Introduction
Cervical cerclage is used to treat cervical insufficiency and to prevent miscarriages
and preterm births in the second trimester of pregnancy. The indication for cerclage
is based on cervical insufficiency, which is diagnosed using the following criteria:
one or more previous miscarriages in the second trimester of pregnancy; occurrence
of painless cervical dilation without contractions; and sonographic confirmation of
a cervical length of < 25 mm before week 24+0 of gestation (GW) in patients who had
a previous miscarriage or late term spontaneous abortion before the 34th GW [1 ]
[2 ]
[3 ]. Vaginal cervical cerclage is an established method to treat cervical insufficiency.
A purse-string stitch (using non-resorbable sutures) is placed around the cervix and
securely
tied for cervical cerclage [4 ]. To create an additional barrier against ascending microorganisms, Erich Saling
has described a total cervical occlusion procedure. After de-epithelialization of
the cervix, it is closed using a running suture with resorbable sutures [5 ]
[6 ]. Different vaginal cerclage (VC) techniques were developed over the last five decades.
They include purse-string sutures placed as high as possible at the cervicovaginal
transition, as described by McDonald, and Shirodkar’s technique, in which the cerclage
is placed as close as possible to the inner cervix after the bladder neck is dissected
from the cervix [2 ]
[7 ].
Non-resorbable sutures (either polyfilament [Mersilene tape, Ethibond] or monofilament
[Prolene]) are used and are removed prior to delivery of the infant. Removal is done
electively at between weeks 36–37 of gestation if the aim is to have a spontaneous
vaginal birth or during cesarean section.
Transabdominal cerclage is an alternative approach used in complex cases where vaginal
cerclage has no prospects of success or vaginal placement is no longer possible due
to extreme cervical shortening (e.g., after conizations or previous cervical surgery)
or the anatomical condition of the cervix [7 ]
[8 ]
[9 ]. Bension already described an abdominal cerclage procedure as an alternative approach
in 1965 [10 ]. The first minimally invasive methods used to place a cerclage were experimental
procedures described in 1998 by Lesser et al. and Scibetta et al. [11 ]
[12 ]. Studies report that laparoscopic transabdominal cervical cerclage (LTC) has similar
success rates (85–90%), better pregnancy outcomes and a lower risk of infection compared
to vaginal cerclage [13 ]. The data demonstrate the feasibility and success rates of laparoscopic transabdominal
cerclage [7 ]
[8 ]
[10 ]
[14 ]
[15 ]
[16 ]
[17 ]
[18 ]
[19 ].
We present two case studies here, in whom cerclage placement early in the second trimester
was necessary due to cervical shortening. As a transvaginal cerclage was no longer
possible due to prior conizations which almost obliterated the exocervix, laparoscopic
transabdominal emergency cerclage was carried out instead.
The focus of this article is to highlight the feasibility and the protective effect
of laparoscopic transabdominal cerclage early in the second trimester of pregnancy,
especially in cases for whom vaginal cerclage is not possible.
Method
The technical aspects, feasibility, safety, and pregnancy outcomes of laparoscopic
transabdominal isthmo-cervical emergency cerclage in the early second trimester of
pregnancy are discussed here.
Two patients presented to our university hospital to plan how to protect their pregnancies.
Prenatal screening had identified cervical shortening in both cases due to conization
with preterm birth and re-conization. The first patient was in week 13+0 of gestation;
the transvaginal cervix could not be exposed, resulting in a primary indication for
emergency laparoscopic cerclage. The second patient was in week 15+4 of her pregnancy
but planned placement of a transvaginal cerclage could not be carried out because
it was not possible to expose the transvaginal cervix intraoperatively. Both patients
underwent needle-free transabdominal laparoscopic isthmo-cervical emergency cerclage
without the use of a manipulator at 13+0 and 15+5 weeks of gestation, respectively.
The written consent of both patients was obtained. Ethical approval was not required
for this publication.
To exclude malformations, the patients underwent extended sonographic screening preoperatively.
