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Transabdominal Cerclage: A Laparoscopic Approach
Transabdominal cerclage: A laparoscopic approach Karen B. Lesser, MD, Joel M. Childers, MD, and Earl A. Surwit, MD Background: The placement of a transabdominal cervical cerclage has been regarded as considerably more morbid than a transvaginal cerclage, in part due to the need for two laparotomies. We describe a technique for the laparoscopic placement and removal of a transabdominal cerclage. Cases: Two cases of women with insufficient cervical tissue to place a transvaginal cerclage were managed with a transabdominal cerclage. In one case, the cerclage was placed laparoscopically; in the other, the band was removed, facilitating uterine evacuation following the diagnosis of a missed abortion. In both cases a laparotomy was avoided. Conclusion: Laparoscopic placement and removal of a transabdominal cerclage are promising options in the treatment of an incompetent cervix. (Obstet Gynecol 1998;91: 855– 6. © 1998 by The American College of Obstetricians and Gynecologists.)
Although most patients with the diagnosis of cervical incompetence can be treated with a transvaginal cervical cerclage, a select group of patients may benefit from a transabdominal approach. Transabdominal cervical cerclage was first described by Benson and Durfee1 in 1965 and appears to benefit patients with extremely short or deformed cervices that preclude placement of a transvaginal cerclage. The obvious disadvantage of such an approach is that a laparotomy is required for placement of the band and for delivery, even in cases of intrauterine demise. We report successful laparoscopic placement and removal of an abdominal cerclage. Cases
experienced several days of pelvic pressure and lower back pain before presenting to her physician with advanced cervical dilatation and prolapsing membranes. An emergency cerclage was placed; however, she delivered at 19 weeks’ gestation. Examination at 10 weeks’ gestation revealed that the right side of the intravaginal portion of her cervix was 0.5 cm in length, and the left side was flush with the vaginal fornix. The cervical os was closed. At 11 weeks estimated gestational age she underwent laparoscopic placement of an abdominal cerclage. A 10-mm disposable trocar was placed at the umbilicus by the direct insertion technique. Under visualization, 5-mm trocars were inserted in the right and left lower quadrants, and a 12-mm trocar was placed suprapubically. The broad ligament was opened bilaterally caudad to the round ligaments and a bladder flap taken down. The uterine arteries were identified at the sidewall bilaterally and tracked medially to the bifurcation of the ascending branch. A window was then created through the broad ligament medial to the uterine vessels at the level of the internal os bilaterally. A 5-mm nonabsorbable polyethersuture (Mersilene Polyesture Suture, Ethicon Inc., Somerville, NJ) was placed through the window, around the posterior aspect of the uterus at the level of the uterosacral ligaments, and up through the window on the other side of the uterus. The nonabsorbable polyether suture was positioned to lie flat around the uterus and tied anteriorly with flat square knots. The distal ends of the band were trimmed and sutured to the band with 2-0 silk ligature using intracorporeal suture techniques. The procedure was complicated by a small amount of venous bleeding from beneath the right uterine artery, which was controlled with clips and packing. The time to perform the procedure was 2 hours, 20 minutes. The patient and fetus tolerated the procedure well and were discharged on the first postoperative day. The remainder of her antepartum course was remarkable for gestational diabetes, which was controlled with diet. At 35 weeks’ gestation she presented with a 2–3 day history of increasingly frequent contractions. An amniocentesis revealed mature pulmonary indices and a glucose of 14 mg/dL. She delivered a healthy 2180-g female by repeat cesarean. A bilateral tubal ligation was performed and the cerclage was removed.
