Laparoscopic abdominal cerclage: a highly effective option for refractory cervical insufficiency

Laparoscopic Cerclage in a Case of Unicornuate Uterus with Cervical Insufficiency and Previous Failed Mc Donald Cerclage with a Successful Outcome: A Case Report

In this report, we describe a 28-year-old woman, with unicornuate uterus and multiple mid-trimester losses, with two failed Mc Donald's cerclage. She presented to us as a case of recurrent pregnancy losses with history suggestive of cervical incompetence and on detailed investigation was found to be ANA and anti-cardiolipin antibody positive and Rh negative. We performed an interval laparoscopic cervical cerclage for her and were able to successfully deliver her at 35 + 3 weeks with a healthy baby by caesarean section after previous five pregnancy losses and two failed Mc Donald's cerclage. Cervical cerclage can be used as an effective method of preventing abortions in unicornuate uterus pregnancy, while laparoscopic cerclage would be a better choice for patients with cervical incompetence with previous failed Mc Donald's cerclage. The possibility of uterine rupture for these high-risk patients should be kept in mind and decision to deliver at appropriate period of gestation so as to avoid uterine rupture and prematurity should be taken.

Updates on laparoscopic cervical cerclage: obstetric outcomes and surgical techniques

Aim

Preterm birth is a worldwide health problem. After unsuccessful transvaginal cerclage, the transabdominal isthmo-cervical cerclage can be indicated. A laparoscopic approach has been described.

Methods

A search was performed including the combination of: "((cerclage) AND (laparoscopy)) AND (pregnancy)". A systematic review was performed to compare indications, outcomes, techniques, and safety.

Results & discussion

42 articles were found through database search. 30 articles were included for review. By reviewing the literature, the transabdominal cervico-isthmic laparoscopic cerclage is highly effective in selected patients with a history of refractory cervical insufficiency. This technique has a high neonatal survival rate when placed in preconceptional or post conceptional patients. Moreover, laparoscopic cervical cerclage is a safe procedure when laparoscopic expertise is present.

The minimally invasive approach to abdominal cerclage: indications, complications, and techniques for placement

PURPOSE OF REVIEW

Laparoscopic abdominal cerclage placement has become the favored approach for management of refractory cervical insufficiency. There are special considerations with respect to surgical method, management of pregnancy loss, and delivery following placement. This review addresses current literature on transabdominal cerclage with a focus on up-to-date minimally invasive techniques.

RECENT FINDINGS

Recent literature on abdominal cerclage has compared laparoscopic and open approaches, evaluated the effect of preconception placement on fertility, and explored the upper gestational limit for dilation and evacuation with an abdominal cerclage in situ .

SUMMARY

The objective of this article is to help minimally invasive surgeons identify candidates for transabdominal cerclage placement, understand surgical risks, succeed in their laparoscopic approach, and appropriately manage patients postoperatively.

Elimination of reserve cells for prevention of HPV-associated cervical cancer

Human papilloma viruses (HPV), that are causative for most squamous cell cervical cancers (SCC), have a simple structure with only a few genes (six early and two late genes). Two of the early HPV genes (E6 and E7) are capable of transforming normal squamous epithelium into cancer. In the last 10 years, a controversial discussion arose as to which cells are primarily involved in cervical carcinogenesis. Virologists traditionally use a research model of stratified squamous epithelium, a permissive environment for completion of a full HPV-life cycle. Basic insights on HPV tropism, HPV life cycle, HPV-uptake, HPV-replication, HPV-gene expression were gained from this model. Stratified squamous epithelium, however, is a low-risk area for SCC. Most SCC develop in an area of endocervical columnar epithelium that undergoes squamous metaplasia. SCC arise after infection of immature squamous metaplasia, proliferating reserve cells/reserve cell hyperplasia and reserve cells of the endocervical columnar epithelium. Study models investigating this pathway of carcinogenesis do not exist and therapeutic consequences deduced from this knowledge are lacking. This review describes in detail cervical carcinogenesis after HPV infection of subcolumnar reserve cells and discusses new intervention strategies for patients. The WHO-launched global strategy to eliminate HPV-associated cervical cancer builds primarily on prophylactic vaccination, screening and treatment. New insights in cervical pathogenesis, may assist in reaching this ambitious WHO goal.

Isthmic retroperitoneal cerclage via vNOTES as a potential alternative to an abdominal cerclage: First technique description

OBJECTIVE

To describe a new technique for performing an isthmic retroperitoneal cerclage via vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES).

DESIGN

Stepwise explanation of the surgical technique using original video footage. This study was exempted from requiring hospital IRB.

SETTING

Department of Obstetrics and Gynaecology, Imelda Hospital, Belgium.

