Department of Obstetrics-Gynecology, University of Rochester, 601 Elmwood Avenue, Box 668, Rochester, NY 14642, USA
1 To whom correspondence should be addressed. e-mail: William_Phipps{at}URMC.Rochester.edu
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Abstract |
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Key words: cerclage/cervical incompetence/operative laparoscopy/surgical techniques
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Introduction |
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In 1998, we described in a case report for the first time the successful use of an interval laparoscopic technique for transabdominal cerclage placement, so as to avoid the need to resort to a laparotomy during the pregnant or non-pregnant state (Scibetta et al., 1998). Here we update that initial report by summarizing our results for the first 11 patients who underwent laparoscopic transabdominal cerclage placement at the Strong Memorial Hospital, an academic teaching hospital, between December 1995 and August 2002.
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Case reports |
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Brief description of surgical technique
Under general anaesthesia, the patient is placed in the dorsal lithotomy position, and a Foley catheter inserted. The vaginal wall/cervix is grasped with a tenaculum anterior to the cervical opening, and an 8 mm dilator placed into the cervix and then secured to the tenaculum. A laparoscopy involving four puncture sites is then carried out, using an umbilical incision for the laparoscope trocar. Findings such as endometriosis or adhesions are treated according to individual circumstances.
The peritoneum of the uterovesical reflection is incised transversely with laparoscopic scissors, and the bladder advanced downward. A 5 mm Mersilene polyester fibre ligature, 30 cm in length (RS-21, Ethicon, Inc., Somerville, NJ, USA), is prepared by first removing the swagged needles from the ends, which are each then tagged with a loop of suture material. The ligature is then passed into the pelvis and positioned behind the uterus. A disposable Endo Close suturing device (Auto Suture Company, Norwalk, CT, USA) is then passed into the abdominal cavity, its tip directed toward the lateral aspect of the uterovesical reflection incision on the left. The tip is guided along the isthmus, medial to the left-sided uterine vessels and through the tissue of the cardinal ligament, so as to pierce the posterior leaf of the broad ligament just above the insertion of the uterosacral ligament. The loop at one end of the Mersilene ligature is grasped with the tip of the device, and the device is pulled back anteriorly, bringing with it the ligature. This sequence of events is then repeated on the right side, so as to bring the other end of the Mersilene ligature anteriorly along the isthmus on the right.
After verifying that the ligature is lying flat and snugly against the isthmus posteriorly (Figure 1), the ends of the ligature are tied together anteriorly and excess ligature material is trimmed (Figure 2). The knot is then secured further by tacking each free end to the underlying band, and the peritoneum is sutured over the knot. The pelvis is lavaged with normal saline solution, haemostasis confirmed, and the laparoscopy terminated in the usual manner.
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Results |
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In case 10, the procedure was complicated by an initially unrecognized penetrating small bowel injury that occurred during lysis of extensive adhesions that involved the bowel and uterus and nearly precluded placing the cerclage. Subsequently, the patient developed a pelvic abscess that was treated with computed tomography (CT)-guided drainage and i.v. antibiotics. This patient had previously had a vaginal delivery at 25 weeks gestation and then a classical Caesarean section at 27 weeks (following premature rupture of membranes) despite transvaginal cerclages. These pregnancies were followed by a hospital admission for pelvic inflammatory disease, and then her last pregnancy, which had resulted in a loss at 20 weeks despite another vaginal cerclage. There were no other surgical complications. Mean estimated blood loss for the 11 cases was <40 ml, with a range of 10100 ml. Mean surgical time (from incision to incision closure) was 68 min, including two cases that included significant concomitant lysis of adhesions (cases 1 and 10, which had surgical times of 85 and 89 min, respectively). The last three cases other than case 10 all had surgical times of <60 min.
Ten of the 11 patients were able to achieve a total of 12 intrauterine pregnancies following cerclage placement, one of which followed embryo transfer of cryopreserved donor oocyte-derived embryos as previously described (Scibetta et al., 1998). The only patient not conceiving had, before the surgery, expressed a desire to conceive in the near future, but subsequently changed her mind about this (case 9).
Of the 12 pregnancies, two resulted in losses at 8 weeks gestation, including one in which a suction dilatation and curettage (D&C) was performed for a missed abortion. Of the remaining 10 pregnancies, one resulted in delivery by Caesarean section at 34.5 weeks of gestation because of concern raised by a fetal heart rate tracing demonstrating recurrent deep variable decelerations, and another resulted in a Caesarean section at 34.5 weeks because of severe pre-eclampsia. The other eight all resulted in deliveries by elective Casarean section at 38 weeks or more. All of the infants born were healthy. None of the cerclages have been removed.
