Novel Vaginal Cerclage Assisted Laparoscopic Cervico-Sacropexy Technique for Uterovaginal Prolapse.

AIM: Laparoscopic hysteropexy is a complicated procedure that requires specialized surgical skills, including precise dissection and suturing. The aim is to describe the technical considerations for performing a new, feasible, and minimally invasive technique to correct apical and concurrent apical and anterior vaginal wall defects. METHOD: A retrospective analysis was conducted on 70 consecutive women who underwent surgery for stage ≥3 uterovaginal prolapse. As a part of the technique, an anterior 2-cm long transverse incision was made at the anterior cervicovaginal junction, and the bladder was dissected through blunt and sharp dissection to the level of the isthmus. A posterior colpotomy was performed. A polypropylene tape was inserted into the cervical connective tissue, and the free arms of the tape were inserted into the peritoneum via the posterior colpotomy. Two arms of the tape were passed from the tunnel parallel and medial to a right sacrouterine fold, then fixed to the anterior longitudinal ligament via the laparoscopic route. RESULTS: The tape can be inserted into the cervix in a median of 15 min, and the laparoscopy procedure can be completed in 24 min. No mesh erosion or long-term complications occurred. At a 1-year control, there were no cases of recurrence. CONCLUSIONS: This novel cervico-sacrocolpopexy technique is a feasible and safe, minimally invasive way to correct apical or multicompartment defects, with a short operation time and an anatomical result that mimics the normal sacrouterine ligament.

A new technique for emergency cerclage: Guard suture method.

Objective The aim of this study was to introduce a novel technique to treat midtrimester cervical insufficiency with prolapsed membranes. Material and methods This retrospective study included patients with singleton pregnancies between 16 and 28 gestational weeks that underwent emergency cervical cerclage in a tertiary center. Patients were divided into two groups as McDonald method and guard suture method group according to the procedure they underwent. The following variables were recorded and evaluated: gestational age at cerclage, cervical length between the suture and external cervical os measured by transvaginal ultrasound on postoperative 1st and 7th day, gestational age at delivery, time between the procedure and delivery, intraoperative complications, newborn intensive care unit (NICU) admission, Apgar scores of neonates, and discharged alive newborns. Results During the study period, 38 patients underwent emergency cerclage procedure. Twenty-three were included in the McDonald group and 15 were in the guard suture group. The mean gestational age at the time of cerclage was 22.1 (17 -27) weeks and the mean gestational age at delivery was 33.9 (26- 38) weeks. Prolongation time between cerclage and delivery was 80.42 (1 - 140) days. Significantly higher 1st and 5th minutes Apgar scores and significantly lower NICU admission was found in the guard suture group (p = 0.04, p = 0.01 and p = 0.02, respectively). Conclusion In cases with cervical insufficiency and prolapsed membranes, emergency cerclage may prevent premature birth by prolonging pregnancy. Guard suture method is safe, effective, and easily applicable and can help obstetricians achieve better fetal and neonatal outcomes.

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

OBJECTIVE: To demonstrate the step-by-step surgical technique of robotic-assisted transabdominal cerclage, highlighting a new posterior compartment approach. DESIGN: Stepwise explanation of a surgical technique using surgical video. SETTING: 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. PATIENT(S): 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. INTERVENTION(S): 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. MAIN OUTCOME MEASURE(S): Intraoperative technique to ensure successful robot-assisted abdominal cerclage placement. RESULT(S): 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. CONCLUSION(S): 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.

Removal of an Abdominal Cerclage by Colpotomy: A Novel and Minimally Invasive Technique.

Abdominal cerclage is an effective treatment for cervical incompetence in patients with a previously failed vaginal cerclage or with anatomic restrictions to a vaginal cerclage. Management of second trimester complications that warrant a delivery impose a complex clinical situation in patients with an abdominal cerclage. We report 3 cases of successful removal of an abdominal cerclage by posterior and anterior colpotomy in the second trimester of pregnancy. This new and minimally invasive surgical technique avoids the need for extensive dilation, laparoscopy, or laparotomy to remove the cerclage and allow a vaginal delivery.

A Novel Cerclage Insertion: Modified Laparoscopic Transabdominal Cervical Cerclage with Transvaginal Removing (MLTCC-TR).

