Research www. AJOG.

org

OBSTETRICS
Laparoscopic cervico-isthmic cerclage: surgical
technique and obstetric outcomes
Wendy L. Whittle, MD, PhD; Sukhbir S. Singh, MD; Lisa Allen, MD; Louise Glaude, RN;
Jacqueline Thomas, MD; Rory Windrim, MD; Nicholas Leyland, MD

OBJECTIVE: The purpose of the study is to review the surgical tech-
nique, complication rate and obstetric outcome associated with the
laparoscopic approach to the placement of the cervico-isthmic
cerclage.
STUDY DESIGN: A prospective cohort study was conducted from
2003-2008 and compared with previously reported cases of cervico-
isthmic cerclage by laparotomy and laparoscopy.
RESULTS: Thirty-one patients underwent cerclage placement during
pregnancy and 34 patients were not pregnant at the time of the surgery.
Seven cases were converted to laparotomy due to complications arising
from uterine vessel bleeding or impaired surgical visibility; 2 pregnan-
cies were lost perioperatively. No other complications occurred. The fe-
tal salvage rate (n 67 pregnancies) was 89% with a mean gestational
age of 35.8 2.9 weeks. Six pregnancies were lost in the second tri-
mester due to the consequences of acute or subacute chorioamnionitis.
CONCLUSION: Our findings suggest that the cervico-isthmic cerclage
placed laparoscopically compares favorably with the traditional laparot-
omy approach.
Key words: abdominal cerclage, cervico-isthmic cerclage,
laparoscopy, laparotomy

Cite this article as: Whittle WL, Singh SS, Allen L, et al. Laparoscopic cervicoisthmic cerclage: surgical technique and obstetric outcomes. Am J Obstet Gynecol
2009;201:364.e1-7.

C ervical incompetence occurs in

0.5-1% of all pregnancies, has a re-
currence risk of 30% and typically pre-
sents in the second trimester as pelvic
pressure and cervical dilation in the ab-
sence of uterine activity or ruptured
membranes.1 The etiology of cervical in-
competence can be classified as (1) a me-
chanical failure of the cervix to remain
From the Division of Maternal-Fetal
Medicine, Department of Obstetrics and
Gynaecology, Mount Sinai Hospital (Drs
Whittle and Windrim and Ms Glaude); the
Department of Obstetrics and Gynaecology,
St. Josephs Health Care Centre (Drs Singh
and Leyland); and the Department of
Obstetrics and Gynaecology, Mount Sinai
Hospital (Drs Allen and Thomas),
University of Toronto, Toronto, ON,
Canada.
Received Nov. 10, 2008; revised Feb. 25,
2009; accepted July 14, 2009.
Reprints not available from the authors.
0002-9378/free
2009 Published by Mosby, Inc.
doi: 10.1016/j.ajog.2009.07.018
For Editors Commentary,
see Table of Contents
closed against the increasing uterine dis-
tention pressure, or (2) a functional fail-
ure due to premature cervical ripening.1
The cervical cerclage through a vaginal
approach was introduced as a mecha-
nism to reinforce the cervical integrity.
In 1965, Benson and Durfee2 introduced
an alternative to the vaginal approach
the placement of a cerclage at the cervical
isthmus: a noose-like suture positioned
around the isthmus in the avascular
space above the cardinal and uterosacral
ligaments placed by laparotomy.3 This
technique was intended when the vagi-
nal approach was not feasible due to al-
tered cervical anatomy (ie, congenital
anomaly, scarring due to cone biopsy, or
laceration at delivery); the indication
was extended by Novy4 to include a
failed transvaginal cerclage in a previous
pregnancy. Cervico-isthmic cerclage re-
views quote a successful pregnancy out-
come rate from 76.5-100%; however, the
morbidity associated with the surgical
procedure is significant.5 In an era when
endoscopic surgery provides a mini-
mally invasive alternative with docu-
mented benefit over the traditional lap-
arotomy approach, it has been proposed
that the cervico-isthmic cerclage could
be completed laparoscopically.6 The ob-
jective of the present study is to review
the surgical technique, morbidity, and
obstetric outcome associated with the
laparoscopic approach to placement of
the cervico-isthmic cerclage. Our find-
ings will be compared with reports of
the traditional cervico-isthmic cerclage
placed by laparotomy and more recently
laparoscopy.7-30
M ATERIALS AND M ETHODS
A prospective observational cohort
study was conducted from January 2003
to June 2008 at Mount Sinai Hospital
(Toronto, Canada) with institutional
ethics board approval (MSH REB no. 06-
0149-E). The indication for cerclage
placement was a presumptive diagnosis
of mechanical cervical incompetence
based on the Novy criteria.4 Pregnant
patients underwent pelvic ultrasound to
confirm viability, and were offered first
trimester aneuploidy screening or diag-
nostic chorionic villi sampling prior to
cerclage placement. After surgery, preg-
nant patients underwent routine cervi-
cal/vaginal swabs and urine culture. All
infections were treated with routine an-
tibiotic therapy; if the test of cure indi-