Case 1
Case 2
A 40-year-old gravida 3, para 1-0-1-1, presented at 10 weeks estimated gestational age for consultation secondary to a history of cervical incompetence and insufficient cervical tissue for placement of a transvaginal cerclage. Her past gynecologic history was remarkable for diethylstilbestrol (DES) exposure in utero. Her first child was delivered in 1981 at term by cesarean. That pregnancy was complicated by gestational diabetes and preterm cervical dilatation without contractions, managed with bed rest. In 1982 she was treated with cryosurgery, which she reported as being treatment for an infection. Her second pregnancy was in 1992. At 18 weeks’ gestation she
A 31-year-old gravida 3, para 2-0-0-2, was referred at 9 weeks estimated gestational age secondary to absence of the intravaginal portion of her cervix with a monoamniotic twin gestation. Her past obstetric history included two vaginal deliveries at term. Subsequent to the birth of her children she had an extensive cone biopsy. On examination, the cervix was closed with the left side flush with the vaginal fornix, and the right side 1 cm in length. Following extensive counseling regarding the risks associated with monoamniotic twins, abdominal cerclage, and the uncertain need for the procedure, the patient underwent placement of an abdominal cerclage by laparotomy at 13 weeks’ gestation. Her postoperative course was unremarkable, and she was discharged 3 days after the procedure.
From the Department of Obstetrics and Gynecology, University of Arizona Health Sciences Center, Tucson, Arizona.
VOL. 91, NO. 5, PART 2, MAY 1998
0029-7844/98/$19.00 PII S0029-7844(97)00655-8
855
At 16 weeks estimated gestational age, oligohydramnios (amniotic fluid index 5 1.7 cm) was diagnosed. Sterile speculum examination failed to detect any leakage of amniotic fluid. On follow-up examination at 17 weeks’ gestation anhydramnios with intrauterine demise of both twins was diagnosed. Following laminaria placement, the patient was brought to the operating room to attempt dilation and evacuation. As the cervix could not be dilated sufficiently with the nonabsorbable polyether suture in place, laparoscopy was performed to remove the band. Laparoscopic band removal took approximately 45 minutes. Following removal of the band, the cervix was further dilated, and the uterine contents were evacuated. The patient was discharged on the day of the procedure.
Comment Although its utility has not been validated in randomized trials, transvaginal cervical cerclage has become an accepted procedure for the treatment of cervical incompetence. More controversial is the use of cerclage in patients at potential risk for early fetal loss secondary to DES exposure and following extensive conization of the cervix. Ludmir et al2 advocated cervical cerclage for women exposed to DES following a prospective study in which 44% of the group managed expectantly required an emergent cerclage. Leiman et al3 reviewed 88 pregnancies subsequent to cone biopsy to determine if there was an effect of the size of the cone on subsequent pregnancy outcome. Second trimester abortion occurred in 18.2% with large cone volumes (greater than 4 cc) compared with 6.5% with small cone volumes (less than 4 cc). The usual treatment of women at risk for cervical incompetence is a cerclage placed transvaginally. This approach may not be possible in women with absent or severely deformed cervices. Transabdominal cervical cerclage has been advocated when placement of a transvaginal cerclage is not feasible technically or when prior transvaginal cerclages have been unsuccessful.4 Data show a fetal survival rate of 89% for transabdominal cervical cerclage performed during pregnancy compared with a fetal salvage rate of 21% in the untreated pregnancies of the same patients.5 Potential advantages to the procedure include placement of the nonabsorbable polyether suture at the level of the internal os, decreased slippage of the suture as it is bordered by the enlarging uterus from above and uterosacral ligaments from below, lack of a foreign body within the vagina that could act as a precipitant of ascending infection and premature labor, and the ability to leave the band in place between pregnancies or place it preconceptionally. Shortcomings of the procedure have included the need for a laparotomy and hospitalization to place the cerclage, prolonged recovery time, increased incidence of fetal death,6 the poten-
856 Lesser et al
Transabdominal Cerclage
tial need for a technically difficult posterior colpotomy or hysterotomy in cases of fetal demise, and increased blood loss and delivery by cesarean. We report two cases in which laparoscopy was used to place (in one case) and remove (in another case) a transabdominal cerclage. Although there is a theoretical concern that fetal acidosis may develop during carbon dioxide peritoneal insufflation, animal studies7 and human case series8 indicate the relative safety of laparoscopy during pregnancy. Removal of the cerclage could be performed by most skilled laparoscopists without additional training. Placement of the cerclage is more difficult technically and should only be attempted by surgeons with a high level of expertise. If a larger series demonstrates comparable success and complication rates to the traditional transabdominal approach, the use of laparoscopy will eliminate some of the drawbacks to placement of the transabdominal cerclage.