STUDY OBJECTIVE: To report on our center's experience of a novel modified approach for laparoscopic cervical cerclage and to evaluate its safety and efficacy preliminarily. DESIGN: Retrospective descriptive study. SETTING: Single academic institution. PATIENTS: Pregnant and nonpregnant women who underwent the modified laparoscopic transabdominal cervical cerclage with transvaginal removing (MLTCC-TR) from June 2016 to April 2019. Eligible participants had multiple adverse obstetric histories or the short cervix and were not suitable for a second transvaginal cerclage. INTERVENTIONS: Preconceptional or postconceptional MLTCC-TR. MEASUREMENTS AND MAIN RESULTS: A total of 24 participants (including 3 first-trimester singleton pregnant women) underwent the MLTCC-TR, giving birth to 27 infants. Among 21 women who underwent preconceptional cerclage, 26 cases of postoperational pregnancies were noted, and the incidence of term labor was 73.07%, which was significantly higher than that in the precerclage group (p <.001). Their mean gestational age at delivery was 37.21 ± 5.05 weeks. Among 3 cases of postconceptional cerclage, the mean gestational age at cerclage was 10.90 ± 2.61 weeks, and all of them had term delivery. The overall neonatal survival rate was 100% (27/27), of which 81.48% (22/27) were term infants. There were no severe perioperative complications directly related to the insertion of cerclage. CONCLUSION: Our new approach of MLTCC-TR may be a relatively effective, feasible, and safe treatment for cervical insufficiency. It may be considered as an acceptable alternative to the traditional laparoscopic cervical cerclage with its superiority of transvaginal removing.

Fertility and pregnancy outcomes after transvaginal cervico-isthmic cerclage.

INTRODUCTION: Prematurity is the leading cause of neonatal morbidity and mortality. Cervical insufficiency seems to be the main risk factor. Treatment is cervical cerclage. In case of failure, a cervico-isthmic cerclage by Fernandez' technique, with the placement of a polypropylene sling by vaginal approach during the first trimester of pregnancy, has proven its effectiveness. The aim of our study is to report effectiveness of Fernandez' cervico-isthmic cerclage in subsequent pregnancies. MATERIALS AND METHODS: This retrospective study, was conducted from March 2002 to April 2014 in the gynecologic department of two teaching hospitals. The inclusion criterion was history of cervico-isthmic cerclage using Fernandez's technique during the previous pregnancy. This study received IRB approval number CEROG 2016-GYN-0302. RESULTS: 125 women underwent a definitive cervico-isthmic cerclage. The total percentage of neonatal survival after 14 weeks was 91% and the total percentage of neonatal survival after 24 weeks of gestation was 98.2%. Out of 114 women, 33 desired a second pregnancy. Out of which 29 had a spontaneous pregnancy. The percentage of total neonatal survival rate after 14 weeks was 92.86% and the percentage of total neonatal survival after 24 weeks was 96.3%. Out of the 29 women with a second pregnancy, 5 women achieved a third pregnancy. The five births occurred after 37 weeks of gestation with a percentage of total neonatal survival of 100%. CONCLUSION: The cervico isthmic cerclage using the technique of Fernandez makes it possible to obtain subsequent pregnancies without further surgery with very satisfactory results regarding neonatal survival.

Additional uses of a vaginal fornices delineator.

A vaginal fornices delineator was introduced in the mid-90s by a gynecologic surgeon named Charles Koh as a device that would facilitate total laparoscopic hysterectomy. It is also used in robot-assisted and traditional laparoscopic hysterectomies. The delineator delineates the vaginal fornices and provides improved visualization of vital structures during a hysterectomy. The determination of the anatomic level of the cervix is vital in the identification of the inferior borders of a total hysterectomy and to avoid injury to the ureters and uterine vessels. As such, we describe 3 gynecologic surgeries in which the identification of this level was suboptimal. Our solution was to utilize a vaginal fornices delineator as the cervical "guide" to enhance this visualization and to allow for a complete and safe surgical outcome. The following surgical scenarios and the surgical facilitation provided by the vaginal fornices delineator will be presented: (1) a postpartum cesarean hysterectomy complicated by a large lower uterine fibroid tumor that distorts the cervix, (2) a robotic-assisted placement of an abdominal cerclage in a first-trimester pregnancy, (3) abdominal hysterectomy complicated by a necrotizing uterine infection and the associated difficulty in the identification of the cervicouterine junction.

Tips and Tricks: Preconceptional Laparoscopic Cervical Cerclage Made Easier and Safer With the Titiz Uterovaginal Manipulator.

