Laparoscopic prepregnancy transabdominal cerclage: operative and pregnancy outcomes for a novel technique of suture placement using port closure device.

Transabdominal cerclage is an effective surgical intervention for preterm birth prevention. Placement of cervical sutures using a port closure device for prepregnancy laparoscopic abdominal cerclage has been used at our unit in recent years. We report the operative and pregnancy outcomes for prepregnancy laparoscopic abdominal cerclage using the port closure device and compare it with the outcomes of the traditional approach. For prepregnancy laparoscopic transabdominal cerclage (n=52), the port closure device approach was associated with less blood loss during surgery (0.95±4.4 mL vs 5.4±15.7 mL; P=.007) and a shorter hospital length of stay (0.0; 0.0-0.0 days vs 1.0; 0.0-1.0 days; P<.001). There were also trends toward shorter operating times (41.4±15.3 minutes vs 50.1±18.0 minutes; P=.167) and lower perioperative complication rates (0.0%; 0/21 vs 16.1%; 5/31; P=.065) when compared with the traditional technique. There was no significant difference between the port closure device technique and the traditional approach in the rate of preterm birth in a subsequent pregnancy (0.0%; 0/9 vs 22.6%; 7/39; P=.248). Use of the port closure device for suture placement during prepregnancy laparoscopic cerclage for preterm birth prevention was reported. This technique was associated with less blood loss and a shorter hospital length of stay, had trends toward shorter operating times and lower perioperative complication rates, and had similar rates of preterm birth.

Tips and Tricks for Robotic-Assisted Trans-Broad Ligament Abdominal Cerclage in Pregnant Patients.

STUDY OBJECTIVE: To demonstrate the surgical techniques for improving safety in robotic-assisted abdominal cerclage via broad ligament window dissection. DESIGN: Stepwise demonstration with narrated video footage. SETTING: An academic tertiary care hospital. Our patient is a 32-year-old G8P2143, with a history of pregnancy loss at 19 and 23 weeks and 1 failed vaginal cerclage, presented to us at 13 weeks and 5 days for abdominal cerclage. We have completed a total of 5 successful procedures with this technique on pregnant patients ranging from 9 to 14 weeks. INTERVENTIONS: Abdominal cerclage during pregnancy can be very risky and challenging to perform; however, it offers an increased success rate for continuing pregnancy [1]. Excessive bleeding and the rupture of membrane during the procedure could lead to pregnancy loss and a failed abdominal cerclage [2,3]. Therefore, seeking a feasible and safer technique would be preferable for the surgeons to decrease surgical risk and complications. We have developed a trans-broad ligament technique that would allow for the bilateral uterine vessels to be clearly exposed, thereby reducing the possibility of accidental damage to a major vessel and eliminating the risk of blind needle placement piercing through the amniotic sac resulting in rupture of membrane and subsequent pregnancy loss [4,5]. A dense adhesion band from the anterior uterus to the anterior abdominal wall was carefully taken down using the monopolar scissors. The assistant gently performed a digital vaginal examination to assist with the creation of a bladder flap. The bladder was carefully dissected off the lower uterine segment and uterus using the monopolar scissors. Bilateral uterine vessels were further skeletonized and exposed anteriorly using blunt dissection and the monopolar scissors. On the right, a window was created in the broad ligament using the monopolar scissors. The right uterine vessels were then further dissected and lateralized, creating a small window medial to the uterine vessels at the level of the internal cervical os. The mersilene tape was guided through the window from anterior to posterior. In a similar fashion, a window was created on the left; the mersilene tape was then guided from posterior to anterior. The mersilene tape was completely placed around the cervix circumferentially at the level of the internal cervical os, medial to the uterine vessels. Both ends of the mersilene tape were then pulled gently, while ensuring that the tape was lying flat on the anterior of the uterus. The tape was then tied anteriorly at the 12 o'clock position in an appropriate tension. A 2-0 silk was then sutured to the tails of the tape to ensure that it would remain in the correct location and prevent the loosening of the knot of mersilene tape. The pelvis was copiously irrigated, and hemostasis was assured. The fetal heart rate was 126 bpm, and patient was discharge next day. A healthy baby, 6 pounds 14 ounces, was delivered by cesarean section at 36 weeks 5 days because of early contractions and pain (Supplemental Appendix 1-4). CONCLUSION: Robotic-assisted abdominal cerclage via broad ligament window dissection offers a possibly feasible and safe technique for surgeons seeking to reduce risks, although further research is needed.