Endocervical smear tests for chlamydia and mycoplasma and vaginal smear tests for
pathogens were carried out prior to surgery to ensure that the patients had no infections.
Case I
A 32-year-old patient (gravida 8, para 3) who had had two previous spontaneous births
and one secondary cesarean section for amnion infection syndrome in week 24+3 of gestation
due to preterm rupture of membranes (PROM) in 23+0 GW presented to our department
in week 13+0 of gestation with a cervical length of 2 cm measured on sonography. The
patient’s prior history included two healthy children and a preterm infant who died
from respiratory distress syndrome. The patient had also had four early spontaneous
abortions followed by curettage and conization two years previously for cervical dysplasia.
Known comorbidities included antiphospholipid syndrome, protein Z deficiency and hypothyroidism.
Her body mass index (BMI) was 22.3.
The patient had a sonographic cervical length of 2 cm; the cervix could not be identified
transvaginally following previous conization, making it impossible to place a vaginal
cerclage. Laparoscopic isthmo-cervical emergency cerclage was indicated in week 13+0
of gestation after the patient had been provided with information and advised.
Case II
Vaginal cerclage was indicated in week 15+5 of gestation in a 35-year-old patient
(gravida 1, para 0) who had previously had 3× conizations (two of them nine years
previously, and one three years previously) and a sonographic cervical length of 2.4 cm.
In this case, intraoperative speculum examination was unable to identify the (remnant
of the) cervix, which made it impossible to carry out a vaginal procedure. Laparoscopic
isthmo-cervical cerclage was therefore indicated. The patient had a body mass index
(BMI) of 31.1. She had no known relevant pre-existing conditions.
Surgical Technique
Laparoscopic transabdominal cerclage (LTC) procedures were carried out under general
anesthesia with the patients in a lithotomy position. A size 14 Foley bladder catheter
was inserted into the bladder under sterile conditions. Laparoscopic access was via
the Palmer point (left subcostal). After insertion of a Verres needle (closed technique),
CO2 was insufflated until a pressure of 12 mmHg was achieved. The intervention was carried
out using a 5 mm 30° optical trocar. Three working trocars (inserted in the lower
abdomen [5 mm] laterally on the left and right and above the symphysis [12 mm]) were
introduced under direct vision. The uterovesical peritoneum was opened using bipolar
coagulation scissors. The bladder was carefully dissected from the uterine isthmus
and pushed aside. This was followed by preparation and exposure of the uterine vessels.
In the second case, the uterus was soft, corresponding to the more advanced week of
gestation in this patient, and
sufficiently enlarged up to the level of the navel (see [Fig. 1 ]). No uterus manipulator was used. An Endo Paddle Retract (Covidien) was used to
push the uterus aside as required for the procedure. The uterine vessels were carefully
prepared and exposed from the ventral and dorsal side (see [Fig. 2 ]). A KELLY forceps (Storz, Germany) was then carefully inserted from dorsal to ventral
through the avascular space between the ascending and descending branches of the uterine
vessels in the paracervical region (see [Fig. 3 ]
a ). A KELLY forceps was then used to pull the 5 mm Mersilene tape (Ethicon, Somerville,
NJ, USA) in an anteroposterior direction between the uterine vessels and the isthmo-cervical
transition (see [Fig. 3 ]
b ). On the right side of the uterus the tape was pulled in a posteroanterior direction
using a KELLY forceps. After correct positioning of the tape about 1 cm above the
uterosacral ligaments, the tape was tied ventrally below the ascending uterine vessels
at the isthmo-cervical transition (see [Fig. 4 ]
a and b ). The uterovesical peritoneum was not closed. The bladder catheter was removed at
the end of the operation. Neither of the patients received tocolytics during the procedure
or immediately afterwards. Both patients received a single perioperative prophylactic
dose of antibiotics consisting of cefuroxim 1.5 g administered intravenously. Sonography
was carried out postoperatively to check fetal vitality and correct positioning of
the tape (see[Fig. 5 ]). The
patients were subsequently monitored in hospital for one or two days. They were discharged
home in good health with intact pregnancies.