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Steps 4 and 5: right and left sided

TABLE 1 placement of cerclage at the
Patient demographics cervico-isthmic junction
Demographic n The needle was introduced medial and
Mean maternal age at cerclage, y 32.6 4.6 (range, 2242) posterior to the uterine vessels, a small pur-
..............................................................................................................................................................................................................................................
Mean gravidity 3.4 2.3 (range, 014) chase of cervical tissue at the level of the
..............................................................................................................................................................................................................................................
cervico-isthmic junction is taken, and the
No. of live children/patient 0.43 (range, 02)
.............................................................................................................................................................................................................................................. needle is followed through anteriorly with
Patients with previous term pregnancy 27.60% the distal end of the suture in the cul-de-
..............................................................................................................................................................................................................................................
T1 loss, % (mean no. T1 loss/patient) 38.5% (0.8 1.8) sac behind the uterus. This step anchored
..............................................................................................................................................................................................................................................
T2 loss, % (mean no. T2 loss/patient) 92.3% (1.6 1.1) the suture on the right side of the uterus.
..............................................................................................................................................................................................................................................
The suture material and needle was passed
Patient with prior TA 13.8%
.............................................................................................................................................................................................................................................. anteriorly across the lower segment to the
Patients with prior failed cerclage 58.0% left side of the uterus. In a similar fashion,
..............................................................................................................................................................................................................................................
Patients with previous cervical surgery (cone, LEEP) 68.7% the needle is placed medial to the left sided
..............................................................................................................................................................................................................................................
Patient with DES exposure 0% uterine vessels and a small purchase of cer-
..............................................................................................................................................................................................................................................
vical tissue at the level of the left sided cer-
Nulligravid/primigravid patients with insufficient cervical tissue 5 (7.6%)
.............................................................................................................................................................................................................................................. vico-isthmic junction was taken as the nee-
DES, diethylstilbestrol; LEEP, loop electrosurgical excision procedure; T1, first trimester; T2, second trimester. dle was passed through posteriorly
Whittle. Laparoscopic cervicoisthmic cerclage. Am J Obstet Gynecol 2009.
through the broad ligament window leav-
ing the needle in the cul-de-sac and secur-
cated ongoing infection, suppressive an- oped bilaterally through a combination ing the suture to the left side of the uterus
tibiotic therapy was prescribed for the of blunt and sharp dissection. (Figure, A and B).
remainder of the pregnancy. Step 6: the cerclage knot secured
Step 2: creation of broad ligament
The cerclage was tied by either an extracor-
Surgical preparation peritoneal windows
poreal or intracorporeal knot at the poste-
The patient was prepared in the dorsal Anteversion of the uterus revealed a
rior aspect of the uterus. The tension of the
lithotomy position with a urinary cathe- transparent posterior leaf of the broad
suture can be adjusted over a transcervical
ter in situ. If the patient was not preg- ligament, an avascular space to create a
5 mm Hegar dilator in the nonpregnant
nant, a transcervical uterine manipula- window in the broad ligament on each
patient. The suture placement should sit at
tor was used; for the pregnant patient, a side of the uterus. Fluid placement in the
the level of the internal cervical os, above
sponge on ring forcep was placed into anterior cul-de-sac facilitated identifica-
the uterosacral ligaments, the knot at the
the vaginal fornix to facilitate uterine tion of the avascular space. The opening
posterior aspect of the uterus (Figure, C
manipulation. A traditional 4 puncture was created by a push and spread tech-
and D).
operative laparoscopy set up is used. Ini- nique through the peritoneum with a
At the conclusion of the procedure,
tial abdominal entry is achieved through laparoscopic grasper and enlarged by
the laparoscopic ports are removed, the
the closed Veress technique at the umbi- stretching the opening parallel and lat-
gas evacuated, and the abdominal wall
licus.16 For cases done during preg- eral to the uterine vessels. Creating this
and skin are repaired in the usual fash-
nancy, the gravid uterus was avoided window allowed for caudal displacement
ion. No tocolytic agents were adminis-
through entry in the left upper quadrant of the ureters and identified the uterine
tered during or post procedure for gravid
by the closed Veress technique or vessels at the cervico-isthmic junction.
patients. Perioperative antibiotics were
through an open Hassan technique at the
Step 3: placement of suture material administered at the discretion of the pri-
umbilicus. Abdominal insufflation was
through broad ligament mary surgeon. Nonpregnant patients
maintained at 12-15 mmHg using CO2.
peritoneal window were discharged home from the postop-
Step 1: development of the A no. 1 Prolene (Ethicon Inc., Somer- erative recovery area; pregnant patients
paravesical and vesico- ville, NJ) suture on a CT-1 needle was were admitted overnight for observation
uterine spaces passed into the abdomen through a and a pelvic ultrasound to confirm fetal
The vesicouterine peritoneum was in- 10-12 mm port on a laparoscopic needle viability.
cised using the CO2 laser (Coherent Inc., holder. It is critical that the needle be set
Santa Clara, CA) or monopolar scissors to pass from the posterior aspect of the R ESULTS
across the lower uterine segment, and a right broad ligament window through Sixty-five patients underwent laparoscopic
combination of sharp and blunt dissec- anteriorly to prepare the trailing suture cervico-isthmic cerclage during the study
tion was used to reflect the bladder from length for the final step; in this step the period; patient demographics are pre-
the lower uterine segment and anterior needle and suture sit lateral to the right sented in Table 1. Thirty-one patients un-
cervix. Paravesical spaces were devel- sided uterine vessels. derwent cerclage placement in the first or

