Laparoscopic Cerclage as a Treatment Option for Cervical Insufficiency

Preconception laparoscopic cervical cerclage for prevention of mid-trimester pregnancy loss and preterm birth: A 6-year study

Objective

To evaluate surgical results and pregnancy outcomes of preconception laparoscopic cervical cerclage (LCC) in women with cervical insufficiency.

Study design

We conducted an observational study in consecutive women who had preconception LCC. Data was prospectively collected from 55 women at high risk of second trimester miscarriage and extreme preterm delivery due to cervical insufficiency who underwent pre-conception LCC between January 2017 - December 2021. This included patient demographics and relevant obstetric & gynaecological history, previous cervical cerclage, operative complications and subsequent pregnancy outcomes. All women included in study had at least one previous unsuccessful transvaginal cervical cerclage. The surgeries were conducted in private tertiary hospital in Hyderabad, India. The follow-up was until December 2022. The primary outcome was neonatal survival. Surgical morbidity and complications were also recorded.

Results

There were 49 pregnancies of which 46 progressed beyond first trimester. 4.34 % (2/46) were delivered between 28 and 33 weeks due to preterm premature rupture of membranes (PPROM). 13.04 % (6/46) including 5 women with pregnancy complications and one with unicornuate uterus needed delivery between 34 and 36 weeks. 82.60 % (38/46) women were delivered at or beyond 37 weeks of pregnancy. In those who carried pregnancy beyond first trimester, live-birth rate and neonatal survival rate were 100 %. All neonates had favourable outcome with no long-term morbidity. There were no intraoperative or immediate postoperative complications. Two women had long-term complication in the form of tape erosion needing further surgery.

Conclusions

This study provides evidence that LCC improves pregnancy outcomes significantly in those with cervical weakness, without increasing the safety risk.

Efficacy of laparoscopic and trans-abdominal cerclage (TAC) in patients with cervical insufficiency: A systematic review and meta-analysis

BACKGROUND

Cervical insufficiency (CI) may result in preterm delivery. We sought out to perform this review and analysis to compare the efficacy of laparoscopic and open transabdominal cerclage (TAC) in patients suffering with CI.

METHODS

Our search included PubMed, Scopus, MEDLINE, ClinicalTrials.Gov, Cochrane and Web of Science. We analyzed the data with Open Meta-Analyst Software as well as Review Manager Software. We included observational and randomized controlled trials that included patients with CI that underwent laparoscopic cerclage or TAC.

RESULTS

We included a total of 43 studies. Laparoscopic and TAC had a positive effect by increasing gestational age (GA); for the laparoscopic group (mean deviation (MD)) = 14.86 weeks (W), 95% CI [10.67, 19.05], P < 0.001) and TAC (MD = 12.79 W, 95% CI [10.97, 14.61], P < 0.001). Furthermore, improvements in all outcomes assessed (total fetal survival rate, neonatal weight, and prevention of delivery at a gestational age of<24 weeks) were all significant with the exception of the prevention of all preterm deliveries<37 weeks; for both laparoscopic at (RR = 0.116, 95% CI [-0.006, 0.238], P = 0.063) and TAC at (MD = 1, 95% CI [0.45, 2.24], P = 1), and for prevention of deliveries<34 weeks for the laparoscopic group (RR = 0.446, 95% CI [-0.323, 1.215], P = 0.256) only.

CONCLUSIONS

Although limited data prevented pregnancy and prepregnancy subgroups as well as a head-to-head comparison, we still found that in patients suffering from CI, both TAC and laparoscopic approaches to cerclage revealed a positive effect in preserving the pregnancy.

Complications of Laparoscopic and Transabdominal Cerclage in Patients with Cervical Insufficiency: A Systematic Review and Meta-analysis

OBJECTIVE

Cervical insufficiency is a defect of the cervix that leads to failure to preserve a full-term intrauterine pregnancy. Laparoscopic cerclage and open transabdominal cerclage (TAC) are effective ways to manage patients with cervical insufficiency. We performed this systematic review and meta-analysis to investigate the complications of laparoscopic cerclage and open TAC in the management of cervical insufficiency.

DATA SOURCES

We searched PubMed, Cochrane, Scopus, and Web of Science using our search strategy and screened the results for our criteria. We extracted the results reported and analyzed them using Open Meta-Analyst (OpenMeta[Analyst], Brown School of Public Health, Providence, RI) and Review Manager (Cochrane Collaboration, London, United Kingdom) software.