Fig. 1
View of the pregnant uterus in week 15+5 of gestation.
Fig. 2
Intraoperative view after dissection and exposure of the uterine vessels.
Fig. 3
Intraoperative view during placement of the tape around the cervix: a ventral view, b dorsal view.
Fig. 4
Intraoperative view after placement of the cerclage tape: a dorsal view before the tape was tied, b ventral view after the tape was tied.
Fig. 5
Postoperative transvaginal control sonography a, b ultrasound and Doppler sonography imaging of the uterine vessels and the tape.
Results
Case I
Adhesions between the bladder and the uterus were found intraoperatively as the patient
was status post-cesarean delivery; the adhesions were dissected. Placement of the
cerclage was successful. The operating time was 93 min (blood loss approx. 45 ml)
and the cerclage had a stabilizing effect. The postoperative course was uncomplicated
and the control sonography and CTG examinations were unremarkable. The patient was
discharged home in a good general condition on the second postoperative day and was
followed up as an outpatient. The further course of the pregnancy was uneventful and
without complications but ended in week 36 of gestation. The patient was delivered
in another hospital by secondary repeat cesarean section due to premature rupture
of membranes. A salpingectomy was carried out as the patient did not wish to have
more children and the Mersilene tape was removed. The female neonate weighed 2786 g
and her APGAR scores were 8/9/10. Blood gas analysis showed an
umbilical cord arterial pH of 7.36. Both mother and child were healthy when they were
discharged home from hospital.
Case II
Extended adhesions between the bowel, adnexa, uterus and pelvis were found intraoperatively.
The adhesions were dissected and placement of the cerclage was successful. The operating
time was 134 min. The estimated blood loss was 40 ml. The postoperative course was
uncomplicated and the patient was discharged home in a good general condition on the
first postoperative day and followed up as an outpatient. After successful cerclage
placement, the further course of the pregnancy was without complications. The patient
was delivered by primary cesarean section in week 39+5 of gestation. The Mersilene
tape was removed intraoperatively. The male neonate weighed 4160 g and his APGAR scores
were 5/9/10. Blood gas analysis showed an umbilical cord arterial pH of 7.20. Both
mother and child were healthy when they were discharged home from hospital.
Discussion
This study presents the outcomes of two patients who underwent laparoscopic isthmo-cervical
emergency cerclage for cervical insufficiency in week 13+0 and week 15+5 of gestation,
respectively. In both patients, the cervix could no longer be exposed vaginally due
to previous conizations. Surgical protection of the pregnancy required transabdominal
cerclage placement.
In a large case series of 101 participants, Lotgering et al. were able to demonstrate
the protective effect of transabdominal isthmo-cervical cerclage in women with cervical
insufficiency in whom transvaginal cerclage was not possible. The mean gestational
age was 14 weeks of gestation for elective cerclage and 18 GW for emergency cerclage.
Perioperative complications included heavy bleeding (n = 3), premature iatrogenic
rupture of membranes (n = 2) and bladder injury (n = 1). Without cerclage placement,
a preterm birth before week 32 of gestation occurred in 76% of cases and the survival
rate was 27.5%. After cerclage placement, the preterm birth rate was 7% and the survival
rate increased to 93.5%. The patients were monitored as inpatients for an average
of 5 days [20 ]. As the expertise in minimally invasive surgical techniques continues to improve,
laparoscopic transabdominal cerclage has prevailed as
the preferred method compared to a laparotomy approach [7 ]
[9 ]
[18 ]. The laparoscopic approach is characterized by low complication rates including
fewer cases with perioperative bleeding and a lower risk of iatrogenic rupture of
membranes and miscarriage [18 ]. The advantages associated with a laparoscopic approach include not having to carry
out large abdominal incisions, shorter hospital stays, faster recovery times and better
aesthetic results [7 ]
[9 ].
Carrying out LTC in an advanced stage of pregnancy is a greater surgical challenge.
