Professional Documents
Culture Documents
A B S T R A C T
Article history:
Received 10 July 2013
Received in revised form 14 February 2014
Accepted 23 May 2014
Objective: We introduce a modied surgical method for laparoscopic cervical cerclage (LCC) and compare
the operative data and obstetric outcomes to those obtained by traditional vaginal cerclage (TVC).
Study design: This is a prospective cohort study in a university-afliated hospital from August 2008
through February 2013. Nineteen patients treated by LCC were prospectively monitored and the
treatment outcomes were compared to a control group consisted of 25 patients that were retrospectively
studied and treated with TVC using traditional McDonald suture. Laparoscopic cervical cerclage was
performed with Mersilene tape and a modied surgical technique. Perioperative complications and
obstetric outcomes were compared between LCC and TVC treatment groups.
Results: No perioperative complications occurred during LCC treatment. Of the 19 LCC patients, 15 (78.9%)
became pregnant during the study period. The fetal salvage rate was 92.3% (12/13) and no adverse events
were encountered. The mean gestational age in LCC group was 36.4 weeks, and it was 17.4 weeks longer
than their previous pregnancy age, which was signicantly higher than obtained by TVC.
Conclusion: This modied technique for laparoscopic cervical cerclage demonstrates good obstetric
outcomes with low risk of adverse events, which may provide a reasonable alternative to achieve
pregnancy success in patients with cervical incompetence.
2014 Elsevier Ireland Ltd. All rights reserved.
Introduction
rC
po
da
aa
ut
or
iza
Keywords:
Cervical cerclage
Laparoscopy
Vaginal cerclage
Cervical incompetence
DR
A R T I C L E I N F O
Co
pi
http://dx.doi.org/10.1016/j.ejogrb.2014.05.032
0301-2115/ 2014 Elsevier Ireland Ltd. All rights reserved.
02/09/2014
126
L. Luo et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 179 (2014) 125129
Table 1
Patient demographics.
Demographic
LC groupa (n = 19)
VC groupb (n = 25)
31 (2735)
2.5 (15)
0
n = 11 (57.8%)
1 (02)
21 (1627)
n = 4 (21.1%)
n = 1 (5.3%)
32 (2841)
2 (03)
0.24 (02)
n = 3 (12%)
0.08 (01)
23 (1730)
n=0
n=0
Note: There were no signicant differences of demographics between the two groups.
a
LC group, laparoscopic group.
b
VC group, vaginal group.
c
T2, second trimester.
Surgical preparation
DR
rC
Technique description
Co
pi
aa
ut
or
iza
da
po
For LCC group, prophylactic laparoscopic cerclage was performed as an interval procedure before pregnancy. The cerclages
were all placed in the same fashion by one surgeon.
Fig. 1. Intraoperative photographs illustrating the modied laparoscopic cervical cerclage method. (A) Step 1: Create paravesical and vesicouterine spaces. (B and C) Step 2:
Identify the contours of the uterine vessels on both sides of the uterine isthmus. (DG) Step 3: Place the Mersilene tape around the cervicourerine junction using a direct
suture technique. (H) Step 4: Ensure that the tape had not passed through the cervical canal by hysteroscopy. (I) Step 5: Tie the tape posteriorly with an intracorporeal knot.
02/09/2014
L. Luo et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 179 (2014) 125129
Table 2
Perioperative data.
Variable (median, range)
LC group
(n = 19)
VC group (n = 25)
29 (2055)
26 (2050)
2 (23)
n=0
18 (1035)
10 (015)
2.5 (24)
n = 1 (4%)
DR
rC
Results
po
Co
pi
aa
ut
or
iza
da
bladder was retracted away from the lower uterine segment and
anterior cervix to create a vesicouterine space.
Step 2: identication of the contour of uterine vessels.
In step 2, the uterine vessels were identied. Incision of the
peritoneum was extended and the anterior leaf of the broad
ligament was opened. The contour of the uterine vessels were
identied on both sides of the uterine isthmus. Up to date
references, the standard step of cervico-isthmic cervical cerclage is
creation of broad ligament peritoneal window [6]. The posterior
peritoneum should be opened to create a window in the broad
ligament, which allows for caudal displacement of the ureters,
identication of the uterine vessels, and a space for a needle to be
passed through into the cervix. In our study, this step was
modied. Since we could clearly see the contours of the uterine
vessels, it was unnecessary to open a window in the broad
ligament.
Step 3: placement of suture material.
