicated with a red arrow, the ureter with a white arrow, and the site of the insertion of the left needle is shown with a blue dot.

The posterior broad ligament is not opened prior to insertion of the needle, as opening the broad ligament risks possible vessel injury and adds complexity.

^{Dr. Jon I. Einarsson}

Fig 3. Twisting the uterus with the uterine manipulator enables the surgeon to better visualize the correct path of the needle placement.

Direct insertion of the needle simplifies the procedure and has not led to any complications thus far.

We prefer to insert the suture posteriorly at the level of the internal os just above the insertion of the uterosacral ligaments. It is helpful to view the uterus and cervix as an hourglass, with the level of the internal os is at the narrowest point of the hourglass.

The suture is passed carefully between the uterine vessels and the cervical stroma. The uterine artery should be lateral to placement of the needle, and the uterosacral ligament should be below. The surgeon should see a pulsation of the uterine artery. The use of blunt needles is advantageous because, especially when newer to the procedure, the surgeon can place the needle in slightly more medial than may be deemed necessary so as to avert the uterine vessels, then adjust placement slightly more laterally if resistance is met.

Suture placement should follow a fairly low-impact path. Encountering too much resistance with the needle signals passage into the cervix and necessitates redirection of the needle with a slightly more lateral placement. Twisting the uterus with the uterine manipulator can be helpful throughout this process.

Once the needles are passed through, they are cut off the Mersilene tape and removed. For suturing, it’s important that the first and second knots are tied down snuggly and flat.

^{Dr. Jon I. Einarsson}

Fig 4. The first knot has been tied down.

I usually ask my assistant to hold down the first knot so that it doesn’t unravel while I tie the second knot. I usually tie 6 square knots with the tape.

^{Dr. Jon I. Einarsson}

Fig 5. All knots have been tied down.

The edges of the tape are then trimmed, and with a 2.0 silk suture, the ends are secured to the lower uterine segment to prevent a theoretical risk of erosion into the bladder.

^{Dr. Jon I. Einarsson}

Fig 6. The ends of the mersilene tape have been tied down with silk suture.

We then close the overlying vesicouterine peritoneum with 2-0 Monocryl suture, tying it intracorporally. Closing the peritoneum posteriorly is generally not necessary.

^{Dr. Jon I. Einarsson}

Fig 7. The vesicouterine peritoneum has been closed

We have not had significant bleeding or severe complications in any of our cases. And while the literature comparing preconception and postconception abdominal cerclage is limited, the risks appear very low especially before pregnancy. Some oozing from the uterine vein can sometimes occur; if this does not resolve once it is tied down, placement of a simple figure of eight suture such as a Monocryl or Vicryl at the posterior insertion of the tape may be necessary to stop the bleeding.

Some surgeons place the abdominal cerclage lateral to the uterine artery, presumably to lessen any risk of vessel injury, but again, our placement medial to the vessels has not led to any significant bleeding. By doing so we are averting a theoretical risk with lateral placement of possibly constricting blood flow to the uterus during pregnancy.

Another technique for suturing that has been described uses a fascial closing device, which, after the needles are removed, passes between the vessels and cervix anteriorly and grasps each end of the suture posteriorly before pulling it through the cervix. My concern with this approach is that entry into the cervix with this device’s sharp needles could cause erosion of the tape into the cervical canal. Piercing of a vessel could also cause bleeding.

Laparoscopic abdominal cerclage can also be placed with robotic assistance, but I don’t believe that the robot offers any benefit for this relatively short, uncomplicated procedure.

A note on patient care

We recommend that patients not become pregnant for 2 months after the laparoscopic abdominal cerclage is placed, and that they receive obstetrical care as high-risk patients. The cerclage can be removed at the time of cesarean delivery if the patient has completed childbearing. Otherwise, if the cerclage appears normal, it can be left in place for future pregnancies.

In the event of a miscarriage, a dilatation and evacuation procedure can be performed with an abdominal cerclage in place, up to 18 weeks of pregnancy. Beyond this point, the patient likely will need to have the cerclage removed laparoscopically to allow vaginal passing of the fetus.

References

1. Shennan A et al. Am J Obstet Gynecol. 2020;222(3):261.E1-261.E9.

2. Clark NV & Einarsson JI. Fertil Steril. 2020;113:717-22.

3. Benson RC & Durfee RB. Obstet Gynecol. 1965;25:145-55.

4. Lesser KB et al. Obstet Gynecol. 1998;91:855-6.

5. Moawad GN et al. J Minim Invasive Gynecol. 2018;25:277-86.