The limited visibility due to the enlarged uterus and the difficult of manipulating
a soft pregnant uterus amply supplied with blood make the procedure considerably more
difficult. For this reason, most LTC procedures reported in the literature are carried
out prior to conception or in the early weeks of pregnancy [7 ]
[9 ]
[14 ]
[21 ]. Saridogan et al. reported on 54 patients with prior conization who had LTC prior
to conception. Of the 37 subsequent pregnancies, 92% (34 births) were successful,
with no significant intraoperative or postoperative complications reported [7 ]. In a retrospective case series by Burger et al., complications such as uterine
perforations or pelvic infection occurred in 3 of 66 cases who had LTC prior to conception.
Of the 52 patients who were followed up, 69.2% became pregnant, and 77.1% of the 35
pregnancies which were fully followed up ended in the third trimester. The overall
fetal survival rate was 77.1%; the rate for the surviving pregnancies was 90.0% [21 ].
In addition to reports on LTCs carried out prior to conception, there are numerous
publications on LTC procedures carried out during pregnancy [2 ]
[7 ]
[8 ]
[15 ]
[17 ]
[18 ]
[22 ]
[23 ]. The data clearly show the safety and effectiveness of LTC in preventing late miscarriage
and preterm births in women with cervical insufficiency or women who previously had
unsuccessful transvaginal cerclage [8 ]
[9 ]
[14 ]
[15 ]
[19 ]
[23 ]
[24 ]
[25 ]
[26 ].
A study by Whittle et al. included 65 patients and had a high rate of perioperative
complications. In 13 cases, it was necessary to switch to laparotomy because of bleeding
from the uterine vessels (n = 5) or limited visibility (n = 2). There were two cases
of perioperative miscarriage. Six pregnancies ended in the second trimester due to
acute or subacute chorioamnionitis followed by late spontaneous abortion. Despite
the high rate of perioperative complications and miscarriages, the neonatal survival
rate was 89%, and the mean duration of pregnancy until delivery was 35.8 ± 2.9 weeks
of gestation [9 ]. The intraoperative use of a needle to place the cerclage as reported in the study
by Whittle et al. could be one factor which might explain the higher rate of complications.
In contrast to their findings, other studies in which LTCs were carried out prior
to conception or in the first trimester showed
significantly lower or no perioperative complications [7 ]
[8 ]
[14 ]
[15 ].
In their study of 11 cases, Abdel Azim et al. showed that LTC can be carried out until
week 12+3 of gestation without complications and without miscarriages until the second
trimester of pregnancy. The mean operating time of 64 min is significantly shorter
than that reported for our two cases, which could be ascribed to the LTC being carried
out in the early weeks of gestation or prior to conception. A needle-free technique
was also employed to minimize complications and the uterine vessels were completely
dissected [14 ]. Ades et al. und Zhao et al. confirmed these positive results and reported on the
feasibility of LTC in the first trimester with high fetal survival rates and no complications.
Zhao et al., in particular, emphasized the benefits of needle-free LTC performed without
a manipulator, reporting successful results for all (n = 10) investigated patients
[15 ]
[27 ]. Cho et al. showed the effectiveness of LTC in patients (n = 20) who had previously
had miscarriages in the second trimester or in whom transvaginal cerclage had failed.
Although one case resulted in an injury to the uterine vein, all other LTC procedures
had no surgical or immediate postoperative complications [25 ]. Shin et al. also demonstrated the feasibility and protective effect of LTC, with
an overall pregnancy survival rate of 90%. Even though several spontaneous abortions
occurred (n = 8; six spontaneous abortions in the first trimester due to fetal anomalies
and two miscarriages in the second trimester), the duration of the pregnancies after
LTC show that LTC can effectively reduce the risk of late miscarriage and preterm
birth [23 ].
