Laparoscopic Cervical Cerclage in Aundh, Pune

Cervical insufficiency is a significant contributor to second-trimester pregnancy loss and spontaneous preterm birth.

Laparoscopic abdominal cervical cerclage is a minimally invasive surgical procedure performed to manage cervical insufficiency, a condition characterized by premature cervical dilation leading to recurrent mid-trimester pregnancy loss. This procedure involves placing a strong suture around the cervix at the level of the internal os to provide mechanical support and prevent premature dilation during pregnancy.

Cervical Cerclage Definition: 

Cervical insufficiency, formerly known as cervical incompetence, refers to a structural weakness of the cervix that causes it to dilate prematurely during pregnancy without labor contractions ( Pains ), typically leading to second-trimester pregnancy loss. 

– Affects 0.1–1% of pregnancies

– Responsible for 15% of recurrent mid-trimester losses

Indications for laparoscopic abdominal cervical cerclage: 

1. History of failed vaginal cerclage
2. Anatomically short or absent cervix due to previous surgeries (conization, LEEP, trachelectomy)
3. Significant cervical scarring making vaginal approach technically difficult
4. History of multiple mid-trimester pregnancy losses despite appropriate management
5. Congenital cervical defects

The laparoscopic approach offers several advantages over the traditional abdominal cerclage via laparotomy, including reduced blood loss, shorter hospital stays, decreased postoperative pain, and faster recovery.

Prior Surgery, 

• Cervical length assessment via transvaginal ultrasound
• Exclusion of other causes of recurrent pregnancy loss is necessary. 
• Patient counseling regarding risks, benefits, and subsequent pregnancy management

Timing: 

1. Interval circlage: Ideally performed pre-conception 
2. Early in pregnancy (10-14 weeks)
3. A better option is after doing early Anomaly scan at 16 weeks. Where uterus rests over the sacral promontory. 

Surgical technique

Equipment and setup:

Standard laparoscopic equipment (3D camera has definite advantages) 

• 10 mm umbilical port for camera
• Two or three 5 mm lateral ports for instruments
• Uterine manipulator (for non-pregnant patients)
• 5 mm Mersilene tape or similar non-absorbable suture material. 

Procedural steps 

• Identification of uterovesical fold
• Reflection of bladder from lower uterine segment and cervix
• Identification of uterine vessels and ureters for avoidance

Cerclage placement:

• Creation of windows in the avascular spaces medial to the uterine vessels bilaterally
• Passage of Mersilene tape or other non-absorbable suture through these windows
• Positioning of the suture at the level of the internal cervical os
• Secure knot tying anteriorly with appropriate tension with keeping Hegar’s dilator in situ. 
• peritoneal closure over the suture. Removal of ports under direct visualization. The last step is of Skin closure. 

Postoperative management: 

• Overnight hospitalization for observation (typically)
• Pain management with oral analgesics
• Early ambulation encouraged
• Return to normal activities within 3-4 days. 

During pregnancy: 

• Fetal Heart Rate monitoring, Uterine Contractions, 
• Limited activity for 24-48 hours
• Regular follow-up with maternal-fetal medicine specialists. 

Outcomes and success rates: 

Laparoscopic abdominal cervical cerclage has demonstrated excellent outcomes in appropriate candidates. 

• Fetal survival rates of 85-95% after cerclage placement
• Significant reduction in mid-trimester losses
• Mean gestational age at delivery typically >34 weeks
• Reduced incidence of preterm birth compared to pre-cerclage history. 

Complications: 

Potential complications of laparoscopic abdominal cervical cerclage include:

Intraoperative:

• Bleeding from uterine vessels
• Bladder or ureteral injury
• Cervical trauma

Postoperative:

• Infection
• Suture erosion
• Cerclage displacement

Obstetric:

• Need for cesarean delivery (universal requirement)

Long-term considerations: 

• Permanent cerclage remains in place for future pregnancies
• All subsequent deliveries must be via cesarean section
• Regular monitoring during pregnancy is essential
• No routine removal after completion of childbearing

Conclusion

Cervical circlage does not cause  any changes in menstrual cycle. Laparoscopic abdominal cervical cerclage represents a significant advancement in the management of cervical insufficiency. When performed by experienced surgeons in appropriately selected patients, it offers excellent outcomes with minimal morbidity. The procedure provides an effective option for women with cervical insufficiency who have failed or are not candidates for vaginal cerclage, allowing many to achieve successful pregnancies despite previous losses.