References 1. Benson RC, Durfee RB. Transabdominal cervicouterine cerclage during pregnancy for the treatment of cervical incompetency. Obstet Gynecol 1965;25:145–55. 2. Ludmir J, Landon MB, Gabbe SG, Samuels P, Mennuti MT. Management of the diethylstilbestrol-exposed pregnant patient: A prospective study. Am J Obstet Gynecol 1987;157:665–9. 3. Leiman G, Harrison NA, Rubin A. Pregnancy following conization of the cervix: Complications related to cone size. Am J Obstet Gynecol 1980;136:14 – 8. 4. Cammarano CL, Herron MA, Parer JT. Validity of indications for transabdominal cerclage for cervical incompetence. Am J Obstet Gynecol 1995;172:1871–5. 5. Novy MJ. Transabdominal cervicoisthmic cerclage: A reappraisal 25 years after its introduction. Am J Obstet Gynecol 1991;164:1635– 42. 6. Branch DW. Operations for cervical incompetence. Clin Obstet Gynecol 1986;29:240 –54. 7. Barnard JM, Chaffin D, Droste S, Tierney A, Phernetton T. Fetal response to carbon dioxide pneumoperitoneum in the pregnant ewe. Obstet Gynecol 1995;85:669 –74. 8. Parker WH, Childers JM, Canis M, Phillips DR, Topel H. Laparoscopic management of benign cystic teratomas during pregnancy. Am J Obstet Gynecol 1996;174:1499 –501.
Address reprint requests to:
Karen B. Lesser, MD University of Arizona Health Science Center Department of Obstetrics and Gynecology 1501 North Campbell Avenue Tucson, AZ 85724 E-mail: [email protected].
Received July 21, 1997. Received in revised form October 7, 1997. Accepted October 31, 1997. Copyright © 1998 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
Obstetrics & Gynecology
Although most patients with the diagnosis of cervical incompetence can be treated with a transvaginal cervical cerclage, a select group of patients may benefit from a transabdominal approach. Transabdominal cervical cerclage was first described by Benson and Durfee1 in 1965 and appears to benefit patients with extremely short or deformed cervices that preclude placement of a transvaginal cerclage. The obvious disadvantage of such an approach is that a laparotomy is required for placement of the band and for delivery, even in cases of intrauterine demise. We report successful laparoscopic placement and removal of an abdominal cerclage. Cases
experienced several days of pelvic pressure and lower back pain before presenting to her physician with advanced cervical dilatation and prolapsing membranes. An emergency cerclage was placed; however, she delivered at 19 weeks’ gestation. Examination at 10 weeks’ gestation revealed that the right side of the intravaginal portion of her cervix was 0.5 cm in length, and the left side was flush with the vaginal fornix. The cervical os was closed. At 11 weeks estimated gestational age she underwent laparoscopic placement of an abdominal cerclage. A 10-mm disposable trocar was placed at the umbilicus by the direct insertion technique. Under visualization, 5-mm trocars were inserted in the right and left lower quadrants, and a 12-mm trocar was placed suprapubically. The broad ligament was opened bilaterally caudad to the round ligaments and a bladder flap taken down. The uterine arteries were identified at the sidewall bilaterally and tracked medially to the bifurcation of the ascending branch. A window was then created through the broad ligament medial to the uterine vessels at the level of the internal os bilaterally. A 5-mm nonabsorbable polyethersuture (Mersilene Polyesture Suture, Ethicon Inc., Somerville, NJ) was placed through the window, around the posterior aspect of the uterus at the level of the uterosacral ligaments, and up through the window on the other side of the uterus. The nonabsorbable polyether suture was positioned to lie flat around the uterus and tied anteriorly with flat square knots. The distal ends of the band were trimmed and sutured to the band with 2-0 silk ligature using intracorporeal suture techniques. The procedure was complicated by a small amount of venous bleeding from beneath the right uterine artery, which was controlled with clips and packing. The time to perform the procedure was 2 hours, 20 minutes. The patient and fetus tolerated the procedure well and were discharged on the first postoperative day. The remainder of her antepartum course was remarkable for gestational diabetes, which was controlled with diet. At 35 weeks’ gestation she presented with a 2–3 day history of increasingly frequent contractions. An amniocentesis revealed mature pulmonary indices and a glucose of 14 mg/dL. She delivered a healthy 2180-g female by repeat cesarean. A bilateral tubal ligation was performed and the cerclage was removed.
