Laparoscopic Transabdominal Cerclage

The Laparoscopic Transabdominal Cerclage is an operation done to place a surgical suture around the cervix at its uppermost part near the transition with the uterine body. This level cannot be reached from the vagina therefore the abdominal approach.

Historically, the procedure was initially performed as an open Transabdominal Cerclage through an incision similar to the one used to perform a caesarean section.

With the advance of new technologies and the ability to safely perform more complex laparoscopic surgery, this approach has been used to perform the Abdominal Cerclage in a less invasive and less traumatic manner.

The Laparoscopic Transabdominal Cerclage is used to treat cases of Cervical Insufficiency where the Transvaginal Cerclage has failed or is not possible. This may happen because the cervix is too short, too irregular or in cases of previous surgery to the cervix to treat cervical cancer or dysplasia. The procedure is also known as Laparoscopic Cerclage, Laparoscopic Transabdominal Cerclage and Laparoscopic Cervico-isthmic Cerclage.

FREQUENTLY ASKED QUESTIONS

When is the Laparoscopic Transabdominal Cerclage indicated?

Each case is different and should be assessed individually as to whether there is an indication for the procedure.

A Laparoscopic Transabdominal Cerclage should be considered as possible treatment if:

- There is a consistent history of Cervical Insufficiency, i.e., cervical dilatation and subsequent fetal loss or premature delivery in the absence of uterine activity.

- A Transvaginal Cerclage done in a previous pregnancy failed to correct the problem.

- The cervix is short or very irregular, usually after surgical procedures such as cone biopsies and previous Transvaginal Cerclage.

When is the Laparoscopic Transabdominal Cerclage performed?

The preferable time to perform the cerclage is when the woman is not pregnant. This is known as pre-pregnancy cerclage or interval procedure. The advantages are that the uterus is smaller, has less blood vessels and can be easily manipulated. Some women only find out that they need a Transabdominal cerclage once they are already pregnant. In this case the operation can be done during pregnancy up until around 12 weeks gestation.

How is the operation done?

The laparoscopy is done with 4 small incisions, about 0.5 cm each; one just below the umbilicus and the other three on the side of the abdomen. A camera is inserted through the umbilical incision and surgical instruments through the other ones.

The surgeon dissects the spaces around the cervix and then places a suture around the upper part of the cervix medial to the uterine arteries. The suture is then tied at the back of the uterus.

How much experience is there with the operation?

There is a fair amount of evidence in the medical literature. Several groups around the world are performing the Laparoscopic Transabdominal Cerclage and reporting good outcomes.

There are a few difficulties in producing statistically significant data.

The main reasons are:

- Abdominal and Laparoscopic cerclages are still done in small numbers and no one surgeon or hospital has done hundreds of cases.

- Different surgeons may use slightly different techniques or suture materials and outcomes in different centres may vary.

- Studies comparing transabdominal cerclage with transvaginal cerclage are difficult to conduct as there may be ethical or emotional constraints. We are usually dealing with high risk patients and random selection of cerclage technique is not always possible.

What type of anaesthesia is used?

All laparoscopic procedures are done under general anaesthesia including the Laparoscopic Cerclage.

How long will I stay in hospital?

Most women go home on the same day, especially if the procedure is done early in the morning. Some women stay overnight and go home the following morning.

How long do I need of work?

This may vary depending on individual recovery. Most women are back to work within ten days.

How long after the operation can I start trying for a pregnancy?

After six weeks or two periods you should be able to start trying.

Will it be more difficult for me to fall pregnant again if I have a suture around the cervix?

No. The suture is external to the cervix and does not interfere with the sperm, the egg or the couple’s ability to fall pregnant.

How will my baby be delivered?

The Transabdominal Cerclage is not removed and the baby is always delivered by Caesarean Section.

What happens if I have an early miscarriage?

If necessary one can have a suction curettage much the same way as if there was no suture. The suture is not that tight and it is possible to dilate the cervix and insert the curette.

What are the complications of a Laparoscopic Transabdominal Cerclage?

Complications and surgical risks are similar to other laparoscopic procedures. These are rare but can happen and include: excessive bleeding, infection and damage to nearby organs such as bladder, bowel and large vessels.

What suture material is used for the Laparoscopic Transabdominal Cerclage?

We use Prolene™, a polypropylene synthetic non-absorbable suture manufactured by Ethicon. It is chosen because of its strength and resistance. It is used in several other procedures such as brain, heart and eye surgery. It has very low infection, allergy and rejection rates.

What is the success of the Laparoscopic Transabdominal Cerclage?

The procedure has been very successful with Obstetric outcomes reported in the literature between 85% and 100%.

As of June 30th 2013, Dr Ades has performed 75 Laparoscopic Transabdominal Cerclages. 5 were done during pregnancy and 70 before pregnancy. There are 30 reported pregnancies in this series. 96% of patients had a live baby. 86% of pregnancies were delivered after 34 weeks. In most cases where there was an early delivery, there was a cause not related to the suture, such as congenital problems, gestational diabetes or placenta praevia. Most pregnancies were completely uneventful and did not require bed rest or other measures.

What happens if I want to fall pregnant again in the future?

The suture stays around the cervix and subsequent pregnancies can be attempted without any further operations.

REFERENCES:

Whittle WL, Singh SS, Allen L, et al. Laparoscopic cervicoisthmic cerclage: surgical technique and obstetric outcomes. Am J Obstet Gynecol 2009;201:364.e1-7

Novy MJ. Transabdominal cervicoisthmic cerclage for the management of repetitive abortion and premature delivery. Am J Obstet Gynecol 1982;1:44-54.

Lesser KB, Childers JM, Surwit EA. Transabdominal cerclage: a laparoscopic approach. Obstet Gynecol 1998;9:855-6.

Novy MJ. Transabdominal cervicoisthmic cerclage: a reappraisal 25 years after its introduction. Am J Obstet Gynecol 1991;164: 1635-41.

Davis G, Berghella V, Talucci M, Wapner RJ. Patients with a prior failed transvaginal cerclage: a comparison of obstetric outcomes with either transabdominal or transvaginal cerclage. Am J Obstet Gynecol 2000;183:836-9.
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