STUDY OBJECTIVE: To demonstrate safe and easy surgical steps to facilitate preconceptional laparoscopic cervical cerclage with the Titiz uterovaginal manipulator. DESIGN: Narrated step-by-step video demonstration of preconceptional laparoscopic cervical cerclage under the guidance of the Titiz uterovaginal manipulator. SETTING: Cervical incompetence or cervical insufficiency is 1 of the causes of preterm birth. Incidence is 0.1% to 1% of all pregnancies. Traditionally, cervical cerclage is placed vaginally, but sometimes it is not possible to perform this procedure vaginally. When this occurs, cerclage needs to be inserted abdominally either by laparotomy or by laparoscopy. Laparoscopic cervical cerclage is indicated when vaginal cerclage has failed or is not possible due to a deficient or a short cervix caused by previous cervical surgery. Although laparoscopic cervical cerclage has a good success rate (90%-100% live births), there is a risk of injury to the bladder, sigmoid colon, and the uterine vessels. It is also important to put the suture in the right place, which is at the internal cervical os (cervico-isthmic junction) and medial to the uterine vessels. Therefore, it can be a challenging operation, especially when the uterus is bulky and more vascular due to adenomyosis or fibroids. INTERVENTION: A 32-year-old woman, G0P0, with the surgical history of cone biopsy presented with a history of infertility. On vaginal examination, there was no vaginal portion of the anterior cervix, and there was only 0.5 cm of the vaginal portion of the posterior cervix. After extensive counseling, the decision was made to perform a preconceptional laparoscopic abdominal cerclage. This video demonstrates the Titiz uterovaginal manipulator components and how to insert the manipulator. It also shows tips and tricks on laparoscopic cervical cerclage: (1) how to determine the anatomic relationships among the bladder, uterine vessels, cervico-vaginal junction and cervico-isthmic part of uterus; (2) how the Titiz uterovaginal manipulator helps to dissect the bladder and uterine arteries and veins safely; and (3) how to determine where and how to pass the sutures. MEASUREMENT AND MAIN RESULTS: The patient was discharged the same day and did not have any postoperative complications. The patient had transvaginal ultrasound 1 week after the operation. Tape was shown to be at the internal cervical os level. CONCLUSIONS: The Titiz uterovaginal manipulator can make preconceptional laparoscopic abdominal cerclage safer and easier.

Use of a uniconcave balloon in emergency cerclage.

Pushing bulging fetal membranes back into the uterine cavity effectively without rupture of fetal membranes during emergency cerclage is a concern to obstetricians. We have developed a new uniconcave balloon device for repositioning fetal membranes into the uterus during emergency cerclage. Our technique can be accomplished easily with few complications.

Cerclage outcome by the type of suture material (COTS): study protocol for a pilot and feasibility randomised controlled trial.

BACKGROUND: Cervical incompetence is one of the causes of preterm birth and mid-trimester pregnancy loss. Cervical cerclage is a surgical procedure to treat cervical incompetence. Cervical cerclage reduces the incidence of preterm birth in women at risk of recurrent preterm birth, without a statistically significant reduction in perinatal mortality or neonatal morbidity. Multifilament/braided sutures such as Mersilene tape have been traditionally used for cervical cerclage. Braided sutures, particularly mesh-like non-absorbable sutures, have been associated with an increased risk of infection and, hence, some obstetricians prefer to use monofilament/non-braided sutures. However, these claims are not substantiated by any scientific or clinical evidence.We propose a pilot/feasibility study which will provide the necessary information for planning a definitive trial investigating the clinical effectiveness of monofilament non-braided suture materials in reducing pregnancy loss rate following cervical cerclage compared to the traditional multifilament braided sutures. METHODS/DESIGN: Women eligible for elective or ultrasound-indicated cerclage at 12 to 21 + 6 weeks of gestation will be randomised to having the procedure using either a monofilament non-braided suture (Ethilon) or a Multifilament braided suture (Mersilene tape) inserted using a McDonald technique. Consent for participation in the Cerclage outcome by the type of suture (COTS) study will be obtained from each eligible participant. CLINICAL TRIALS REGISTRATION: COTS is registered with the International Standard Research for Clinical Trials (ISRCTN17866773). Registered on 27 March 2013.

[Prevention of preterm birth by Shirodkar cerclage--clinical results of a retrospective analysis]. / Klinische Ergebnisse der Cerclage nach Shirodkar bezüglich der Prävention der Frühgeburtlichkeit--eine retrospektive Analyse.