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curred. All patients delivering after 24

TABLE 2 weeks of gestation underwent cesarean
Pregnancy outcomes following laparoscopic section with the cerclage left intact; no op-
cervico-isthmic cerclage placement erative complications of this surgery oc-
Outcome n curred. Six patients had the cerclage re-
Perioperative pregnancy loss n2 moved at the time of delivery and a tubal
..............................................................................................................................................................................................................................................
T1 SA n1 ligation performed. The cerclage was re-
..............................................................................................................................................................................................................................................
moved in 1 patient at the time of delivery at
T1 TA n1
.............................................................................................................................................................................................................................................. term as it was no longer intact, and 1 pa-
IUFD n1 tient had the cerclage removed postpar-
..............................................................................................................................................................................................................................................
Delivery 24 wk with NND n6 tum through a posterior colpotomy as it
..............................................................................................................................................................................................................................................
Delivery 24 wk n 54 had eroded through the posterior fornix
..............................................................................................................................................................................................................................................
into the vagina.
Mean GA if pregnancy lasted 12 wk 34.4 5.4 wk (17-39 wk)
.............................................................................................................................................................................................................................................. Sixty-seven pregnancies have occurred
Mean GA if pregnancy lasted 24 wk 35.8 2.9 wk (24.5-39 wk) in this study cohort and 8 patients remain
..............................................................................................................................................................................................................................................
Distribution of GA at delivery 24 28 wk n 2 nonpregnant. The overall pregnancy suc-
28 32 wk n 5 cess rate defined as number of live births
32 36 wk n 10 per number of pregnancies is 80.6%; de-
36 wk n 53
.............................................................................................................................................................................................................................................. tails of pregnancy outcomes are presented
NND with delivery 24 wk n1 in Table 2. Three pregnancies were aborted
..............................................................................................................................................................................................................................................
No. of NICU admissions n 12 in the first trimester (1 patient had a termi-
..............................................................................................................................................................................................................................................
No. with long-term sequelae of prematurity n0 nation due to fetal trisomy 21); all 3 cases
..............................................................................................................................................................................................................................................
were managed by dilatation and curettage
Weeks of pregnancy gained: 13.2 Mean GA at delivery in last pregnancy
prior to cerclage: 19.7 8.0 wk
through the cerclage. The mean gestational
Mean GA at first delivery age at delivery for all remaining pregnan-
postcerclage: 32.9 8.8 wk cies was 34.4 5.4 weeks (17.0 39.0 wk); 1
..............................................................................................................................................................................................................................................
Fetal salvage rate No. of liveborn children at last patient experienced an intrauterine fetal
6.5-fold improvement pregnancy prior to cerclage: 8/67 demise unrelated to the indication for the
(11.9%) cerclage. Cerclage failure was defined as
No. of liveborn children at first delivery prior to neonatal viability between
pregnancy 12 wk postcerclage 13 and 23 6 weeks of gestation; 6 patients
53/60 (88.3%)
.............................................................................................................................................................................................................................................. experienced a cerclage failure with a mean
GA, gestational age; IUFD, intrauterine fetal demise; NICU, neonatal intensive care unit; NND, neonatal death; T1 SA, first
trimester spontaneous abortion; T1 TA, first trimester therapeutic abortion.
gestational age at presentation of 20.7
Whittle. Laparoscopic cervico-isthmic cerclage. Am J Obstet Gynecol 2009. 2.9 weeks (range, 17.0 23.0 wk). Details of
the clinical presentations are presented in
Table 3; all failures were attributed to the
second trimester (16 weeks gestation) tients were pregnant. Two patients experi-
clinical consequences of acute or subacute
and 34 patients were not pregnant at the enced a perioperative pregnancy loss; both
chorioamnionitis and occurred in women
time of the surgery. Seven cases were con- cases had been converted to laparotomy
with a history of recurrent second trimes-
verted to laparotomy due to either compli- due to bleeding requiring uterine vessel li-
ter loss. Each patient was managed with a
cations arising from uterine vessel bleeding gation and 1 of the cases was 16 weeks
posterior colpotomy for cerclage removal
(n 5) or impaired surgical visibility (n gestation. No other immediate surgical
followed by a vaginal delivery; all patients
2) due to morbid obesity; 6 of these pa- complications related to laparoscopy oc-
received intravenous antibiotics due to the
clinical diagnosis of chorioamnionitis, and
TABLE 3 1 patient was septic with a positive blood
Details of pregnancy failure culture for Escherichia coli.
No. of cerclage failures 6 The mean gestational age at delivery if
Mean GA at failure 20.7 / 2.9w (1723) the pregnancy continued past viability was
..............................................................................................................................................................................................................................................
35.8 2.9 weeks (range, 24.539.0 wk)
Reason for failure PPROM n3
.............................................................................................................................................. (Table 4). The net number of weeks of
Cervical dilatation clinical chorioamnionitis n2 pregnancy gained for those patients who
..............................................................................................................................................
Preterm labor n2 had experienced a previous pregnancy loss
..............................................................................................................................................................................................................................................
Placental pathology Acute stage II/III chorioamnionitis n6 was 13.5 weeks of gestation with a 6.5-fold
..............................................................................................................................................................................................................................................
PPROM, premature preterm ruptured membranes
increase in the number of liveborn chil-
Whittle. Laparoscopic cervico-isthmic cerclage. Am J Obstet Gynecol 2009.
dren compared with the pregnancy imme-
diately preceding the cerclage. Twelve ba-