Abdominal cerclage in a patient with a neocervix with planned cesarean hysterectomy at delivery.

Pregnancies complicated by congenital uterine anomalies (CUA) with a neocervix present a variety of challenges for the obstetrician. Abdominal cerclage can be utilized to help prevent preterm delivery in a patient with a neocervix. A 14-year-old female presented with right adnexal pain and was found to have a complex uterine anomaly resembling a noncommunicating unicornuate uterus with a cervix embedded in the rudimentary horn. A neocervix was created during surgical removal of the rudimentary horn. The patient became pregnant at age 24, and a transabdominal cerclage served an important role in the prevention of preterm delivery. Although limited data exists regarding the outcomes for the use of abdominal cerclage after the creation of a neocervix, term delivery is possible with said intervention.

Comparison of laparoscopic abdominal cerclage and transvaginal cerclage for the treatment of cervical insufficiency: a retrospective study.

PURPOSE: To compare the pregnancy outcome of patients with cervical insufficiency (CI) underwent prophylactic laparoscopic abdominal cervical cerclage (LAC) and transvaginal cervical cerclage (TVC). METHODS: A retrospective trial was carried out in the Department of Gynecology, Qingdao Women and Children's Hospital, Shandong Province, China. A total of 217 women with cervical insufficiency underwent the prophylactic cerclage, and the surgical approach was decided by the patients or depended on doctors' advice. The primary outcome measure was the fetal outcome. Secondary outcome measures were delivery of an infant at ≥ 34th gestational weeks, newborn birth weight, neonatal intensive care center (NICU) occupancy, and postoperative complications. Nonparametric variables were analyzed with the Mann-Whitney (U) test, and categorical type outcomes were analyzed with the Chi-square test or the Fisher's exact test. A P value < 0.05 was considered significant. Data analysis was performed using SPSS Statistics Version 19. RESULTS: As of follow-up date, 154 eligible patients were included in this study, with 74 (48.1%) women in the LAC group and 80 (51.9%) in the TVC group. The total fetal survival rate in the two groups was 90.3% (139/154), of which the rate significantly higher in the LAC group compared to the TVC group (97.3% vs. 83.8%, P < 0.01). The delivery of an infant at ≥ 34th gestational weeks was significantly higher in the LAC group compared to the TVC group (94.6% vs. 71.3%, P < 0.01). Compared to the TVC group, the mean newborn birth weight was higher, and the NICU occupancy rate was less in the LAC group (3293.4 ± 542.8 g vs. 2953.6 ± 704.4 g, P = 0.002; 2.8% vs. 17.9%, P = 0.003). COMPLICATIONS: No fatal surgical complications occurred in both groups. CONCLUSION: In patients with cervical insufficiency, the history-indicated conception of prophylactic LAC appears to have a better pregnancy outcome than TVC.

Pregnancy-preserving Laparoendoscopic Single-site Surgery for Gynecologic Disease: A Case Series.