In spite of the continuous progress in prenatal care, 1 out of 10 babies is born too early--tendency rising worldwide. As a consequence of the heterogeneous aetiology of preterm birth, there is still no single and efficient interventional therapy. Cerclage is one option for pregnancies with cervical insufficiency, whereas the clinical benefit is discussed controversially. We analyzed in a retrospective study with 120 patients the effect of a cerclage intervention regarding pregnancy prolongation. Patients with cervical incompetence and Shirodkar cerclage were compared to those undergoing conservative treatment. As expected, gestational age at delivery was significantly lower after emergency cerclage (31 weeks) compared to prophylactic (36 weeks) and therapeutic cerclage (35 weeks). Prolongation differs significantly between the prophylactic (18 weeks), therapeutic (14 weeks) and emergency cerclage (10 weeks) groups. Conservative management achieved 8 weeks prolongation. Of note, particularly emergency cerclage in cases with advanced cervical incompetence resulted in a substantially higher pregnancy prolongation (10 weeks) compared to no intervention (one week). The efficiency of cerclage operations has to be assessed in a differentiated manner based on the clinical situation and indication. The clinical benefit depends strongly on proper patient selection.

Cervical cerclage and type of suture material: a survey of UK consultants' practice.

OBJECTIVE: The main aim of the survey was to explore current practices with regards to cervical cerclage procedures amongst UK consultants with particular emphasis on the type of suture material used. METHODS: An electronic survey of UK consultant members and fellows of the Royal College of Obstetricians and Gynaecologists and who previously agreed to be contacted for survey purposes. RESULTS: There were 261 respondents to the survey and 88% routinely performed cerclage. The majority performed the procedure between 12 and 16 weeks' gestation (88.7%; n = 180/203), following the McDonald technique (83.4%; n = 166/199) and using a braided suture material (86.6%; n = 175/202). Although only 27 of the 202 responders (13.4%) used a monofilament suture for cerclage (75%; n = 149/201) of clinicians stated that they were not sure what is the best suture material to be used. CONCLUSION: There is considerable variation in practice amongst Consultant obstetricians with regards to cervical cerclage. Although most respondents use the traditional braided suture material, a significant proportion of them were not sure what is the best suture material to use. The "gestation at delivery" rate was judged to be the most important outcome for a future study.

Supracervical cerclage with intracavitary balloon to control bleeding associated with placenta previa.

OBJECTIVE: A supracervical cerclage suturing technique with an intracavitary balloon (SCCB) was developed to simultaneously compress bleeding from the placental bed and the outside uterine wall. STUDY DESIGN: Twenty cesarean sections were performed due to placenta previa over three years. The SCCB was used in 13 patients with uncontrolled bleeding after failure of conventional methods. The conventional surgical hemostatic techniques were applied first in patients with copious bleeding due to placenta previa. If bleeding continued, a three-way Foley catheter was inserted into the uterine cavity through the cervix and SCCB was performed. About 50-100 mL of normal saline was infused to inflate the catheter balloon. On the next morning, attempts were made to withdraw the F-catheter but if bleeding started again, another 12 h of pressure was provided. RESULTS: The mean removal time for the intracavitary Foley catheter was 20.6±12.3 h. There was one case of subtotal hysterectomy after the SCCB. All patients were followed for at least 12 months. There were no specific complications related to the procedure. All women returned to their normal menstrual cycles and one had an ongoing third trimester pregnancy. CONCLUSION: The SCCB is a simple and effective technique to control bleeding associated with placenta previa.

Labor outcomes after Shirodkar cerclage.

OBJECTIVE: To describe labor outcomes in women who had a Shirodkar cerclage placed during pregnancy and removed before labor. METHODS: A review was conducted of 69 patients with a singleton pregnancy and a Shirodkar cervical cerclage placed before 24 weeks' gestation. Indications for cerclage were history indicated, ultrasound indicated or physical examination indicated. RESULTS: The mean time from cerclage removal to delivery was 9.4 +/- 8.8 days. The overall cesarean delivery rate was 18.8%, with the majority (9 of 13) being for fetal indications. Two (2.9%) patients had a uterine rupture of an unscarred uterus and 2 (2.9%) patients had an umbilical cord prolapse. Four (5.8%) patients had a cervical laceration requiring repair. CONCLUSION: Patients with a Shirodkar cerclage placed and removed during the index pregnancy appear to have a higher than expected rate of cesarean delivery for fetal indications and complications associated with significant neonatal morbidity including uterine rupture and cord prolapse.