We used a 5-mm Mersilene tape with straight needle for direct
suture. To avoid uterine vessel and ureter damage, the straight
needle was carefully inserted into the exposed anterior surface of
the cervix on the right side at the level of the cervico-isthmic
junction and medially to the uterine vessels but not into the broad
ligament. The needle was passed through the muscular layer of
the cervix, with a small piece of cervical tissue remaining outside
the noose. The tape was passed in the anterior to posterior
direction, and the needle withdrawn from the posterior surface of
the cervix on the same side. In a similar fashion, the straight
needle was inserted in the anterior surface of the cervix on the left
side and passed in the anterior to posterior direction through the
muscular layer.
Step 4: hysteroscopy check and cerclage knot secured.
After placing the tape around the internal os, a hysteroscopy
check was conducted to ensure that the tape had not passed
through the cervical canal. The knot was rmly tied on the
posterior side to avoid potential bladder irritation. The tension of
the noose can be adjusted over a transcervical 6# Hegar dilator. The
visceral peritoneum was left unclosed.
At the conclusion of the procedure, the laparoscopic ports are
removed, the gas evacuated, and the abdominal wall and skin are
repaired in the usual fashion. A single dose of antibiotics was
administered perioperatively. All patients were encouraged to
127
Table 3
Main outcome of LC group patients.
Variable
LC group
Not pregnant
Still being pregnant
T1b loss
T2c loss
Preterm labor
Full-term labor
n = 4a
n=4
n=1
n=1
n=1
n=8
a
Three patients were not intent to be pregnant yet, one was with male-factor
infertility.
b
T1, rst trimester.
c
T2, second trimester.
02/09/2014
128
L. Luo et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 179 (2014) 125129
Table 4
Comparison of details of obstetric outcomes.
Variable
LC group (n = 10)
VC group (n = 25)
P value
n = 1 (10%)
n = 1 (10%)
n = 8 (80%)
38 (2039)
38.1 (n = 8)
n = 1 (10%)
n=0
n=0
16.5 (123)
n=9
90%
n = 2 (8%)
n = 7 (28%)
n = 16 (64%)
35 (27.637.7)
38 (n = 16)
n = 9 (36%)
n = 2 (8%)
n = 1(4%, retinopathy)
11 (2.629)
n = 22
88%
NS
NS
NS
0.005
NS
NS
NS
NS
0.039
NS
po
rC
DR
delivery age, while in TVC group, this number was 11 weeks, which
made a statistically differences between the two groups (p = 0.039).
Only one LCC patient experienced premature rupture of the
membrane (at 20 weeks) and the fetus was aborted vaginally after
removing the cerclage by mini-laparotomy. Other viable pregnancies in LCC group were delivered by caesarean section. The cervical
sutures were left in situ at the time of caesarean section. In TVC
group, the sutures were removed at 37 weeks of gestation or with
the onset of labor if earlier, and the patients were allowed to
deliver as appropriate.
Co
pi
aa
ut
or
iza
da
Discussion
Table 5
Cumulative results of cervico-isthmic cerclage placed by laparoscopy.
Cerclage by laparotomy:
study and year
Patient
no.
Patient no.
conceived
Pregnancy
no.
Intraoperative
complication rate (%)
Fetal survival
rate (%)
1
11
20
3
1
1
Duriung pregnancy
Before pregnancy
During pregnancy
Before pregnancy
Before pregnancy
During pregnancy
10
2
1
0
9
0
0
0
0
100
83
95
100
100
Not reported
Not reported
37.1
36.2
38
38.4
Not reported
1
3
11
65
1
12
10
26, n = 34
12
0
0
0
10.7
0
0
Not reported
100
80
100
75
Not reported
Not reported
35.8
37
Not reported
1
2
Before pregnancy
During pregnancy
Before pregnancy
34 not pregnant, 31 pregnant
Pregnant
5 during pregnancy and 7
before pregnancy
Before pregnancy
Before pregnancy
1
12
21
2
1
Not
reported
1
3
10
67
1
12
0
0
100
Not reported
38
Not reported
1
3
137
19
Before pregnancy
Before pregnancy
Before pregnancy
1
2
68
15
2
Not
reported
1
2
136
15
Not reported
0
6, n = 136
0
100
100
81.6, n = 130
92.9
28
37
36, n = 103
38.2
1
2
02/09/2014
L. Luo et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 179 (2014) 125129
rC
DR
po
Conict of interest
Co
pi
aa
ut
or
iza
da
straight needle into the anterior surface of the cervix on one side
with a small piece of cervical tissue remaining outside the noose to
decrease the possibility of damage to the uterine vessels and
ureters, excessive blood loss, and compression of the uterine
vessels. The surgical duration was relatively short and blood loss
was minimal, with a 0% perioperative complication rate up to now.