INTERVENTION

A circumferential vaginal incision is made around the cervix after infiltration of the tissue with local anaesthetic and adrenaline. The bladder is deflected from the cervix up to the level of the isthmus but the peritoneum is not opened. The rectum is deflected from the cervix up to the level of the isthmus but the peritoneum is not opened. A Gelpoint vPath (9.5 cm) (Applied Medical, Rancho Santa Margarita) is used as a vNOTES port. The inner ring of the Alexis is inserted into the retroperitoneal dissection space around the cervix, covering the bladder anteriorly and the rectum posteriorly. An insufflation stabilization bag (ISB) is connected to the Gelseal cap to minimize pressure fluctuations within the confines of the retroperitoneal operative space. The paracervical space is opened just inferior to the uterine artery. A paracervical tunnel is made from the anterior to the posterior retroperitoneal space just lateral to the cervix and just inferior to the uterine artery. This procedure is performed bilaterally. A vessel loop is inserted from anterior to posterior through the paracervical tunnel on each side of the cervix. The Gelseal cap is removed and an Ethibond-2 suture is tied to the vessel loop. The Gelseal cap is placed again. By pulling on the vessel loop, it is replaced by the Ethibond suture. The Ethibond suture is now tied endoscopically to complete the cerclage; alternatively the suture could be tied vaginally without endoscopic instruments to the surgeon's preference. The vNOTES port is removed and the vaginal mucosa is sutured to the cervix again using a resorbable suture.

DISCUSSION

Abdominal cerclage is the preferred approach to treat patients with refractory cervical insufficiency [1]. Over the last 20 years this technique increasingly gets performed laparoscopically with similar success rates [2]. The new transvaginal approach demonstrated in this video article may help reduce the invasivess even more by avoiding abdominal incisions and opening the peritoneum, while still benefiting from the vNOTES endoscopic visualization and minimally invasive instruments [3]. The cerclage is placed permanently at the level of the isthmus, similar to an abdominal cerclage. It is placed more cranially than a McDonald or Shirodkar cerclage and leaves no non-resorbable sutures in the vagina [4]. It can be an alternative to a conventional transvaginal cervicoisthmic cerclage [5,6] in patients with a narrow vagina and without uterine descensus. Following the guidelines of the IDEAL collaboration we present this technique to be peer reviewed in its early developmental phase before starting further studies [7].

CONCLUSION

This is a first feasibility and technique description report on performing a retroperitoneal isthmic cervical via vNOTES. This technique should be considered new, not to be performed on pregnant patients or outside of clinical trials, and only in carefully counselled patients.

The effectiveness of transabdominal cerclage placement via laparoscopy or laparotomy: a systematic review and meta-analysis

OBJECTIVE

Failure or technical impossibility to place a prophylactic transvaginal cerclage in women with cervical insufficiency justifies the need for an abdominal cerclage. In this systematic review and meta-analysis, we studied the obstetrical and surgical outcomes of laparoscopic and open laparotomy abdominal cerclage approaches performed before (interval) or during pregnancy.

DATA SOURCES

We performed a systematic literature search in PubMed, Embase, and the Cochrane Library for studies on laparoscopic and open laparotomy abdominal cerclage placement in February 2022.

STUDY ELIGIBILITY CRITERIA

All studies on laparoscopic or open laparotomy placement of an abdominal cerclage with at least 2 patients that reported on our primary outcomes were included.

METHODS

All included studies were assessed for quality and risk of bias with an adjusted Quality in Prognosis Study tool. Random effects meta-analyses were performed for the primary outcomes, namely fetal survival and gestational age at delivery.

RESULTS

Our search yielded 83 studies with a total of 3398 patients; 1869 of those underwent laparoscopic cerclage placement and 1529 underwent open laparotomy placements. No studies directly compared the 2 cerclage approaches. The survival (overall, 91.2%) and gestational age at delivery (overall, 36.6 weeks) were not statistically different between the approaches. For the procedure during pregnancy, the laparoscopic group showed significantly less blood loss >400 mL (0% vs 3%), a slightly lower procedure-related fetal loss (0% vs 1%), a shorter hospital stay but a longer operation duration than the open laparotomy group. For the interval cerclages, the laparoscopic group showed significantly fewer wound infections (0% vs 3%) and a shorter hospital stay than the open laparotomy group, but showed comparable offspring preterm birth and survival rates.

CONCLUSION

Based on indirect comparisons, the laparoscopic and open laparotomy abdominal cerclage placements at interval or during pregnancy produced similar outcomes in terms of survival and gestational age at delivery. There are some small differences in perioperative care, surgical complications, interventions, and complications during pregnancy. This implies that both methods of abdominal cerclage placement have high success rates and thus we cannot conclude that one of the methods is superior for the placement of an abdominal cerclage.