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Discussion |
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Our outcomes and those of von Theobald (2002) also compare favourably with those following a newly described transvaginal approach, more elaborate than the more commonly used Shirodkar or McDonald techniques, that results in a cerclage stated to have characteristics essentially identical to those using a transabdominal approach (Golfier et al., 2001
). Golfier et al. used this approach in 20 women, primarily as an interval procedure, and reported results for 23 pregnancies in 15 women whose pregnancy extended beyond 16 weeks. Of these 23 pregnancies, there were three losses before 24 weeks, three deliveries of live infants before 34 weeks, and 17 deliveries of live infants after 34 weeks. A possible advantage of the approach used by Golfier et al. compared with ours is that theirs would presumably be more amenable to being done under spinal or epidural anaesthesia, although in fact general anaesthesia was used in all of their cases.
It is of note that both our series and that of Golfier et al. (2001) included patients who had no history of either a mid-trimester loss or a premature delivery. Specifically, this was the case for five of our patients (cases 2, 3, 5, 7 and 9), all of whom had cervical anatomy that would have made the placement of a conventional transvaginal cerclage impossible. Similarly, eight of the 20 patients described by Golfier et al. (2001
) underwent surgery on a prophylactic basis, mostly because of an absent exocervix following surgery for cervical cancer. It is quite possible that, especially such patients without prior losses, would have had good obstetrical outcomes without any cerclage, but our five such patients elected to proceed with the surgery because of the perceived risks associated with their anatomy per se.
An obvious disadvantage of our approach, also the case for any interval cerclage procedure, is that a pregnancy progressing past the first trimester may never subsequently occur. This disadvantage could be circumvented by placing the cerclage laparoscopically only after the presence of an ongoing pregnancy is confirmed, but we have been reluctant to do so because of concern about haemorrhage-related complications. As discussed in our earlier report, we continue to believe that the firm nature of the non-pregnant cervical isthmus facilitates the ability of the surgeon to avoid injuring the uterine vessels. In this regard, we are aware of only one published case report of laparoscopic placement of a transabdominal cerclage during pregnancy (Lesser et al., 1998). Although the outcome of that case was ultimately favourable, during surgery there was bleeding from the uterine vessels on one side that required the use of haemostatic clips and packing, and operating time was prolonged. Along these same lines, the possibility of excessive bleeding has long been recognized to be problematic when a transabdominal cerclage is placed by laparotomy during pregnancy (Cammarano et al., 1995
; Zaveri et al., 2002
), and a decreased risk of bleeding was cited specifically as an advantage for placement in the non-pregnant state in a case series reported in 1997 that involved abdominal cerclages placed by laparotomy in both non-pregnant and pregnant women (Craig and Fliegner, 1997
).
Assuming the laparoscopic approach we describe is only used for non-pregnant women, the desire to avoid surgery with no benefit warrants restricting the procedure to women reasonably likely to achieve a viable pregnancy. This of course is the case for any intervention, including tubal surgery and conventional IVF, the ultimate purpose of which is to produce a pregnancy. Additionally, as emphasized by Novy (1991) and Cammarano et al. (1995
) for the transabdominal approach in general, it is important to limit the procedure to those cases in which a conventional transvaginal approach is not reasonably likely to be successful. In many cases, depending on individual circumstances, patients with a history of a single or even two failed transvaginal cerclage procedures may still be managed successfully with a repeat transvaginal procedure. Nonetheless, the presence of seemingly adequate cervical anatomy for a repeat transvaginal procedure is only one factor to be considered when a transabdominal approach is also being contemplated. This point of view is supported by a recent study (Davis et al., 2000
), which retrospectively assessed pregnancy outcomes of patients with prior failed transvaginal cerclages for whom a transvaginal approach was feasible based on cervical anatomy, and specifically compared repeat transvaginal procedures with the conventional transabdominal approach. In that study, the transabdominal group, despite greater numbers of prior failed transvaginal procedures and prior mid-trimester losses, had significantly better outcomes than the repeat transvaginal group.
If an early loss occurs once the cerclage has been placed, the use of a dilator as described allows for the ability of a suction D&C to be performed, as occurred in case 1. In the event of a later loss that requires removal of the cerclage, so as to allow for uterine evacuation from below, consideration should be given to attempting the removal laparoscopically, as described in two case reports (Lesser et al., 1998; Scarantino et al., 2000
) in which a cerclage had been placed by laparotomy during pregnancy.
Overall, our results suggest that a laparoscopic approach prior to pregnancy should be considered as an alternative to laparotomy during pregnancy for patients for whom a transabdominal cerclage is deemed necessary. The technique we describe could be used by any surgeon or surgical team possessing both good laparoscopic surgical skills and experience with transabdominal cerclage placement by laparotomy. Clearly it would be ideal if a randomized study directly comparing our approach with that of Golfier et al. (2001) or others was performed in a properly selected population, similar to the recent study of Althuisius et al. (2000
, 2001), who compared management strategies in cases at lower risk for adverse obstetric outcomes from cervical incompetence. Unfortunately, execution of such a study might be problematic as a practical matter, given the relatively small numbers of women for whom a conventional transvaginal procedure is likely to be inadequate. In any event, hopefully larger series and/or comparative studies confirming our results will be published over the next several years.
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References |
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Submitted on February 5, 2003; accepted on May 9, 2003.