In our series, patients in the LCC group achieved satised results
in obstetric outcomes. The fetal survival rate in the LCC group was
as high as 92.3% with a mean gestational age of 36.4 weeks, and
weeks gained for the gestational age to previous pregnancies was
17.4 weeks. No long-term sequelae of prematurity happened.
These results are in accordance with past studies (Table 5)
demonstrating a total fetal survival rate after laparoscopic
abdominal cerclage of 81.6% (75100%, n = 130) and an average
gestational age at birth of 36 weeks (n = 103), which was reported
to be better than the TVC approach. However, limited to the small
case number, fetal salvage rate and mean gestational age in the
present study were similar between the two groups. Only weeks
gained for the gestational age to previous pregnancies showed
statistically superiority in LCC group.
To sum up, our results showed that this modied approach
maintained the strong point of TAC to placement of a cervicoisthmic cerclage at the level of the cervicoisthmic junction, while it
simplied the surgical steps to be much easier to master by most
gynecologist and it further reduced the operative morbidity to be
as minimal invasive as TVC. Based on our results, this modied LCC
method is safe and probably more effective, and its indications can
be extended to those of traditional transvaginal cerclage. Some
may argue that LCC have obvious disadvantages including the need
of another laparoscopic surgery or laparotomy to remove the tape
once second-trimester miscarriage or intrauterine fetal death
happens, and the delivery mode for full-term or premature
delivery can only be cesarean section. However, for the high risk
patients who have experienced painful recurrent fetal losses and
strongly demand for a baby to take home, it is worth the risk of
another laparoscopic surgery or mini-laparotomy for a probably
better obstetric result. Meanwhile, cesarean section seems to be
minor drawback for these patients given their complex and
difcult obstetric history.
Another controversial point is the optimal time for cerclage
surgery. Most studies reported that the timing of cerclage
placement did not inuence the gestational age at delivery,
although cerclage failure did occur more often when inserted
during pregnancy [5,9]. In our study, all patients underwent the
modied LCC surgery before pregnancy. We believe cerclage
insertion should be avoided during pregnancy for the following
reasons. First, the pelvic cavity and the uterus are more congested
during pregnancy and surgeries during pregnancy can lead to
excessive bleeding. Second, since the gravid uterus is enlarged, the
surgical visibility is relatively poor and transcervical uterine
manipulators cannot be used, so cerclage placement is a greater
challenge for surgeons. Third, postoperative rupture of membranes
and fetal loss are still possible following transabdominal cervical
cerclage; if conducted before pregnancy, such considerations can
129
References
[1] Marx PD. Transabdominal cervicoisthmic cerclage: a review. Obstet Gynecol
Surv 1989;44:51822.
[2] Shennan A, Jones B. The cervix and prematurity: aetiology, prediction and
prevention. Semin Fetal Neonatal Med 2004;9:4719.
[3] McDonald IA. Suture of the cervix for inevitable miscarriage. J Obstet Gynaecol
Br Emp 1957;64:34650.
[4] Benson RC, Durfee RB. Transabdominal cervico uterine cerclage during
pregnancy for the treatment of cervical incompetency. Obstet Gynaecol
1965;25:14555.
[5] Whittle WL, Singh SS, Allen L, et al. Laparoscopic cervicoisthmic cerclage:
surgical technique and obstetric outcomes. Am J Obstet Gynecol 2009;201
(364):e17.
[6] Gallot D, Savary D, Laurichesse H, Bournazeau JA, Amblard J, Lmery D.
Experience with three cases of laparoscopic transabdominal cervical cerclage
and two subsequent pregnancies. Br J Obstet Gynaecol 2003;110(7):696700.
[7] Carter JF, Soper DE, Goetzl LM, et al. Abdominal cerclage for the treatment of
recurrent cervical insufciency: laparoscopy or laparotomy? Am J Obstet
Gynecol 2009;201(111):e14.
[8] Carter JF, Soper DE. Laparoscopic abdominal cerclage. J Soc Laparoendosc Surg
2005;9(4):4913.
[9] Al-Fadhli R, Tulandi T. Laparoscopic abdominal cerclage. Obstet Gynecol Clin
North Am 2004;31(September (3)):497504.
[10] Umstad MP, Quinn MA, Ades A. Transabdominal cervical cerclage. Aust N Z J
Obstet Gynaecol 2010;50(October (5)):4604.
02/09/2014