METHODS OF STUDY SELECTION

We included all randomized controlled and observational trials performed on patients with cervical insufficiency undergoing open TAC or laparoscopic cerclage that matched our search strategy. We excluded letters to the editor, reviews, meetings/conference abstracts, non-English or nonhuman studies, and instances where the full text was not available.

TABULATION, INTEGRATION, AND RESULTS

We included a total of 33 trials. Both interventions of laparoscopic cerclage and open TAC were associated with significantly less total fetal loss (laparoscopic cerclage, relative risk [RR] 0.03; 95% confidence interval [CI], 0.01-0.08; p <.001, and open TAC, RR 0.19; 95% CI, 0.07-0.51; p <.009). The overall blood loss in open TAC was 110.589 mL (95% CI, 93.737-127.44; p <.001), and in laparoscopic cerclage, it was 24.549 mL (95% CI, 9.892-39.205; p = .001). In addition, open TAC had a positive effect regarding incidence of hemorrhage >400 mL (RR 0.077; 95% CI, 0.033-0.122; p <.001). Preterm premature rupture of membranes was significant in the open TAC (RR 0.037; 95% CI, 0.019-0.055; p <.001) and laparoscopic cerclage groups (RR 0.031; 95% CI, 0.009-0.053; p = .006).

CONCLUSION

Laparoscopic cerclage may be safer than open TAC in the management of cervical insufficiency because we found a statistically significant lower incidence of fetal loss, blood loss, and rate of hemorrhage in the laparoscopic cerclage group. Clinically, this evidence may help support favoring a laparoscopic approach over an open one in appropriate patients, although it is unclear whether this benefit is limited to cerclages placed either before pregnancy or placed in the first-trimester or both.

Laparoscopic Cervical Encerclage in Pregnancy in 6 Steps

STUDY OBJECTIVE

Cervical insufficiency occurs in 0.1% to 1 % of all pregnancies and is associated with a high risk of second-trimester abortion and/or preterm delivery [1]. Laparoscopic encerclage is highly recommended for a previous failed vaginal encerclage and is superior to the laparotomy approach in terms of low morbidity and faster recovery [2]. Laparoscopic encerclage in pregnancy is more challenging than that in the nonpregnant state. This is because of the enlarged uterine size, engorged uterine vessels, and infeasibility of using a uterine manipulator. The standardization and description of the technique are the main objectives of this video (Video 1). We have described the surgery in 6 steps that could make this procedure easier and safer.

DESIGN

A step-by-step video demonstration of the technique.

SETTING

Paul's Hospital, Centre for Advanced Endoscopy & Infertility Treatment, Kochi, India. A 29-year-old pregnant woman, gravida 3 abortions 2, at 13 weeks period of gestation, with a history of 2 second-trimester abortions owing to cervical insufficiency. The patient had a failed vaginal cervical encerclage at 18 weeks in the second pregnancy.

INTERVENTIONS

This is a step-wise laparoscopic approach for successful cervical encerclage in pregnancy. In this video, we demonstrate our technique for laparoscopic cervical encerclage in a pregnant woman's uterus in 6 steps using a Mersilene tape (Ethicon US, LLC, Somerville, NJ) as follows: (1) Opening the uterovesical fold and dissecting the bladder, (2) opening the left broad ligament and creating a window, (3) opening the right broad ligament and creating a window, (4) placing the Mersilene tape on the left side medial to the uterine vessels at the cervicoisthmic junction, (5) placing the Mersilene tape on the right side medial to the uterine vessels at the cervicoisthmic junction, (6) tying the Mersilene tape anteriorly.

CONCLUSION

The standardization of laparoscopic cervical encerclage in pregnancy using the above 6 steps could make this procedure easier and safer to perform. Moreover, the standardization of the surgical technique could shorten the learning curve.

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.

Cervical cerclage in twin pregnancy

Cervical cerclage in women with twin pregnancy is not routinely indicated but appears to be beneficial in subjects with a history of preterm birth or very short cervix or dilated cervix. There is a paucity of literature data regarding transabdominal or laparoscopic cervical cerclage (LCC) in twin pregnancy. It is uncertain whether LCC is more effective than transvaginal cerclage. Our own experience of 24 cases of LCC in twin pregnancy showed encouraging results. Further, well-planned studies are required to answer whether, when, and how cervical cerclage should be performed in women with twin pregnancy.

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.