Case 1
Case 2
A 40-year-old gravida 3, para 1-0-1-1, presented at 10 weeks estimated gestational age for consultation secondary to a history of cervical incompetence and insufficient cervical tissue for placement of a transvaginal cerclage. Her past gynecologic history was remarkable for diethylstilbestrol (DES) exposure in utero. Her first child was delivered in 1981 at term by cesarean. That pregnancy was complicated by gestational diabetes and preterm cervical dilatation without contractions, managed with bed rest. In 1982 she was treated with cryosurgery, which she reported as being treatment for an infection. Her second pregnancy was in 1992. At 18 weeks’ gestation she
A 31-year-old gravida 3, para 2-0-0-2, was referred at 9 weeks estimated gestational age secondary to absence of the intravaginal portion of her cervix with a monoamniotic twin gestation. Her past obstetric history included two vaginal deliveries at term. Subsequent to the birth of her children she had an extensive cone biopsy. On examination, the cervix was closed with the left side flush with the vaginal fornix, and the right side 1 cm in length. Following extensive counseling regarding the risks associated with monoamniotic twins, abdominal cerclage, and the uncertain need for the procedure, the patient underwent placement of an abdominal cerclage by laparotomy at 13 weeks’ gestation. Her postoperative course was unremarkable, and she was discharged 3 days after the procedure.
From the Department of Obstetrics and Gynecology, University of Arizona Health Sciences Center, Tucson, Arizona.
VOL. 91, NO. 5, PART 2, MAY 1998
0029-7844/98/$19.00 PII S0029-7844(97)00655-8
855
At 16 weeks estimated gestational age, oligohydramnios (amniotic fluid index 5 1.7 cm) was diagnosed. Sterile speculum examination failed to detect any leakage of amniotic fluid. On follow-up examination at 17 weeks’ gestation anhydramnios with intrauterine demise of both twins was diagnosed. Following laminaria placement, the patient was brought to the operating room to attempt dilation and evacuation. As the cervix could not be dilated sufficiently with the nonabsorbable polyether suture in place, laparoscopy was performed to remove the band. Laparoscopic band removal took approximately 45 minutes. Following removal of the band, the cervix was further dilated, and the uterine contents were evacuated. The patient was discharged on the day of the procedure.
