Laparoscopic Cerclage as a Treatment Option for Cervical Insufficiency

Abstract

Background: The traditional surgical treatment for cervical insufficiency is vaginal placement of a cervical cerclage. However, in a small number of cases a vaginal approach is not possible. A transabdominal approach can become an option for these patients. Laparoscopic cervical cerclage is associated with good pregnancy outcomes but comes at the cost of a higher risk of serious surgical complications. The aim of the present study was to evaluate intraoperative and long-term pregnancy outcomes after laparoscopic cervical cerclage, performed either as an interval procedure or during early pregnancy, using a new device with a blunt grasper and a flexible tip. Methods: All women who underwent laparoscopic cervical cerclage for cervical insufficiency in our institution using the Goldfinger® device (Ethicon Endo Surgery, Somerville, NJ, USA) between January 2008 and March 2014 were included in the study. Data were collected from the patientsʼ medical records and included complications during and after the above-described procedure. Results: Eighteen women were included in the study. Of these, six were pregnant at the time of laparoscopic cervical cerclage. Mean duration of surgery was 55 ± 10 minutes. No serious intraoperative or postoperative complications occurred. All patients were discharged at 2.6 ± 0.9 days after surgery. One pregnancy ended in a miscarriage at 12 weeks of gestation. All other pregnancies ended at term (> 37 weeks of gestation) with good perinatal and maternal outcomes. Summary: Performing a laparoscopic cervical cerclage using a blunt grasper device with a flexible tip does not increase intraoperative complications, particularly in early pregnancy. We believe that use of this device, which is characterized by increased maneuverability, could be an important option to avoid intraoperative complications if surgical access is limited due to the anatomical situation. However, because of the small sample size, further studies are needed to confirm our findings.

Zusammenfassung

Hintergrund: Die Therapie einer Zervixinsuffizienz besteht aktuell in der vaginalen Cerclage. In einigen wenigen Fällen ist dies nicht möglich, sodass die laparoskopische zervikale Cerclage eine Therapieoption sein kann, die aber mit einem höheren Risiko intraoperativer Komplikationen assoziiert ist. Das Ziel unserer Studie besteht darin, sowohl die intraoperative Sicherheit als auch die Langzeitergebnisse der mit einem „neuen“ Instrument durchgeführten laparoskopischen zervikalen Cerclage – präkonzeptionell oder in der Frühschwangerschaft durchgeführt – zu evaluieren. Methoden: Eingeschlossen wurden alle Frauen, bei denen zwischen Januar 2008 und März 2014 eine laparoskopische zervikale Cerclage mittels dem Goldfinger®-Instrument (Ethicon Endo Surgery, Somerville, NJ, USA) aufgrund einer Zervixinsuffizienz durchgeführt wurde. Es wurden alle Daten der Patientinnen inklusive der peri- und postoperativen Komplikationen der oben beschriebenen Operationstechniken gesammelt. Ergebnisse: Achtzehn Frauen wurden in unsere Studie eingeschlossen. Zum Zeitpunkt der durchgeführten laparoskopischen zervikalen Cerclage waren 6 Patientinnen schwanger. Die mittlere Operationsdauer betrug 55 ± 10 Minuten. Es traten keine ernsthaften peri- und postoperativen Komplikationen auf. Alle Patientinnen konnten nach 2,6 ± 0,9 Tagen aus dem Spital entlassen werden. Bei einer Patientin kam es zu einem Abort in der 12. SSW. Bei allen anderen Schwangerschaften kam es zur Geburt am Termin (> 37. SSW) mit gutem perinatalen und maternalen Outcome. Zusammenfassung: Das Durchführen einer laparoskopischen zervikalen Cerclage mit diesem flexiblen Instrument scheint die intraoperative Komplikationsrate – insbesondere in der Frühschwangerschaft – nicht zu erhöhen. Die Verwendung des flexiblen und sehr gut manövrierbaren Instruments ist eine interessante Möglichkeit bei Patientinnen mit anatomisch schwierigen Verhältnissen und der Notwendigkeit einer zervikalen Cerclage. Um die guten Resultate zu bestätigen sind weitere Studien notwendig.

Key words

laparoscopic cerclage - Goldfinger® device - prematurity - cervical insufficiency - cervical cerclage - transabdominal cerclage

Schlüsselwörter

laparoskopische Cerclage - Goldfinger®-Gerät - Frühgeburtlichkeit - Zervixinsuffizienz - zervikale Cerclage - transabdominale Cerclage