Comparison of transvaginal cervical cerclage versus laparoscopic abdominal cervical cerclage in cervical insufficiency: a retrospective study from a single centre

Background

Cervical cerclage has been proposed as an effective treatment for cervical insufficiency, but there has been controversy regarding the surgical options of cervical cerclage in singleton and twin pregnancies. This study aimed to compare the pregnancy outcomes between transvaginal cervical cerclage (TVC) and laparoscopic abdominal cervical cerclage (LAC) in patients with cervical insufficiency. We also aimed to evaluate the efficacy and safety, and provide more evidence to support the application of cervical cerclage in twin pregnancies.

Methods

A retrospective study was carried out from January 2015 to December 2021. The primary outcomes were the incidence of spontaneous preterm birth (sPTB) < 24 weeks, < 28, < 32, < 34 weeks, and < 37weeks, gestational age at delivery, and the incidence of admission for threatened abortion or preterm birth after cervical cerclage. The secondary outcomes included admission to the Neonatal Intensive Care Unit, adverse neonatal outcomes and neonatal death. We also analysed the pregnancy outcomes of twin pregnancies after cervical cerclage.

Results

A total of 289 patients were identified as eligible for inclusion. The LAC group (n = 56) had a very low incidence of sPTB ˂ 34 weeks, and it was associated with a significant decrease in sPTB < 28 weeks, ˂32 weeks, ˂34 and < 37 weeks, and admission to the hospital during pregnancy for threatened abortion or preterm birth after cervical cerclage (0 vs.27%; 1.8% vs. 40.3%; 7.1% vs. 46.8%; 14% vs. 63.5%, 8.9% vs. 62.2%, respectively; P < 0.001), and high in gestational age at delivery compared with the TVC group (n = 233) (38.3 weeks vs.34.4 weeks,P < 0.001). Neonatal outcomes in the LAC group were significantly better than those in the TVC group. The mean gestational age at delivery was 34.3 ± 1.8 weeks, with a total foetal survival rate of 100% without serious neonatal complications in twin pregnancies with LAC.

Conclusion

In patients with cervical insufficiency, LAC appears to have better pregnancy outcomes than TVC. For some patients, LAC is a recommended option and may be selected as the first choice. Even in twin pregnancies, cervical cerclage can improve pregnancy outcomes with a longer latency period, especially in the LAC group.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05108-w.

The comparative analysis of laparoscopic or transvaginal cerclage in pregnancies with cervical insufficiency: a retrospective cohort study

OBJECTIVE

To evaluate the efficacy and safety of prophylactic cervical cerclage by laparoscopy in pregnant women versus transvaginal way.

DESIGN

Retrospective, monocentric cohort study was performed.

SETTING

The First Affiliated Hospital of Sun Yat-sen University.

PATIENTS

Cases with cervical insufficiency (defined by previous history of painless second or early third trimester pregnancy loss/losses) were selected.

INTERVENTIONS

Laparoscopic or transvaginal cerclage were conducted. The maternal information and the neonatal data were collected and compared. The pregnancy outcomes including the incidence of full-term labor and gestational weeks at delivery were defined as the primary outcomes. Neonatal survival and birth weight, neonatal complications were evaluated as the secondary outcomes.

MEASUREMENTS AND MAIN RESULTS

Totally 36 twin pregnant cases and 82 singleton pregnant cases were managed with cerclage, either trans-laparoscopy (totally 78 cases) or transvaginal (totally 40 cases). Demographic characteristics showed no significant differences. Cases in laparoscopic group had a prolonged gestational age at delivery (36.43 ± 0.93 weeks and 33.60 ± 2.78 weeks, respectively, P < 0.001), a higher incidence of full-term labor (60.26% vs 42.50%, P = 0.05) with no significant difference of perinatal mortality (P = 0.661). Meanwhile, higher incidence of normal birth weight infants (88.46% vs 67.50%, P = 0.007) was shown in laparoscopic group with no more complications such as the cases of neonatal with Apgar < 7 (P = 0.296), and the incidence of NICU admission (P = 0.237). Besides, LTC showed good efficiency on VTC in the incidence of full-term labor: HR 0.24 (95% CI 0.070-0.85), P < 0.001. While LSC showed the similar efficiency on VSC: HR 0.734 (95% CI 0.36-1.49), P = 0.857, showing that cases with twin pregnancy may benefit more from laparoscopic cerclage.

CONCLUSIONS

The comparative effect between laparoscopic and transvaginal cerclage in pregnant women showed that laparoscopic cerclage may be a relatively effective and safety prophylactic way for cervical insufficiency. This would be an acceptable and safe replace for traditional transvaginal cervical cerclage.

Removal of laparoscopic cerclage stitches via laparotomy and rivanol-induced labour: A case report and literature review

BACKGROUND

Laparoscopic cervical cerclage is performed for patients with abnormal cervical anatomy and/or transvaginal cervical cerclage failure. However, the method of removing the stitches to allow labour induction remains controversial. According to published literature, stitches are removed through laparoscopic or transvaginal methods. Herein, we report, for the first time, a case of a patient who had undergone laparoscopic cerclage, and then underwent removal of stitches by laparotomy and labour induction in the third trimester of pregnancy.