STUDY OBJECTIVE: The study objective was to assess the feasibility of laparoendoscopic single-site surgery (LESS) for the management of nonobstetric, gynecologic disease processes in pregnant patients. DESIGN: A retrospective case series of 13 pregnant women aged 21 to 42 years who underwent LESS for various gynecologic pathology. If able to be contacted, the patients were followed up until the delivery of the fetus. SETTING: The surgeries were performed in a single institution between January 2015 and June 2019. PATIENTS: The patients were selected if a laparoscopic intervention was indicated. INTERVENTIONS: The cases included 6 ovarian cystectomies and 2 salpingo-oophorectomies for adnexal masses; 1 myomectomy for a degenerated myoma; 1 salpingectomy for a heterotopic pregnancy; 2 cerclage placements for recurrent pregnancy loss and cervical insufficiency; and 1 paratubal cystectomy. The patients underwent LESS through a 2.5-cm umbilical incision. The masses were exteriorized using a laparoscopic specimen retrieval bag, with the exception of 2 large adnexal masses, which were aspirated at the incision site, exteriorized after content drainage, and cystectomies performed extracorporeally. The fascial incision was repaired with a permanent suture. MEASUREMENTS AND MAIN RESULTS: Various data were collected from patients, including age, surgical and obstetric history, gestational age at surgery, and ultrasonic imaging results. The outcomes measured were operative duration, intraoperative bleeding, postoperative symptoms, fetal monitoring before and after surgery, pathologic findings, conversions, intraoperative complications, and pregnancy outcomes. Eight cases were performed in the first trimester, 4 in the second trimester, and 1 in the third trimester, with the surgeries lasting between 45 minutes and 298 minutes. The blood loss ranged from 5 mL to 300 mL, and postoperative symptoms of mild pelvic or abdominal pain were reported. There were 2 conversions to traditional multiport laparoscopic surgery for the 2 cerclage cases, and there were no open surgery conversions or intraoperative complications. The fetal heart rate ranged between 130 beats per minute and 167 beats per minute postoperatively. Of the 9 patients who were able to be contacted for follow-up, all had successful deliveries. One patient was healthy at 31 weeks and 5 days without complication at the time of her last follow-up. CONCLUSION: LESS may be performed by experienced surgeons on gravid patients in any trimester for adnexal masses, myomas, heterotopic pregnancy, and cervical incompetence. Future multiple-center studies may provide further evidence that LESS is a feasible and safe option for gynecologic surgery during pregnancy.

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 Technique to Minimize Contamination for Cervical Cancer Surgery Patients.

The Laparoscopic Approach to Cervical Cancer (LACC) trial changed the surgical management of cervical cancer worldwide. It was a multinational phase III clinical trial that reported lower survival and higher rate of abdominopelvic recurrences in minimally invasive surgery (MIS) than those of open surgery after hysterectomy. It is possible that tumor exposure to the peritoneal cavity in the MIS arm may account for these differences. We propose a novel technique to minimize peritoneal contamination of malignant cells present at the cervical os by placing a vaginal cerclage abdominally to create a seal at the apex of the vagina during MIS radical hysterectomy. The 2 patients in this work remain healthy and disease-free more than 18 months after surgery using this novel technique. We intend this work to serve as a platform both for offering a safe alternative to the open approach supported by the LACC trial and, most importantly, for promoting discussion of the results of the LACC trial and further research on surgical techniques in the treatment of cervical cancer. MIS has repeatedly been shown to have lower rates of infection, fewer complications, and shorter hospital stays while providing oncologic care that is noninferior to open approach.

No. 373-Cervical Insufficiency and Cervical Cerclage.

OBJECTIVE: The purpose of this guideline is to provide a framework that clinicians can use to determine which women are at greatest risk of having cervical insufficiency and in which set of circumstances a cerclage is of potential value. EVIDENCE: Published literature was retrieved through searches of PubMed or Medline, CINAHL, and The Cochrane Library in 2018 using appropriate controlled vocabulary (e.g., uterine cervical incompetence) and key words (e.g., cervical insufficiency, cerclage, Shirodkar, cerclage, McDonald, cerclage, abdominal, cervical length, mid-trimester pregnancy loss). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to June 2018. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care.

Robot assisted laparoscopic abdominal cerclage: two case reports.

OBJECTIVE: In this work we report the first use of robot-assisted preconceptual abdominal cerclage in the Czech Republic with subsequent live birth. We present two patients with a history of late pregnancy losses (late miscarriage) who underwent robotic abdominal cerclage. DESIGN: Case report. SETTING: Department of Obstetrics and Gynecology, University Hospital Olomouc, Faculty of Medicine and Dentistry, Palacký Univesity, Olomouc. METHODS: The da Vinci S surgical system was used for the robot-assisted abdominal cerclage. RESULTS: One robot-assisted laparoscopic transabdominal cerclage patient delivered at term a live infant and the second patient currently undergoes infertility treatment with in vitro fertilization. CONCLUSION: Robotic abdominal cerclage is a relatively new minimally invasive method for treatment of cervical insufficiency. This technique provides 3D visualization and better instrumentation than the conventional laparoscopic approach.

What is the impact of preconception abdominal cerclage on fertility: evidence from a randomized controlled trial.

