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Laparoscopic transabdominal cervicoisthmic cerclage
FERTILITY AND STERILITY@ VOL. 69, NO. 1, JANUARY 1998 Copyright 01998 American Society for Reproductive Medicine Published by Elsevier Science Inc. Printed on acid-free paper in U.S.A.
Laparoscopic cervicoisthmic
transabdominal cerclage
Joseph J. Scibetta, M.D., Stephan R. Sanko, M.D., and William R. Phipps, M.D. Department
of Obstetrics
and Gynecology,
University of Rochester,
Rochester,
New York
Objective: To report a laparoscopic technique for placement of a transabdominal cervicoisthmic cerclage. Design: Detailed case report of one of three patients undergoing described procedure. Setting: University hospital. Patient: A 39-year-old infertile patient with a history of cervical adenocarcinoma in situ and two cone biopsies, resulting in an essentially absent exocervix. Intervention(s): Laparoscopic transabdominal cervicoisthmic cerclage placement, as an interval procedure, followed by ET of cryopreserved donor oocyte-derived embryos. Main Outcome Measure(s): Clinical outcome. Result(s): Establishment of a pregnancy delivered at 38% weeks of gestation by elective cesarean section. Conclusion(s): Patients believed to require a transabdominal cerclage may undergo a laparoscopic interval procedure, obviating the need for a laparotomy before or during pregnancy. (Fertil Steril@ 1998;69:161-3. 01998 by American Society for Reproductive Medicine.) Key Words: Cerclage, cervical incompetence, operative laparoscopy
Received April 18, 1997; revised and accepted September 2, 1997. Reprint requests: William R. Phipps, M.D., Department of Obstetrics and Gynecology, University of Rochester, 601 Elmwood Avenue, Box 668, Rochester, New York 14642 (FAX: 716-273-4187; e-mail: bphipps@obgyn. rochester.edu). 001%0282/98/$19.00 PII SO01 5-0282(97)00444-5
A small subset of patients with cervical incompetence cannot be adequately managed with a transvaginal cerclage operation because of extremely short, deformed, and/or scarred cervices. Many such patients, however, may be candidates for placement of a transabdominal cervicoisthmic cerclage (1). Overall, pregnancy outcomes have been highly favorable after placement of such a cerclage via laparotomy, performed either dining pregnancy or preconceptionally as an interval procedure (l-3). We describe in this report, for the first time, a laparoscopic technique for placement of a transabdominal cervicoistbmic cerclage as an interval procedure. To date, we have used the technique described in three patients, each of whom had an abnormally short and deformed cervix unsuitable for transvaginal cerclage placement. The patient described in this case report was the first to achieve a pregnancy beyond 8 weeks. Another patient conceived after surgery but underwent a suction dilation and curettage
completion procedure at 8 weeks of gestation because of a missed abortion.
CASE REPORT A generally healthy 39-year-old woman (gravida 3, para 0) presented with a history of infertility and several prior surgical procedures, including a cervical cone biopsy performed 4 years earlier for severe squamous dysplasia. Her first two pregnancies had been electively terminated many years earlier. Two conventional IVF-ET cycles had been aborted because of a poor follicular response to gonadotropins. She had then conceived after ET during a donor oocyte IVF-ET cycle but had a first trimester spontaneous pregnancy loss. The procedure described in this report was performed 4 months after a second cone biopsy performed for cervical adenocarcinoma in situ with pathologically negative endocervical margins, in anticipation of another ET using cryopreserved embryos obtained at the time of the
161
donor oocyte IVF-ET cycle. Before the procedure, cervical examination revealed a markedly short, distorted exocervix, with the cervical opening nearly flush with the vaginal apex. The uterus sounded to a depth of 6% cm. These anatomic findings precluded placement of a transvaginal cerclage, either as an interval procedure or during a subsequent pregnancy. Accordingly, the patient and her husband were counseled about transabdominal cerclage options, and a decision was made to proceed with laparoscopic placement as an interval procedure as described below. Research Subject Review Board approval to proceed in this fashion was not necessary according to institutional guidelines. At the time of the procedure, the patient’s internal pelvic anatomy was normal except for minimal endometriosis involving the bladder flap area. Ten weeks later, she underwent ET of three cryopreserved-thawed embryos. She conceived, and an ultrasonogram at ‘7 weeks of gestation demonstrated a normal ongoing singleton pregnancy. The pregnancy progressed uneventfully. An uncomplicated elective cesarean section was conducted at 38% weeks, with the delivery of a healthy 3,840-g male infant. At the time of the cesarean section, the Mersilene band used for the cerclage was visible posteriorly and was palpable circumferentially in the lower uterine segment through the hysterotomy incision, forming a ring approximately 1% cm in diameter.