Comment Although its utility has not been validated in randomized trials, transvaginal cervical cerclage has become an accepted procedure for the treatment of cervical incompetence. More controversial is the use of cerclage in patients at potential risk for early fetal loss secondary to DES exposure and following extensive conization of the cervix. Ludmir et al2 advocated cervical cerclage for women exposed to DES following a prospective study in which 44% of the group managed expectantly required an emergent cerclage. Leiman et al3 reviewed 88 pregnancies subsequent to cone biopsy to determine if there was an effect of the size of the cone on subsequent pregnancy outcome. Second trimester abortion occurred in 18.2% with large cone volumes (greater than 4 cc) compared with 6.5% with small cone volumes (less than 4 cc). The usual treatment of women at risk for cervical incompetence is a cerclage placed transvaginally. This approach may not be possible in women with absent or severely deformed cervices. Transabdominal cervical cerclage has been advocated when placement of a transvaginal cerclage is not feasible technically or when prior transvaginal cerclages have been unsuccessful.4 Data show a fetal survival rate of 89% for transabdominal cervical cerclage performed during pregnancy compared with a fetal salvage rate of 21% in the untreated pregnancies of the same patients.5 Potential advantages to the procedure include placement of the nonabsorbable polyether suture at the level of the internal os, decreased slippage of the suture as it is bordered by the enlarging uterus from above and uterosacral ligaments from below, lack of a foreign body within the vagina that could act as a precipitant of ascending infection and premature labor, and the ability to leave the band in place between pregnancies or place it preconceptionally. Shortcomings of the procedure have included the need for a laparotomy and hospitalization to place the cerclage, prolonged recovery time, increased incidence of fetal death,6 the poten-
856 Lesser et al
Transabdominal Cerclage
tial need for a technically difficult posterior colpotomy or hysterotomy in cases of fetal demise, and increased blood loss and delivery by cesarean. We report two cases in which laparoscopy was used to place (in one case) and remove (in another case) a transabdominal cerclage. Although there is a theoretical concern that fetal acidosis may develop during carbon dioxide peritoneal insufflation, animal studies7 and human case series8 indicate the relative safety of laparoscopy during pregnancy. Removal of the cerclage could be performed by most skilled laparoscopists without additional training. Placement of the cerclage is more difficult technically and should only be attempted by surgeons with a high level of expertise. If a larger series demonstrates comparable success and complication rates to the traditional transabdominal approach, the use of laparoscopy will eliminate some of the drawbacks to placement of the transabdominal cerclage.
References 1. Benson RC, Durfee RB. Transabdominal cervicouterine cerclage during pregnancy for the treatment of cervical incompetency. Obstet Gynecol 1965;25:145–55. 2. Ludmir J, Landon MB, Gabbe SG, Samuels P, Mennuti MT. Management of the diethylstilbestrol-exposed pregnant patient: A prospective study. Am J Obstet Gynecol 1987;157:665–9. 3. Leiman G, Harrison NA, Rubin A. Pregnancy following conization of the cervix: Complications related to cone size. Am J Obstet Gynecol 1980;136:14 – 8. 4. Cammarano CL, Herron MA, Parer JT. Validity of indications for transabdominal cerclage for cervical incompetence. Am J Obstet Gynecol 1995;172:1871–5. 5. Novy MJ. Transabdominal cervicoisthmic cerclage: A reappraisal 25 years after its introduction. Am J Obstet Gynecol 1991;164:1635– 42. 6. Branch DW. Operations for cervical incompetence. Clin Obstet Gynecol 1986;29:240 –54. 7. Barnard JM, Chaffin D, Droste S, Tierney A, Phernetton T. Fetal response to carbon dioxide pneumoperitoneum in the pregnant ewe. Obstet Gynecol 1995;85:669 –74. 8. Parker WH, Childers JM, Canis M, Phillips DR, Topel H. Laparoscopic management of benign cystic teratomas during pregnancy. Am J Obstet Gynecol 1996;174:1499 –501.
Address reprint requests to:
Karen B. Lesser, MD University of Arizona Health Science Center Department of Obstetrics and Gynecology 1501 North Campbell Avenue Tucson, AZ 85724 E-mail: [email protected].
Received July 21, 1997. Received in revised form October 7, 1997. Accepted October 31, 1997. Copyright © 1998 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
Obstetrics & Gynecology