The laparoscopic uterine cerclage
What is the laparoscopic cerclage and when is it indicated?
The surgical intervention where a band is placed around the cervical-isthmic region of the uterus in as a form of treatment for cervical isthmic insufficiency is called laparoscopic cerclage.
This intervention is usually performed before conception or in the early stages of the first trimester of the pregnancy (up to the 11th week of gestation).
When is it recommended?
- Surgical interventions that alter the anatomy of the uterine cervix – a greater portion of the cervix is absent (cervical conization or electro-resection, uterine or cervical malformations, post cervical neoplasia trachelectomy). As a consequence to these surgical interventions, the classic transvaginal cerclage is impossible.
- Failure of the transvaginal cerclage.
What does it imply?
The procedure is done laparoscopically, under general anesthesia, by using four 5 mm incisions – one for the optical instrument and three for the surgical instruments. After identifying the urinary bladder and the ureters, the surgeon dissects the anatomical spaces surrounding the cervix, exposing the uterine arteries for visualization. A polypropylene band is then placed around the uterine cervix, medially to the uterine vessels.
The most opportune moment to perform the cerclage is before pregnancy. The advantages of performing surgery on the non-pregnant uterus are its smaller dimensions, the absence of uterine varicose veins and easier manipulation, and most of all, without any concern regarding the wellbeing of the fetus. Nevertheless, some women find out that they need a transabdominal cerclage when they are already pregnant. The surgery can be performed up until the 11th-12th week of gestation, with no fetal risk, and an equally effective procedure to the one performed before pregnancy.
What are the advantages of the laparoscopic cerclage?
Primarily, less bleeding, less post-operatory scar complications and a swifter recovery compared to open abdominal cerclage. The patients who have undergone abdominal laparoscopic cerclage have seen a significantly higher neonatal survival rate as compared to the ones who have undergone the classic intervention.
The abdominal laparoscopic cerclage lowers the miscarriage or premature birth risks, along with a very high chance of success. Studies show an increased neonatal survival rate associated to the patients who have undergone abdominal laparoscopic cerclage, as compared to the repeated transvaginal cerclages performed on women with premature births, despite a vaginal cerclage.
What risks does the surgery involve?
Similarly to any other surgical procedure, the main associated risks are: excessive bleeding, infection, as well as injury of the proximal viscera, such as the uterine bladder, intestine, or the great vessels. In our experience, no such intra- or postoperative complications were encountered.
What should be expected after undergoing laparoscopic cerclage?
The recovery is rapid and painless. The patients can continue to perform all their day to day activities, such as working or driving. Walking, pregnancy-focused Pilates and other light exercise is allowed.
In our experience, most pregnancies are normal and without any complications after the laparoscopic cerclage is performed. There is no need for the patient to stop working. There is no need for rest in bed.
A cesarean section is recommended around the gestational age of 38-39 weeks.
All the routine pregnancy investigations, such as fetal ultrasonography, fetal morphology and blood tests should be performed, as indicated by your obstetrician.
What are the contraindications?
Highly intense or vigorous physical activity is forbidden. Lifting objects weighing more than 5 kg should be avoided.
In the improbable event of uterine contractions, the obstetrician should be alerted and the appropriate treatment should be administered.
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