Description of Technique Under general anesthesia, the patient is placed in the dorsal lithotomy position, followed by insertion of a Foley catheter. The vaginal wall or cervix is grasped with a tenaculum anterior to the cervical opening, and an g-mm dilator is placed into the cervix. The dilator is then secured to the tenaculum with umbilical tape. Subsequent identification of the tenaculum attachment site by moving the tenaculum is often beneficial, as is uterine manipulation using the dilator. A laparoscopy is then performed with the use of an umbilical incision for the laparoscope trocar, with initially two secondary trocars placed through both lower quadrants laterally. The peritoneum of the uterovesical reflection is incised transversely with laparoscopic scissors, and the incision is extended to expose the lateral aspect of the isthmus on each side. The bladder is advanced downward as necessary. A 5-mm Mersilene polyester fiber ligature, 30 cm in length (RS-21; Ethicon, Inc., Somerville, NJ), is then prepared by first removing the swaged needles from each end. Each end is then tagged with a loop of suture material, such as 0 silk. The ligature is then passed into the pelvis through one of the secondary trocar sheaths and positioned behind the uterus. A 5-mm suprapubic midline incision is then made, through which a disposable Endo Close suturing device 162
Scibetta et al.
Techniques and instrumentation
The Endo Close device (thin arrow) has pierced the posterior leaf of the broad ligament on the right side, and the remaining free end of the Mersilene ligature has been grasped by its loop. The thick arrow shows the left-sided ligature tunnel site, through which the ligature has already been passed, just above the left uterosacral ligament.
(Auto Suture Company, Norwalk, CT) is passed into the abdominal cavity. When its plunger is not depressed, this device presents a cutting edge at its tip when tissue resistance is met. The tip is directed toward the lateral aspect of the uterovesical reflection incision on the left. With the plunger of the device depressed, to maintain a blunt presenting tip, the device is guided along the isthmus, medial to the leftsided uterine vessels, and through the tissue of the cardinal ligament, 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. The loop is then released from the device. This sequence of events is then repeated on the right side, to bring the other end of the Mersilene ligature anteriorly along the isthmus on the right (Fig. 1). At this point, the Endo Close device is removed, and a 5-mm trocar-sheath combination is placed through the same suprapubic midline incision site. After making certain that the ligature is lying flat and snugly against the isthmus (Fig. 2), a single knot is tied down anteriorly with an instrument tie technique. A suitable grasper is then placed through the suprapubic midline incision site, to stabilize the first knot, and two additional knots are placed, again with an instrument tie technique. Any remaining excess ligature material is trimmed, and the knot is secured further by tacking each free end of the ligature to the underlying band immediately adjacent to the knot with 2-O silk (Fig. 3). The peritoneum is then sutured over the knot. The pelvis is lavaged with normal saline solution, hemoVol. 69, No. 1, January 1998
The ligature is lying flat and snugly against the isthmus posterioriy,above the insertions of the uterosacral ligament bilaterally. The instrument points to the left-sided ligature tunnel site.
over 20 cases performed via laparotomy, primarily during pegnancy, with a tonsil clamp having been used in lieu of the Endo Close device for the creation of the tunnel along the isthmus. We are not aware of any reusable instrument that might be used in lieu of the Endo Close device. We believe our technique could be used by any surgeon or surgical team with a combination of good operative laparoscopic skills and experience placing a transabdominal cervicoisthmic cerclage via laparotomy. The laparoscopic approach has the obvious advantage of obviating the need for a laparotomy. As is the case for other pelvic surgeries (4), such a laparotomy performed as an interval procedure is probably more likely to result in pelvic adhesions than is our procedure, making achievement of a pregnancy more difficult. The other option, deferring the procedure until after an apparently viable pregnancy has been achieved, has the distinct disadvantage of requiring a laparotomy during pregnancy.
stasis is confirmed, and the laparoscopy is terminated in the usual manner.