INTRODUCTION: There is documented concern that cerclage may cause cervical stenosis or changes to the cervical mucus, which may reduce fertility. The aim of this study is to determine whether placement of a preconception abdominal cerclage affects fertility. MATERIAL AND METHODS: This was a planned subgroup analysis of a randomized controlled trial comparing abdominal cerclage, high vaginal cerclage or low vaginal cerclage. Women with a history of previous second-trimester miscarriage or preterm birth despite having a low vaginal cerclage, presenting to specialist preterm birth services in the UK, were eligible for inclusion. Only women randomized before conception were included in this analysis. Women randomized to abdominal cerclage had the surgery performed before conception (abdominal group). Women randomized to high or low transvaginal cerclage received it in the subsequent pregnancy (control group). RESULTS: Abdominal cerclage was performed in 19 women and transvaginal cerclage in 48 women. Overall, there was no statistically significant difference between time to conception between the two groups (hazard ratio 1.34; 95% confidence interval 0.72-2.50, p = 0.35). Rates of conception at 6, 12, and 18 months were similar - 37% in abdominal group vs. 35% in control group at 6 months (relative risk 1.04; 95% confidence interval 0.52-2.10; p = 0.91); 58% in abdominal group vs. 42% in control group at 12 months (relative risk 1.39; 95% confidence interval 0.84-2.31, p = 0.21); 74% in abdominal group vs. 56% in control group at 18 months (relative risk 1.31; 95% confidence interval 0.91-1.89; p = 0.15). CONCLUSION: This subgroup analysis of randomized data indicates that abdominal cerclage does not affect fertility rates.

Cervical length after cerclage: comparison between laparoscopic and vaginal approach.

PURPOSE: The aim of our study was to investigate the sonographic changes of the cervical length during pregnancy after the placement of a transvaginal cervical cerclage (TVC) or a laparoscopic abdominal cerclage (LAC) in patients with cervical insufficiency (CI). METHODS: Between January 2008 and March 2015, a retrospective analysis of all women undergoing a prophylactic laparoscopic (LAC group) or transvaginal (TVC group) cerclage due to cervical insufficiency was conducted. Nonparametric variables were analysed with the Mann-Whitney (U) test, and categorical-type outcomes were analysed with the Fisher's exact test. A p value <0.05 was considered as significant. Data analysis was performed using Prism 5 for Mac OS X. RESULTS: Thirty-eight patients were included. Of these, 18 and 20 underwent an LAC and a TVC, respectively. Mean gestational age at surgery in the LAC and TVC groups was 11.4 ± 1.6 and 17 ± 3 weeks, respectively (p < 0.05). The cervical length prior to surgery was similar among the two groups. After cerclage placement, the distance between the tape and the external cervical os differed significantly between the two groups (LAC: 31.5 ± 8.8 mm vs TVC: 13.5 ± 4.9 mm; p < 0.0001) (Fig. 1). During pregnancy, the cervical length in the TVC group showed a significant shortening (from 26.6 ± 7 mm before surgery to 13.2 ± 7 mm at 33 weeks; p < 0.0001), while in the LAC group, the cervical length remained unchanged. CONCLUSIONS: In patients with CI, LAC is associated with a better preservation of the cervical length throughout pregnancy as compared to TVC.

Robotic Cerclage in Advanced-stage Endometriosis.

STUDY OBJECTIVE: To show a stepwise surgical technique of robotic-assisted transabdominal cerclage placement in a patient with deeply infiltrative endometriosis. DESIGN: A step-by-step surgical tutorial using narrated video. SETTING: The George Washington University Hospital. Local institutional review board approval is not required for case reports (Canadian Task Force Classification III). PATIENTS: A 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. INTERVENTIONS: Indications 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; »-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. CONCLUSION: A 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 OBJECTIVE: To demonstrate the step-by-step surgical technique of "needle-free" robotic-assisted transabdominal cerclage placement. DESIGN: Through surgical video footage, presentation of a step-by-step demonstration of robotic-assisted laparoscopic placement of abdominal cerclage (Canadian Task Force classification III). SETTING: The 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. PATIENTS: The 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. INTERVENTIONS: Robotic-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. CONCLUSION: A needle-less robotic-assisted laparoscopic technique can be performed safely and effectively in both gravid and nongravid patients.