• References

• 1 Alfirevic Z, Stampalija T, Roberts D et al. Cervical stitch (cerclage) for preventing preterm birth in singleton pregnancy. Cochrane Database Syst Rev 2012; (4) CD008991
• 2 Raio L, Ghezzi F, Di Naro E et al. Duration of pregnancy after carbon dioxide laser conization of the cervix: influence of cone height. Obstet Gynecol 1997; 90: 978-982
• 3 Becher N, Hein M, Danielsen CC et al. Matrix metalloproteinases in the cervical mucus plug in relation to gestational age, plug compartment, and preterm labor. Reprod Biol Endocrinol 2010; 8: 113
• 4 Petersen LK, Uldbjerg N. Cervical collagen in non-pregnant women with previous cervical incompetence. Eur J Obstet Gynecol Reprod Biol 1996; 67: 41-45
• 5 Lash AF, Lash SR. Habitual abortion: the incompetent internal os of the cervix. Am J Obstet Gynecol 1950; 59: 68-76
• 6 Shirodkar VN. A new method of operative treatment for habitual abortions in the second trimester of pregnancy. Antiseptic 1955; 52: 299-300
• 7 Kyvernitakis I, Khatib R, Stricker N et al. Is early treatment with a cervical pessary an option in patients with a history of surgical conisation and a short cervix?. Geburtsh Frauenheilk 2014; 74: 1003-1008
• 8 Kypros Nicolaides, Kingʼs College Hospital London. Randomized study of pessary versus standard management in women with increased chance of premature birth. Oral presentation. FMF Congress Nizza, 2014.
• 9 McDonald IA. Suture of the cervix for inevitable miscarriage. J Obstet Gynaecol Br Commonw 1957; 64: 346-353
• 10 Harger JH. Cerclage and cervical insufficiency: an evidence-based analysis. Obstet Gynecol 2002; 100: 1313-1327 Erratum in: Obstet Gynecol 2003; 101: 205 Erratum in: Obstet Gynecol 2003; 101: 205
• 11 Benson RC, Durfee RB. Transabdominal cervicouterine cerclage during pregnancy for the treatment of cervical incompetency. Obstet Gynecol 1965; 25: 145-155
• 12 Scibetta JJ, Sanko SR, Phipps WR. Laparoscopic transabdominal cervicoisthmic cerclage. Fertil Steril 1998; 69: 161-163
• 13 Lesser KB, Childers JM, Surwit EA. Transabdominal cerclage: a laparoscopic approach. Obstet Gynecol 1998; 91 (5 Pt 2) 855-856
• 14 Riiskjaer M, Petersen OB, Uldbjerg N et al. Feasibility and clinical effects of laparoscopic abdominal cerclage: an observational study. Acta Obstet Gynecol Scand 2012; 91: 1314-1318
• 15 Burger NB, Einarsson JI, Brölmann HA et al. Preconceptional laparoscopic abdominal cerclage: a multicenter cohort study. Am J Obstet Gynecol 2012; 207: 273.e1-273.e12
• 16 Burger NB, Brölmann HA, Einarsson JI et al. Effectiveness of abdominal cerclage placed via laparotomy or laparoscopy: systematic review. J Minim Invasive Gynecol 2011; 18: 696-704
• 17 Ghomi A, Rodgers B. Laparoscopic abdominal cerclage during pregnancy: A case report and a review of the described operative techniques. J Minim Invasive Gynecol 2006; 13: 337-341
• 18 Carter JF, Soper DE, Goetzl LM et al. Abdominal cerclage for the treatment of recurrent cervical insufficiency: laparoscopy or laparotomy?. Am J Obstet Gynecol 2009; 201: 111.e1-111.e4
• 19 Liddell HS, Lo C. Laparoscopic cervical cerclage: a series in women with a history of second trimester miscarriage. J Minim Invasive Gynecol 2008; 15: 342-345
• 20 Nicolet G, Cohen M, Begue L et al. Laparoscopic cervico-isthmic cerclage evaluation. Gynecol Obstet Fertil 2009; 37: 294-299
• 21 Mingione MJ, Scibetta JJ, Sanko SR et al. Clinical outcomes following interval laparoscopic transabdominal cervico-isthmic cerclage placement: case series. Hum Reprod 2003; 18: 1716-1719
• 22 Luo L, Chen SQ, Jiang HY et al. Successful treatment of cervical incompetence using a modified laparoscopic cervical cerclage technique: a cohort study. Eur J Obstet Gynecol Reprod Biol 2014; 179 C: 125-129
• 23 Ades A, May J, Cade TJ et al. Laparoscopic transabdominal cervical cerclage: a 6-year experience. Aust N Z J Obstet Gynaecol 2014; 54: 117-120
• 24 Whittle WL, Singh SS, Allen L et al. Laparoscopic cervico-isthmic cerclage: surgical technique and obstetric outcomes. Am J Obstet Gynecol 2009; 201: 364.e1-364.e7
• 25 Robinson SM, White SA. The use of Goldfinger(TM)(Ethicon Endo Surgery) to facilitate laparoscopic distal pancreatectomy. Ann R Coll Surg Engl 2009; 91: 524-525
• 26 Cho CH, Kim TH, Kwon SH et al. Laparoscopic transabdominal cervicoisthmic cerclage during pregnancy. J Am Assoc Gynecol Laparosc 2003; 10: 363-366
• 27 Agdi M, Tulandi T. Placement and removal of abdominal cerclage by laparoscopy. Reprod Biomed Online 2008; 16: 308-310
• 28 Deffieux X, de Tayrac R, Louafi N et al. Transvaginal cervico-isthmic cerclage using polypropylene tape: surgical procedure and pregnancy outcome: Fernandezʼs procedure. J Gynecol Obstet Biol Reprod (Paris) 2006; 35 (5 Pt 1) 465-471
• 29 Deffieux X, Faivre E, Senat MV et al. Transvaginal cervicoisthmic cerclage using a polypropylene sling: pregnancy outcome. J Obstet Gynaecol Res 2011; 37: 1297-1302