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    Laparoscopic abdominal cerclage found effective for cervical insufficiency

    Pregnancy and perioperative outcomes are extremely favorable with laparoscopic abdominal cerclage placement, according to the results of a retrospective study presented at the 46th AAGL Global Congress on Minimally Invasive Gynecology.

    The consecutive case series of 106 laparoscopic abdominal cerclage placements due to cervical insufficiency from 2007 to 2017 was performed exclusively by principal investigator Jon I. Einarsson MD, PhD, director of the Division of Minimally Invasive Gynecologic Surgery at Brigham and Women's Hospital in Boston.

    “The fetal salvage rate, which is the percentage of viable neonate surviving until hospital discharge, was 93%,” Dr. Einarsson told Contemporary OB/GYN. “This finding is consistent with smaller series studies, including our own conducted back in 2010.”

    Furthermore, the operating time for the current series was less than 1 hour (on average 55 minutes), with minimal blood loss (27 mL) and no major complications.

    Nonetheless, Dr. Einarsson acknowledged that there has been “some pushback” against placement of a laparoscopic abdominal cerclage. Certain physicians believe the technique is inferior to a large-incision laparotomy because they feel the cerclage can’t be tied as tightly around the cervix.

    In response to criticism of the laparoscopic procedure, Dr. Einarsson noted that he co-authored a meta-analysis a few years ago. “After reviewing the entire literature, we found there was no difference in outcomes between laparoscopy and a laparotomy,” he says.

    Benefits of the laparoscopic approach include that patients return home the same day as opposed to a hospital stay of 2 days and that recovery typically occurs in 2 to 3 days versus being out of commission for 4 to 6 weeks. “These advantages are significant,” Dr. Einarsson stated.

    The cost of laparoscopy is also lower than a laparotomy because of no hospitalization.

    On the other hand, there is definitely a learning curve with laparoscopy. “This is not a very common procedure,” Dr. Einarsson said. “But it is certainly much easier to perform when the patient is not pregnant. That is our preference.”

    Of the 106 study cases, 95 patients had laparoscopy before conception. Among the remaining 11 patients who were pregnant, 1 patient lacked fetal viability after cerclage placement, “even though the cerclage was placed without any complications,” Dr. Einarsson said. “So it is better if you can avoid placement during pregnancy.”

    To perform cerclage placement laparoscopically, Dr. Einarsson uses standard 5-mm Mersilene tape (Ethicon)–the same suture that is used for a transvaginal cerclage. “The tape has two needles that are fairly blunt at the tip, which is desirable because the most critical step in the procedure is passing the needles between the cervix and the uterine artery,” he said. “That space is very limited. Surgeons are worried they will perforate those vessels.”

    Hence, the two needles are directed toward the cervix. “If you feel a lot of resistance, you know you are entering the cervix, in which case you can move the needle or the trajectory of the needle just a hair lateral from the cervix and try again as opposed to going out too laterally where you can enter the vessels,” Dr. Einarsson explained.

    In addition, if the patient is not pregnant, a uterine manipulator is employed. “When passing a needle, I twist the uterus to the side,” Dr. Einarsson said. “This allows you to observe both the anterior and the posterior portion of the cervix and the lower uterus at the same time. That definitely makes the procedure much easier.”

    A third pearl is that with Mersilene tape, the first knot needs to be tied very tight. The second knot, though, is even more critical because without proper tension, “the first knot will unravel and you will end up with an air knot, whereby the stitch is not tight around the cervix,” Dr. Einarsson said. “Therefore, when you are tying down the second knot, you have to be very careful not to pull on the first knot.”

    Dr. Einarsson typically ties about six knots total around the cervix.

    When a woman loses a pregnancy due to cervical incompetence, “it is a very traumatic event for the woman and the family,” said Dr. Einarsson, a professor of obstetrics, gynecology and reproductive biology at Harvard Medical School. “The standard of care currently is to place a transvaginal cerclage before a subsequent pregnancy.”

    However, Dr. Einarsson feels that placing a laparoscopic cerclage initially may potentially be a better option. “In today’s environment, we can perform this as an outpatient procedure with very minimal risk of complications and a short operating time,” he said. “These women are also the most grateful and happy patients that we have. They are very appreciative.”

    Unfortunately, though, insurance companies currently generally do not cover an abdominal cerclage or a laparoscopic cerclage, “unless the woman has had a failed vaginal cerclage first,” Dr. Einarsson said. 

    REFERENCE

    Pepin KJ, Clark NV, Einarsson J. Laparoscopic Abdominal Cerclage: Tips and Tricks . [AAGL abstract 299]. J Minim Invasive Gynecol. 2017;24(suppl):S101.

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