The retrospective study by Chung et al. presents the results of LTC in 299 patients
including the neonatal outcomes. The procedure was generally carried out in week 12.5
of gestation with a mean operating time of 47.4 min and a mean intraoperative blood
loss of 70.1 ml. LTC was performed largely free of complications and the fetal survival
rate was 85.9%. 80% of preterm births occurred at a late stage between week 32 and
week 37 of gestation. Postnatally, 23 neonates (13.1%) needed to be transferred to
neonatal intensive care but there were no long-term sequelae. The mean gestational
age at delivery was 37 weeks and the mean birthweight was 2678 g. The cerclage tape
was left in place during cesarean delivery, and 29 women went on to have a further
successful pregnancy with the tape already in place [19 ]. The shorter operating times but higher blood loss in this study compared to those
recorded for our
cases could indicate that they used special needles and possibly manipulators to position
the tape, although this is not clear from the available information. These results
do not just show the safety and effectiveness of LTC as a preventive measure against
repeated spontaneous loss of pregnancy but also the positive effects on neonatal outcomes,
especially for patients in whom other cerclage methods have failed.
In the study by Kavallaris et al., laparoscopic emergency cerclage was generally carried
out in week 14.4. of gestation (14.2–16 GW), and no perioperative or postoperative
complications were reported. The average operating time was 88 min (80–95 min) and
the estimated blood loss during the procedure was less than 100 ml. In contrast to
our approach, they placed the cerclage tape under ultrasound monitoring using a tape
needle. All of the women in their study were delivered after the 38th GW by elective
cesarean section and the perinatal survival rate was 100% [8 ]. In our two cases, the mean operating time was 113.5 min (93–134 min), which is
about 25 min longer than in the study by Kavallaris et al. In contrast to Kavallaris
et al., we weighed up the risk of complications and decided against using a needle,
opting instead for blunt dissection to place the tape. This definitely prolonged the
operating
times. In one of our patients, surgery was made even more complicated by the presence
of extensive adhesions. With a blood loss of less than 50 ml, our estimated blood
loss was significantly lower compared to the study by Kavallaris et al.
Bolla et al. demonstrated another technique with the successful use of the Goldfinger
dissector (Ethicon Endo Surgery, Somerville, NJ, USA) to place a Mersilene tape in
a mixed cohort of pregnant women and women who had not yet conceived. The procedure
was carried out without complications and with minimal blood loss. The inclusion of
different manipulators according to gestational age demonstrates an adaptive approach
to minimize the risks [24 ].
Wolfe et al. described the options and challenges of robot-assisted cerclages, which
were successfully carried out without immediate complications despite the longer operating
times. But one of their patients had a uterine rupture, which highlights the potential
risk of these interventions but also emphasizes the importance of LTC as a protective
measure after conventional methods have failed [28 ].
In their study, Wang et al. presented an innovative method for transabdominal cervical
cerclage in which the tape is placed laparoscopically and removed transvaginally.
This technique combines the benefits of both approaches by reducing the risk of unnecessary
cesarean sections or abdominal surgery in the event of a late miscarriage by providing
the option of removing the cerclage knot. The procedure was carried out in 24 women,
three of whom were pregnant. The mean operating time was 35.50 ± 11.23 min and the
procedure was carried out without complications and with a minimal blood loss of less
than 30 ml. All of the pregnant patients delivered at or near term [13 ]. Despite the obvious benefits of this approach, there are some circumstances where
this method is unsuitable, especially if (as was the case in our two patients) there
is no visible residual cervix and the pregnancy is advanced. In such a
situation, the risk of serious complications such as vascular injury or damage to
the uterus can increase significantly. This underscores the need to select patients
carefully and to assess risks on an individual basis before using this method.
Data are also available which examine the effectiveness of laparoscopic transabdominal
cerclage compared to other cerclage methods in women with a high risk of late miscarriage
and preterm birth due to cervical insufficiency.