DISCUSSION The technique described in this report is essentially identical to that previously used by the senior surgeon (JJS) in
The knot has been tied down anteriorly, and the free end of the ligature has been secured to the band adjacent to the knot on each side. The tenaculum attached to the vaginal wall or cervix has been elevated, and an instrument is shown pointing to the attachment site of the tenaculum.
To date, we have restricted the laparoscopic approach to cases performed as an interval procedure, with no complications of any kind, and minimal blood loss. The firm nature of the nonpregnant cervical isthmus makes it relatively easy to guide the Endo Close device along its lateral margin to avoid the uterine vessels and ureter. On the other hand, because of cervical softening, the same laparoscopic appreach during pregnancy might be associated with a higher risk of bleeding, because of a diminished ability to distinguish between the isthmus and adjacent vessels by tactile feedback. An obvious disadvantage of our procedure, or any interval procedure, is that pregnancy may either never occur or result in an early loss, presumably unrelated to cervical incompetence. Use of the dilator as described helps prevent postoperative cervical stenosis, allowing for a dilation and curettage procedure to be performed if such an early loss does occur, as was the case for one of our patients. Nonetheless, it is important to restrict the procedure described not only to women with valid indications for a transabdominal cervicoisthmic cerclage, as is the case when the procedure is performed via laparotomy during pregnancy (l-3) but also to women who are reasonably likely to achieve a viable pregnancy, to avoid unnecessary surgery altogether. References 1. Novy MJ. Transabdominal cervicoisthmic cerclage: a reappraisal 25 years after its introduction. Am J Obstet Gynecol 1991;164:1635-41. 2. Cammarano CL, Herron MA, Parer JT. Validity of indications for transabdominal cervicoisthmic cerclage for cervical incompetence. Am J Obstet Gynecol 1995;172:1871-5. 3. Gibb DM, Salaria DA. Transabdominal cervicoisthmic cerclage in the management of recurrent second trimester miscarriage and preterm delivery. Br J Obstet Gynaecol 1995;102:802-6. 4. Luciano AA. Management of adhesions via laparoscopy. In: Soderstrom RM, editor. Operative laparoscopy: the masters’ techniques. New York: Raven Press. 1993:121-6.
FERTILITY
& STERILITY@
163
Laparoscopic cervicoisthmic
transabdominal cerclage
Joseph J. Scibetta, M.D., Stephan R. Sanko, M.D., and William R. Phipps, M.D. Department
of Obstetrics
and Gynecology,
University of Rochester,
Rochester,
New York
Objective: To report a laparoscopic technique for placement of a transabdominal cervicoisthmic cerclage. Design: Detailed case report of one of three patients undergoing described procedure. Setting: University hospital. Patient: A 39-year-old infertile patient with a history of cervical adenocarcinoma in situ and two cone biopsies, resulting in an essentially absent exocervix. Intervention(s): Laparoscopic transabdominal cervicoisthmic cerclage placement, as an interval procedure, followed by ET of cryopreserved donor oocyte-derived embryos. Main Outcome Measure(s): Clinical outcome. Result(s): Establishment of a pregnancy delivered at 38% weeks of gestation by elective cesarean section. Conclusion(s): Patients believed to require a transabdominal cerclage may undergo a laparoscopic interval procedure, obviating the need for a laparotomy before or during pregnancy. (Fertil Steril@ 1998;69:161-3. 01998 by American Society for Reproductive Medicine.) Key Words: Cerclage, cervical incompetence, operative laparoscopy
Received April 18, 1997; revised and accepted September 2, 1997. Reprint requests: William R. Phipps, M.D., Department of Obstetrics and Gynecology, University of Rochester, 601 Elmwood Avenue, Box 668, Rochester, New York 14642 (FAX: 716-273-4187; e-mail: bphipps@obgyn. rochester.edu). 001%0282/98/$19.00 PII SO01 5-0282(97)00444-5
A small subset of patients with cervical incompetence cannot be adequately managed with a transvaginal cerclage operation because of extremely short, deformed, and/or scarred cervices. Many such patients, however, may be candidates for placement of a transabdominal cervicoisthmic cerclage (1). Overall, pregnancy outcomes have been highly favorable after placement of such a cerclage via laparotomy, performed either dining pregnancy or preconceptionally as an interval procedure (l-3). We describe in this report, for the first time, a laparoscopic technique for placement of a transabdominal cervicoistbmic cerclage as an interval procedure. To date, we have used the technique described in three patients, each of whom had an abnormally short and deformed cervix unsuitable for transvaginal cerclage placement. The patient described in this case report was the first to achieve a pregnancy beyond 8 weeks. Another patient conceived after surgery but underwent a suction dilation and curettage
completion procedure at 8 weeks of gestation because of a missed abortion.