Insuffisance cervicale et cerclage cervical.

OBJECTIF: La présente directive clinique a pour but de fournir un cadre de référence que les cliniciens pourront utiliser pour identifier les femmes qui sont exposées aux plus grands risques de connaître une insuffisance cervicale, ainsi que pour déterminer les circonstances en présence desquelles la mise en place d'un cerclage pourrait s'avérer souhaitable. RéSULTATS: La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans PubMed ou MEDLINE, CINAHL et The Cochrane Library en 2012 au moyen d'un vocabulaire contrôlé (p. ex. « uterine cervical incompetence ¼) et de mots clés appropriés (p. ex. « cervical insufficiency ¼, « cerclage ¼, « Shirodkar ¼, « cerclage ¼, « MacDonald ¼, « cerclage ¼, « abdominal ¼, « cervical length ¼, « mid-trimester pregnancy loss ¼). Les résultats ont été restreints aux analyses systématiques, aux essais comparatifs randomisés / essais cliniques comparatifs et aux études observationnelles. Aucune restriction n'a été appliquée en matière de date ou de langue. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'en janvier 2011. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales. VALEURS: La qualité des résultats est évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau). RECOMMANDATIONS.

Transabdominal Cervical Cerclage: Laparoscopy Versus Laparotomy.

STUDY OBJECTIVE: To evaluate the obstetric outcome, surgical morbidity, and pre-abdominal cerclage characteristics of women undergoing transabdominal cerclage (TAC) via laparotomy or laparoscopy. DESIGN: Prospective cohort study (Canadian Task Force classification II-2). SETTING: University hospital. PATIENTS AND INTERVENTION: Between 2007 and 2014, 51 patients underwent laparoscopic abdominal cervical cerclage to treat cervical incompetence. These women were compared with a historical cohort of 18 patients who underwent the same procedure via laparotomy between 1995 and 2011. All of the women had a diagnosis of cervical incompetence based on previous obstetric history and/or a short or absent cervix. MEASUREMENTS AND MAIN RESULTS: The fetal survival rate postcerclage was 100% in the laparotomy group (n = 30 pregnancies) and 98% in the laparoscopy group (n = 54 pregnancies). There were no perioperative pregnancy losses in either group. The median gestation age was 36.9 weeks (range: 35.0-37.3) in the laparotomy group and 37.0 weeks (range: 34.7-38.0) in the laparoscopy group. Complications were recorded in 4 (22%) cases from the laparotomy group and 1 (2%) of the laparoscopies; however, the types of complications might not be comparable between groups. There were no conversions to laparotomy in the laparoscopy group. Pre-TAC median gestational age in the laparotomy group was 24.0 weeks (range: 20.0-25.1) with 19 (57.6%) previous pregnancies occurring after transvaginal cervical cerclage placement. The corresponding laparoscopy pre-TAC median gestational age was 22.0 weeks (range 19.0-34.0) with 40 (40%) previous pregnancies having a transvaginal cerclage. Before the TAC, women in the laparotomy group had lost 25 babies, and 63 babies were lost in the laparoscopy group. After TAC, these numbers were 0 and 1. CONCLUSIONS: Our findings show that transabdominal cervical cerclage placed laparoscopically appears to be as effective as TAC placed via laparotomy. Neither approach was associated with serious or long-term complications. Because of this finding, the approach depends on the surgical experience and expertise of the unit in conjunction with discussion with the patient.

Robotic-assisted Abdominal Cerclage Placement During Pregnancy and Its Challenges.