CASE SUMMARY

A patient who underwent laparoscopic cervical cerclage due to cervical insufficiency became pregnant naturally following the operation. At 31 wk of pregnancy, severe foetal malformations were found. To successfully induce labour, cerclage stitches were removed via laparotomy, and rivanol was injected directly into the uterus. Following successful induction of labour, the patient delivered a dead foetus.

CONCLUSION

This report provides a reliable scheme of removing cerclage stitches for patients who have undergone laparoscopic cerclage but experience severe foetal malformations.

Is an abdominal cerclage indicated with a cervical myomectomy? A case report

INTRODUCTION

Cervical myomectomy can compromise cervical integrity and the risk of subsequent cervical incompetence is unclear. In this case report, the literature on cervical myomectomies is reviewed as well as that on the potential benefits of cervical cerclage.

CASE PRESENTATION

A 30-year-old woman, nulligravida, with a 12 cm cervical leiomyoma consulted for heavy menstrual bleeding and pelvic pain. After failure of multiple medical therapies, a laparoscopic cervical myomectomy was successfully performed after pre-operative uterine artery embolization using absorbable gelatin sponges to reduce surgical blood loss.

DISCUSSION

A concomitant laparoscopic cerclage was achieved in order to prevent cervical incompetence, given that the full thickness of the anterior cervix was penetrated during the myomectomy.

An update on uterine cervix pathologies related to infertility

Many papers and reviews have described the changes of the cervix during pregnancy, cervical cancer, sexually transmitted infections, and cervicovaginal microbiota. In this Views and Reviews, we focus on some specific topics in relation to the uterine cervix and infertility: early cervical cancer and fertility sparing surgery, cesarean scar defect, cervical incompetence, and cervical müllerian anomalies.

Laparoscopic Cervical Cerclage: Do Not Catch the Wrong Needle, or What to Do Next if It Happens!

STUDY OBJECTIVE

To present a technique to correct the misplacement of tape during laparoscopic cervical cerclage. Catching and introducing the wrong needle resulted in a knot formed around the right adnexa.

DESIGN

Step-by-step demonstration of the mistake and the technique to correct it.

SETTING

A patient para 0+V (V corresponds to 5) with cervical insufficiency was managed with laparoscopic interval cerclage [1-3]. The patient's 2 most recent pregnancies had been managed with emergency transvaginal cerclage, which failed to prolong her gestation beyond 24 weeks.

INTERVENTIONS

Before the cerclage procedure a 2.0 × 0.8-cm deep endometriotic nodule was excised. Both curved needles were straightened extracorporeally, and the tape was dropped inside the peritoneal cavity. The first needle was introduced successfully through the right side. After insertion of-what was believed to be-the same needle through the left side following the opposite direction, it was discovered that a tight knot had been formed around the right adnexa (Fig. 1). To avoid complete removal, the needleless tape was pulled back completely from the right side (Supplemental Fig. 1), and this end was stitched to a straight needle 2-0 polyglactin suture. The much thinner needle passed easily through the already created path, along with the tape (Supplemental Fig. 2), and the procedure was completed as planned (Supplemental Fig. 3).

CONCLUSION

When performing laparoscopic cervical cerclage with the tape and needles inside the abdomen, it is important to keep both under constant view. In the event of misplacement, no need to completely remove the tape. The tape's cut end can still be reintroduced successfully, stitched to a straight needle suture.

Anatomical and functional changes in arteries of uterine circulation after modified laparoscopic transabdominal cerclage in pregnancy: A case report and review of the literature

Modified laparoscopic transabdominal cerclage (LTAC) was developed as a safer approach for the treatment of cervical insufficiency in pregnancy, with the cerclage tape placed lateral to the uterine vessels. We describe and review the evolution of a woman who successfully underwent an LTAC at 12 weeks of gestation, whose fetus developed growth retardation after 32 weeks. Three-dimensional power Doppler reconstruction viewed both uterine arteries (UtAs) inside of the cerclage until the second trimester. Thereafter, the visualization of UtAs showed the development of a rich array of collateral vascularization, adaptation supported by the findings of low velocity and pulsatility of blood flow in the UtAs. The appearance of the UtAs varies throughout the gestation. There is a moderate variation of the shape and curvature that could result due to their elongation. Furthermore, the cervical length increased during gestation, from 20 to 30 mm. We speculate that this is a mechanical modeling during the late gestation. More studies are needed to understand the hemodynamic and mechanical effects as well as the impact on fetal growth and development of modified LTAC in women with a short cervix or cervical incompetence.