CASE REPORT A generally healthy 39-year-old woman (gravida 3, para 0) presented with a history of infertility and several prior surgical procedures, including a cervical cone biopsy performed 4 years earlier for severe squamous dysplasia. Her first two pregnancies had been electively terminated many years earlier. Two conventional IVF-ET cycles had been aborted because of a poor follicular response to gonadotropins. She had then conceived after ET during a donor oocyte IVF-ET cycle but had a first trimester spontaneous pregnancy loss. The procedure described in this report was performed 4 months after a second cone biopsy performed for cervical adenocarcinoma in situ with pathologically negative endocervical margins, in anticipation of another ET using cryopreserved embryos obtained at the time of the
161
donor oocyte IVF-ET cycle. Before the procedure, cervical examination revealed a markedly short, distorted exocervix, with the cervical opening nearly flush with the vaginal apex. The uterus sounded to a depth of 6% cm. These anatomic findings precluded placement of a transvaginal cerclage, either as an interval procedure or during a subsequent pregnancy. Accordingly, the patient and her husband were counseled about transabdominal cerclage options, and a decision was made to proceed with laparoscopic placement as an interval procedure as described below. Research Subject Review Board approval to proceed in this fashion was not necessary according to institutional guidelines. At the time of the procedure, the patient’s internal pelvic anatomy was normal except for minimal endometriosis involving the bladder flap area. Ten weeks later, she underwent ET of three cryopreserved-thawed embryos. She conceived, and an ultrasonogram at ‘7 weeks of gestation demonstrated a normal ongoing singleton pregnancy. The pregnancy progressed uneventfully. An uncomplicated elective cesarean section was conducted at 38% weeks, with the delivery of a healthy 3,840-g male infant. At the time of the cesarean section, the Mersilene band used for the cerclage was visible posteriorly and was palpable circumferentially in the lower uterine segment through the hysterotomy incision, forming a ring approximately 1% cm in diameter.
Description of Technique Under general anesthesia, the patient is placed in the dorsal lithotomy position, followed by insertion of a Foley catheter. The vaginal wall or cervix is grasped with a tenaculum anterior to the cervical opening, and an g-mm dilator is placed into the cervix. The dilator is then secured to the tenaculum with umbilical tape. Subsequent identification of the tenaculum attachment site by moving the tenaculum is often beneficial, as is uterine manipulation using the dilator. A laparoscopy is then performed with the use of an umbilical incision for the laparoscope trocar, with initially two secondary trocars placed through both lower quadrants laterally. The peritoneum of the uterovesical reflection is incised transversely with laparoscopic scissors, and the incision is extended to expose the lateral aspect of the isthmus on each side. The bladder is advanced downward as necessary. A 5-mm Mersilene polyester fiber ligature, 30 cm in length (RS-21; Ethicon, Inc., Somerville, NJ), is then prepared by first removing the swaged needles from each end. Each end is then tagged with a loop of suture material, such as 0 silk. The ligature is then passed into the pelvis through one of the secondary trocar sheaths and positioned behind the uterus. A 5-mm suprapubic midline incision is then made, through which a disposable Endo Close suturing device 162
Scibetta et al.
Techniques and instrumentation
The Endo Close device (thin arrow) has pierced the posterior leaf of the broad ligament on the right side, and the remaining free end of the Mersilene ligature has been grasped by its loop. The thick arrow shows the left-sided ligature tunnel site, through which the ligature has already been passed, just above the left uterosacral ligament.