STUDY OBJECTIVE: To demonstrate a surgical video of 2 cases, in which the steps of robotic-assisted abdominal cerclage placement were delineated in one and a uterine vessel injury was repaired in the other. DESIGN: Step-by-step explanation of the technique using a surgical video (Canadian Task Force classification III). SETTING: The procedures were performed at a teaching hospital. The first patient was a 25-year-old gravida 4 para 0, with a history of cervical incompetence, who was 13 weeks pregnant at the time of surgery. She had failed McDonald cerclage and was referred for abdominal cerclage placement. The second patient was a 32-year-old gravida 6 para 0 who was 15 weeks pregnant. She had a history of 3 second-trimester miscarriages with painless cervical dilation and had failed McDonald cerclage during her previous pregnancy. Both patients were taken to the operating room for robotic-assisted abdominal cerclage placement early in the second trimester. INTERVENTIONS: Robotic-assisted abdominal cerclage placement was performed with ultrasound guidance. The procedure was begun with formation of the bladder flap [1]. An avascular space between the ascending and descending branches of uterine artery, at the level of the cervicoisthmic junction, was subsequently developed. The Mersilene tape was passed through this space in a posterior-to-anterior direction and pulled taut until it was laid flat along the posterior uterine wall. Six knots were then placed with the Mersilene tape on the anterior aspect of the uterus. The free ends of the tape were trimmed and approximated with a nonabsorbable suture to prevent knot slippage. The vesicouterine reflection was then reapproximated, and correct cerclage placement was confirmed with transvaginal ultrasound. In the second case, an incidental uterine vessel injury occurred during development of the avascular space. Hemostasis was attained immediately by clamping the vessel with the fenestrated graspers. Permanent hemostasis required application of the vascular clips, proximally and distally on the lacerated arterial site. CONCLUSION: A robotic approach was chosen for our patients requiring transabdominal cerclage placement during pregnancy, in an attempt to decrease the surgical morbidity associated with laparotomy [2,3]. Despite the challenges introduced by the enlarged gravid uterus, both procedures were successfully completed, and the patients delivered at term via cesarean section.

Pre and post-conceptional abdominal cerclage by laparoscopy or laparotomy.

The objective of this study was to evaluate the efficacy of abdominal cerclage via laparoscopy vs laparotomy and before vs after conception. We evaluated 16 studies of abdominal cerclage involving a total of 678 cases published between 1990 and 2013. We estimated the effect of laparotomy over laparoscopy and the effect of preconceptional over postconceptional cerclage using a generalized linear model by treating the success rates (third-trimester delivery and live birth) as dependent variables and laparotomy and preconceptional as independent factors. The results demonstrated that there was no difference in the rates of third-trimester delivery and live birth rates between preconceptional abdominal cerclage via laparoscopy (71.4%-83.3% and 90%-100%, respectively) or laparotomy (97.3%-100% and 100%, respectively). For postconceptional cerclage, the rates of third-trimester delivery and live birth via laparoscopy were 70% and 70% to 100%, respectively, and via laparotomy were 77.4% to 99.5% and 85.2% to 100%, respectively. There was no difference in the live birth rates when abdominal cerclage was performed before or during pregnancy. We concluded that the rates of third-trimester delivery and live birth after abdominal cerclage via laparoscopy are high and comparable to those via laparotomy. The efficacy of the procedure performed either before or during pregnancy is similar. Abdominal cerclage performed before conception is more practical than after conception. With the inherent advantages of laparoscopy over laparotomy, abdominal cerclage performed via laparoscopy is preferable, in particular when performed in non-pregnant women.

Favorable surgical and obstetrical outcomes in pre- and postconceptional laparoscopic abdominal cerclage: a large multicenter cohort study.