In a prospective study, Carter et al. analyzed the effectiveness of LTC compared to
abdominal cerclage (AC) in a cohort of 19 patients. LTC was typically carried out
earlier in pregnancy (median: 9 ± 2 GW) than AC (median: 12 ± 2 GW; p = 0.02), and
LTC was no longer considered an option after week 13 of gestation due to the increasing
size of the uterus. No intraoperative or postoperative complications occurred and
75% of the pregnancies treated with LTC and 71% of the pregnancies treated with AC
led to the birth of a viable infant. LTC had a higher success rate of 80% compared
to 60% for AC [29 ]. These findings were supported by the study by Huang et al., which compared LTC
with standard transvaginal cerclage (VC) in 289 patients. LTC was usually carried
out early in the first trimester (8–10 GW) whereas VC was carried out between the
12th and the 18th week of gestation or as an emergency measure between
the 17th and the 25th GW. LTC led to lower preterm birth rates and a higher median
gestational age at delivery of 38.3 weeks compared to 36.4 weeks with VC. Moreover,
the LTC group had a significantly lower hospitalization rate for imminent preterm
births. Serious complications such as cervical tears und postpartum bleeding were
only observed in the VC group. Although there were no significant differences between
the groups with regards to severe neonatal complications, the LTC group had a higher
fetal survival rate (98.3% compared to 89.4%), better neonatal outcomes with regards
to birth weight and APGAR scores and a lower rate of admission to neonatal intensive
care [30 ]. The study by Chen et al. also emphasizes the superior effectiveness and safety
of LTC compared to VC. This study evaluated 134 patients who had LTC before week 14
of gestation with no use of a manipulator, while non-pregnant patients had a
hysteroscopy using a manipulator. The Mersilene tape was placed twice around the cervix
using a needle with no perioperative or postoperative complications. The results showed
significantly better outcomes for the LTC group compared to the VC group. There were
more deliveries at term (24 of 26 in the LTC group vs. 15 of 33 in the VC group, p = 0.0001)
and a higher neonatal survival rate (25 of 26 in the LTC group vs. 23 of 32 in the
VC group, p = 0.0001). The mean duration of pregnancy at delivery was also longer
in the LTC group (37.88 ± 0.83 weeks for the LTC group vs. 32.91 ± 7.20 weeks for
the VC group, p = 0.0001) [17 ]. These results underscore the advantages of LTC in preventing preterm births and
improving pregnancy outcomes in high-risk patients with cervical insufficiency.
Bleeding from the uterine vessels is one of the most common complications of LTC,
particularly during pregnancy [9 ]. Many authors use a tape needle to position the tape in the avascular space between
the ascending and descending branches of the uterine vessels [8 ]
[9 ]
[15 ]
[31 ]. In our two cases, the vessels were already enlarged due to the advanced pregnancy,
which increased the risk of bleeding. To minimize the risk we decided against carrying
out traumatic punctures. Instead, after blunt dissection and careful exposure of the
uterine vessels at the transition from the cervix to the uterine body, a KELLY forceps
was used to
guide the tape through the avascular space and tie the tape securely.
Many authors use a uterus manipulator to manipulate the uterus and simplify the steps
of the operation, especially during cerclage placement prior to conception [7 ]
[9 ]
[32 ]. We decided against using a uterus manipulator because of the limited visibility
and difficulty of exposing the residual cervix in a vaginal procedure as well as the
necessity of minimizing the risk of pregnancy loss. In their case series, which included
five patients in the second trimester of pregnancy, Kavallaris et al. also took the
decision not to use a manipulator for the same reasons [8 ].
An overview of the above-reported case series of laparoscopic transabdominal cerclage
procedures carried out during pregnancy is given in [Table 1 ].
Table 1
Overview of studies on laparoscopic transabdominal cerclage carried out during pregnancy.
Author
Year
Patients
Pros/Retr
No LTC
LTC prior to conception (prec.)
LTC post conception (postc.)