(Auto Suture Company, Norwalk, CT) is passed into the abdominal cavity. When its plunger is not depressed, this device presents a cutting edge at its tip when tissue resistance is met. The tip is directed toward the lateral aspect of the uterovesical reflection incision on the left. With the plunger of the device depressed, to maintain a blunt presenting tip, the device is guided along the isthmus, medial to the leftsided uterine vessels, and through the tissue of the cardinal ligament, 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. The loop is then released from the device. This sequence of events is then repeated on the right side, to bring the other end of the Mersilene ligature anteriorly along the isthmus on the right (Fig. 1). At this point, the Endo Close device is removed, and a 5-mm trocar-sheath combination is placed through the same suprapubic midline incision site. After making certain that the ligature is lying flat and snugly against the isthmus (Fig. 2), a single knot is tied down anteriorly with an instrument tie technique. A suitable grasper is then placed through the suprapubic midline incision site, to stabilize the first knot, and two additional knots are placed, again with an instrument tie technique. Any remaining excess ligature material is trimmed, and the knot is secured further by tacking each free end of the ligature to the underlying band immediately adjacent to the knot with 2-O silk (Fig. 3). The peritoneum is then sutured over the knot. The pelvis is lavaged with normal saline solution, hemoVol. 69, No. 1, January 1998
The ligature is lying flat and snugly against the isthmus posterioriy,above the insertions of the uterosacral ligament bilaterally. The instrument points to the left-sided ligature tunnel site.
over 20 cases performed via laparotomy, primarily during pegnancy, with a tonsil clamp having been used in lieu of the Endo Close device for the creation of the tunnel along the isthmus. We are not aware of any reusable instrument that might be used in lieu of the Endo Close device. We believe our technique could be used by any surgeon or surgical team with a combination of good operative laparoscopic skills and experience placing a transabdominal cervicoisthmic cerclage via laparotomy. The laparoscopic approach has the obvious advantage of obviating the need for a laparotomy. As is the case for other pelvic surgeries (4), such a laparotomy performed as an interval procedure is probably more likely to result in pelvic adhesions than is our procedure, making achievement of a pregnancy more difficult. The other option, deferring the procedure until after an apparently viable pregnancy has been achieved, has the distinct disadvantage of requiring a laparotomy during pregnancy.
stasis is confirmed, and the laparoscopy is terminated in the usual manner.
DISCUSSION The technique described in this report is essentially identical to that previously used by the senior surgeon (JJS) in
The knot has been tied down anteriorly, and the free end of the ligature has been secured to the band adjacent to the knot on each side. The tenaculum attached to the vaginal wall or cervix has been elevated, and an instrument is shown pointing to the attachment site of the tenaculum.
To date, we have restricted the laparoscopic approach to cases performed as an interval procedure, with no complications of any kind, and minimal blood loss. The firm nature of the nonpregnant cervical isthmus makes it relatively easy to guide the Endo Close device along its lateral margin to avoid the uterine vessels and ureter. On the other hand, because of cervical softening, the same laparoscopic appreach during pregnancy might be associated with a higher risk of bleeding, because of a diminished ability to distinguish between the isthmus and adjacent vessels by tactile feedback. An obvious disadvantage of our procedure, or any interval procedure, is that pregnancy may either never occur or result in an early loss, presumably unrelated to cervical incompetence. Use of the dilator as described helps prevent postoperative cervical stenosis, allowing for a dilation and curettage procedure to be performed if such an early loss does occur, as was the case for one of our patients. Nonetheless, it is important to restrict the procedure described not only to women with valid indications for a transabdominal cervicoisthmic cerclage, as is the case when the procedure is performed via laparotomy during pregnancy (l-3) but also to women who are reasonably likely to achieve a viable pregnancy, to avoid unnecessary surgery altogether. References 1. Novy MJ. Transabdominal cervicoisthmic cerclage: a reappraisal 25 years after its introduction. Am J Obstet Gynecol 1991;164:1635-41. 2. Cammarano CL, Herron MA, Parer JT. Validity of indications for transabdominal cervicoisthmic cerclage for cervical incompetence. Am J Obstet Gynecol 1995;172:1871-5. 3. Gibb DM, Salaria DA. Transabdominal cervicoisthmic cerclage in the management of recurrent second trimester miscarriage and preterm delivery. Br J Obstet Gynaecol 1995;102:802-6. 4. Luciano AA. Management of adhesions via laparoscopy. In: Soderstrom RM, editor. Operative laparoscopy: the masters’ techniques. New York: Raven Press. 1993:121-6.
FERTILITY
& STERILITY@
163