BACKGROUND: Cervical incompetence is an important cause of extremely preterm delivery. Without specialized treatment, cervical incompetence has a 30% chance of recurrence in a subsequent pregnancy. Recently, the first randomized controlled trial showed significant superiority of abdominal cerclage compared with both high and low vaginal cerclage in preventing preterm delivery at <32 weeks of gestation and fetal loss in patients with a previous failed vaginal cerclage. OBJECTIVE: This study aimed to assess surgical and obstetrical outcomes in patients with pre- and postconceptional laparoscopic abdominal cerclage placement. Furthermore, it also aimed to perform subgroup analysis based on the indication for cerclage placement in order to identify patients who benefit the most from an abdominal cerclage. STUDY DESIGN: A retrospective multicenter cohort study with consecutive inclusion of all eligible patients from 1997 onward in the Dutch cohort (104 patients) and from 2007 onward in the Boston cohort (169 patients) was conducted. Eligible patients had at least 1 second- or third-trimester fetal loss due to cervical incompetence and/or a short or absent cervix after cervical surgery. This includes loop electrosurgical excision procedure, conization, or trachelectomy. Patients were divided into the following subgroups based on the indication for cerclage placement: (1) previous failed vaginal cerclage, (2) previous cervical surgery, and (3) other indications. The third group consisted of patients with a history of multiple second- or early third-trimester fetal losses due to cervical incompetence (without a failed vaginal cerclage) and/or multiple dilation and curettage procedures. The primary outcome measure was delivery at ≥34 weeks of gestation with neonatal survival at hospital discharge. Secondary outcome measures included surgical and obstetrical outcomes, such as pregnancy rates after preconceptional surgery, obstetrical complications, and fetal survival rates. RESULTS: A total of 273 patients were included (250 in the preconceptional and 23 in the postconceptional cohort). Surgical outcomes of 273 patients were favorable, with 6 minor complications (2.2%). In the postconceptional cohort, 1 patient (0.4%) had hemorrhage of 650 mL, resulting in conversion to laparotomy. After preconceptional laparoscopic abdominal cerclage (n=250), the pregnancy rate was 74.1% (n=137) with a minimal follow-up of 12 months. Delivery at ³34 weeks of gestation occurred in 90.5% of all ongoing pregnancies. Four patients (3.3%) had a second-trimester fetal loss. The indication for cerclage in all 4 patients was a previous failed vaginal cerclage. The other subgroups showed fetal survival rates of 100% in ongoing pregnancies, with a total fetal survival rate of 96%. After postconceptional placement, 94.1% of all patients with an ongoing pregnancy delivered at ³34 weeks of gestation, with a total fetal survival rate of 100%. Thus, second-trimester fetal losses did not occur in this group. CONCLUSION: Pre- and postconceptional laparoscopic abdominal cerclage is a safe procedure with favorable obstetrical outcomes in patients with increased risk of cervical incompetence. All subgroups showed high fetal survival rates. Second-trimester fetal loss only occurred in the group of patients with a cerclage placed for the indication of previous failed vaginal cerclage, but was nevertheless rare even in this group.

Robotic-assisted single-site abdominal cerclage in the bicornuate uterus patient with cervical insufficiency.