GW
Complications
Intraoperative bleeding (ml)
Suture material
Used meedle
Used manipulator
Operating time
GW at delivery
Birthweight (g)
Neonatal survival rate
g = grams; GW = week of gestation; LTC = laparoscopic transabdominal cerclage; ml
= milliliters; n/s = not specified; prec. = prior to conception; prosp = prospective
study; postc. = after conception; retr = retrospective study
Cho CH [25 ]
2003
20
Retr
20
12.1 (11–14)
1 (5%)
< 100
Mersilene
yes
yes
55 (40–75)
> 34
n/s
95%
Wolfe L [28 ]
2008
2
n/s
2
11 (10–12)
no
25–30
Mersilene
yes
yes
191 (149–233)
36.5(35–38)
2664–3203
100%
Carter JF [29 ]
2009
19
pros
7
6
6
9 ± 2
no
n/s
Mersilene
yes
n/s
n/s
35.5 ± 2
2780 + 1479
80%
Whittle WL [9 ]
2009
65
pros
34
31
14
19.3%
n/s
Prolene
yes
prec.: yes
postc.: sponge with forceps
n/s
35.8 ± 2.9
n/s
89%
Ades A [22 ]
2014
64
n/s
61
3
1st trimester
1.6%
< 100
Prolene
yes
n/s
30–120
35.8
n/s
95.8%
Bolla D [24 ]
2015
18
retr
12
6
11.4 ± 1.6
no
< 20
Mersilene
Goldfinder
prec.: yes
postc.: no
55 ± 10
37.3 ± 1.9
n/s
100
Shin SJ [23 ]
2015
80
pros
80
12.1 (11–15)
no
< 100
Dagrofil (polyfilament polyester)
yes
no
52 (25–100)
36.3 ± 2.7
2690 (1860–3750)
72 (90%)
Chen Y [17 ]
2015
134
n/s
33
58
43
< 14
no
n/s
Mersilene
yes
prec.: yes
postc.: no
n/s
37.88 ± 0.83
3006 ± 403
96% (25/26)
Wang YY [13 ]
2020
24
retr
21
3
10.90 ± 2.61
1 (4.2%)
< 30 (10–50)
Mersilene
yes
prec.: yes
postc.: no
35.50 ± 11.23
37.21 ± 5.05
n/s
100%
Kavallaris A [8 ]
2021
5
retr
0
5
14.4 (14.2–16)
no
< 100
Mersilene
yes
no
88 (80–95)
83.1 (38.0–38.5)
3190 (2980–3350)
100%
Abdel Azim S [14 ]
2021
11
retr
7
4
n/s
no
n/s
Mersilene
no
prec.: yes
postc.: no
62 (37–126)
34 + 4 (27 + 0–38 + 1)
2640 g (700–3105)
100%
Chung H [19 ]
2021
299
retr
299
12.5 (10.5–17.5)
no
70.1 (0–200)
n/s
n/s
n/s
47.4 (15–100)
37 (26–40)
2678 (690–4100)
85.9%
Zhao B [27 ]
2022
10
n/s
10
13.5 (12–15)
no
200–400
Mersilene
no
no
15–30
37.3 (35+4–38+5)
2645 g (2150–3240)
100%
Huang G [30 ]
2022
289
retr
233
47
9
8–10
no
n/s
Mersilene
yes
prec.: yes
postc.: no
n/s
38.3
n/s
98.3%
Current study
2
retr
0
0
2
14.4 (14–16)
no
< 50
Mersilene
no
no
113.5
37.5 (35+4–39+5)
(2786–4160)
100%
Delivery by cesarean section is usually necessary after placement of an LTC [4 ]
[7 ]
[8 ]
[14 ]
[29 ]. The cerclage may be left in place if the mother wishes to have further children.
Several successful pregnancies have been described in the literature in which the
cerclage had been left in situ [7 ]
[9 ]
[29 ].
The literature presented here confirms that laparoscopic transabdominal cerclage is
a safe, very effective and feasible alternative if, for some reason, vaginal cerclage
is not possible or fails. Most of the available data are from case reports or case
series which use and report on different techniques, so there is currently no standard
procedure. Every technique has its own advantages and limitations. Recent studies
have emphasized the effectiveness and success of LTC, not just prior to conception
and in the first trimester of pregnancy but also in the second trimester. These findings
are especially relevant if transvaginal cerclage cannot be carried out or it fails.
Future studies in this field should focus on optimizing the techniques and on evaluating
the long-term effects on mother and child to further improve current practice and
increase safety.