OBJECTIVE: To demonstrate the surgical techniques for improving safety in robotic-assisted abdominal cerclage in patients with bicornuate uteri complicated by recurrent pregnancy loss and cervical insufficiency. DESIGN: Stepwise demonstration with narrated video footage. SETTING: An academic tertiary care hospital. PATIENTS: Our patient is a 22-year-old G2P0020 with a history of recurrent pregnancy loss. During her first pregnancy, she was asymptomatic until 19 weeks and delivered because of a preterm premature rupture of membranes. A transvaginal cerclage was performed for her second pregnancy at 14 weeks, which ended at 16 weeks because of preterm premature rupture of membranes. The final magnetic resonance imaging report noted a "bicorporeal uterus with duplication of the uterine body, resulting in two markedly divergent uterine horns that are fused at the isthmus... unlike a typical didelphic uterus, a single, non septated cervix is noted, which shows normal appearances, measuring 3.8 cm in length." Given her history of a uterine anomaly and recurrent pregnancy loss in the absence of other biochemical factors, her maternal-fetal medicine specialist referred her to us as the patient strongly desired future viable pregnancies. The patient was counseled on multiple alternatives, including different methods of performing the cerclage, and ultimately decided on the robotic-assisted (Da Vinci Xi) prophylactic abdominal cerclage. INTERVENTIONS: The bicornuate uterus is a rare class IV mullerian duct anomaly caused by the impaired fusion of the mullerian ducts in the uterus, classically appearing in imaging studies as a heart-shaped uterus. This patient demographic reports a high incidence of obstetric complications. Pregnancy in such a uterus causes complications like first- and second-trimester pregnancy loss, preterm labor, low-birthweight infants, and malpresentation at delivery.1 Researchers have postulated that there is an abnormal ratio of muscle fibers to connective tissue in a congenitally abnormal cervix. During pregnancy, an inadequate uterine volume may lead to increased intrauterine pressure and stress on the lower uterine segment, which can lead to cervical incompetence.2 To address cervical incompetence, cervical cerclages are a commonly utilized procedure, as recent studies demonstrate that the incidence of term pregnancies in the group with documented cervical incompetence treated with cerclage placement increased from 26% to 63%.3 One observational study noted improved obstetrical outcomes occurred with interval placement, a cerclage placed in between pregnancies in the nongravid uterus, compared with cerclage placement between 9 and 10 weeks gestation, with the mean gestational age for delivery at 32.9 weeks and 34.5 weeks when a cerclage was placed in gravid and nongravid women, respectively.4 In addition, another retrospective study was done, which demonstrated a lower incidence of neonatal death with prophylactic cerclages.5 Operating on a nonpregnant uterus offers several benefits, including its reduced size, fewer and smaller blood vessels, and simplified handling. Moreover, there are clearly no concerns regarding the fetus. In the decision to use a robotic-assisted platform vs. laparoscopic, a systematic review showed the rates of third-trimester delivery and live birth (LB) using laparoscopy during pregnancy were found to be 70% and 70%-100%, respectively. The same review demonstrated slightly improved outcomes via the robotic route regarding gestational age at delivery (median, 37 weeks), rates of LB (90%), and third-trimester delivery (90%).6 Additional factors contributing to the preference for robotics in surgical procedures include incorporating advanced tools, which can enhance the robotic system's advantages compared with traditional laparoscopy. An invaluable tool in this context is the simultaneous utilization of Firefly mode, which employs a near-infrared camera system, achieved through injecting indocyanine green dye or integrating other light sources concurrently. The intravenous administration of indocyanine green is acknowledged widely for its safety and efficacy as a contrast agent in the evaluation of microvascular circulation and organ vascularization. This property equips surgeons with heightened precision when guiding the needle, proving especially advantageous when faced with challenges in visualizing vascular anatomy. In our specific case, we harnessed the capabilities of Firefly mode in conjunction with hysteroscopic light, enabling us to vividly illustrate the contours of a bicornuate uterus from both external and internal perspectives. We demonstrate a simplified technique of the abdominal cerclage, one cerclage around the internal cervical os of the uterus, using a robotic-assisted platform in a nongravid patient. The surgery began with the eversion of the umbilicus, and a 15-mm skin incision was made in the umbilicus. A Gelpoint mini advanced access site laparoscopy device was inserted into the incision, and CO2 was allowed to insufflate the abdominal cavity with careful attention given to intraabdominal pressure. Once the DaVinci was docked, the surgeon began the creation of a bladder flap. The bladder was carefully dissected from the lower uterine segment and both uteri using monopolar scissors. The anatomical differences of a bicornuate uterus prompted the surgeon to dissect a wider circumference for safety reasons, where a wider dissection offers a better view of the uterine vessels and ease of introducing the Mersilene tape later on. Bilateral uterine vessels were further skeletonized and exposed anteriorly using blunt dissection and monopolar scissors. After further dissection and lateralization, the final result creates a landmark medial to the right uterine vessels at the level of the internal cervical os with which the needle of the Mersilene tape will be able to pass through. The Mersilene tape was guided from anterior to posterior via a previously straightened needle. Similarly, a landmark was created on the left, and the Mersilene tape was directed from anterior to posterior. The Mersilene tape was placed circumferentially around the internal cervical os of the bicornuate uterus, medial to the uterine vessels. Both ends of the Mersilene tape were then gently pulled, ensuring that the tape was lying flat on the anterior of the internal cervical os with no bowels or uterine vessels within it. The tape was then tied posteriorly at the 6 o'clock position with appropriate tension. A 2-0 silk was then sutured to the tails of the tape using the purse-string technique to ensure that it would remain securely tied and in the correct position. Hemostasis was assured. Both a hysteroscopy and a cystoscopy were done after the completion of the cerclage to ensure that no tape or sutures were seen within the cervical canal or the uterine cavity. None were observed. MAIN OUTCOMES MEASURES: The success criteria for the surgery were identified as the patient's ability to attain a viable pregnancy after the cerclage placement, along with achieving LB. RESULTS: Subsequently, a spontaneous pregnancy was achieved. An infant weighing 3 pounds and 16 ounces was delivered by cesarean section at 36 weeks because of an oligohydramnios. The infant is currently healthy at 13 pounds. CONCLUSION: Robotic-assisted abdominal cerclage around the internal cervical os in a bicornuate uterus offers a possibly feasible and straightforward technique for surgeons seeking to reduce risks, although further research is needed.