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www.AJOG.org Obstetrics Research
perioperative complications as the cer-
TABLE 4 vico-isthmic cerclage placed by laparot-
Effect of timing and indication for cerclage on pregnancy outcome omy (10% vs 0-25%, respectively; Table
Indication for cervico-isthmic cerclage 5). The main complication of either ap-
.....................................................................................................................................................................................................................................
Previous T2 loss / cone biopsy 31.2 / 7.8 w (1738 w) proach was excessive blood lossin our
.....................................................................................................................................................................................................................................
Previous failed vaginal cerclage / cone biopsy 34.1 / 5.3 w (2038 w) series no patient required a blood trans-
.....................................................................................................................................................................................................................................
fusion. The second most common com-
Nulliparous with prior cone biopsy 1 delivery at 34 w
....................................................................... plication was the conversion to laparot-
3 delivery at 37 w omy due to surgical visibilitysuch a
..............................................................................................................................................................................................................................................
Timing of cerclage: mean GA at delivery for complication should be considered in
pregnancies 12 w the context that 58 women were spared a
.....................................................................................................................................................................................................................................
Cerclage placed in pregnancy 32.9 / 8.8 w laparotomy by having the cerclage
.....................................................................................................................................................................................................................................
Cerclage placed nonpregnant 34.5 / 4.9 w placed laparoscopically. Since the cer-
..............................................................................................................................................................................................................................................
clage is placed similar to a noose in the
Pregnancy failures (perioperative loss, IUFD, delivery
24 w, NND) area of the cervical isthmus, a potential
.....................................................................................................................................................................................................................................
complication is compression of the uter-
Cerclage placed in pregnancy n7
..................................................................................................................................................................................................................................... ine vessels leading to compromised uter-
Cerclage placed nonpregnant n2 ine blood flow and subsequent fetal de-
..............................................................................................................................................................................................................................................
IUFD, intrauterine fetal demise; NND, neonatal death. mise; our perioperative losses could be
Whittle. Laparoscopic cervico-isthmic cerclage. Am J Obstet Gynecol 2009. attributed to uterine vessel compression
but may also be in part due to specific
vessel ligation to arrest excessive bleed-
bies were admitted to the neonatal with a cerclage placed in the vaginal por-
intensive care unit, 1 baby died due to ex- ing. The reported perioperative loss rate
tion of the cervix in the subsequent preg-
treme prematurity, and no other long- nancy.1 This therapeutic intervention is by us and others did not occur with any
term sequelae of prematurity were re- based on the assumption that the struc- greater incidence using the laparoscopic
ported. Nine patients have had a second tural integrity of the cervical tissue has approach and likely is a risk of this type
term (37 weeks) pregnancy with the insufficient strength to act as a barrier to of cerclage regardless of the surgical ap-
same cerclage in situ, and 1 patient has had delivery against the increasing intrauter- proach. As the uterine size increases it
3 term pregnancies. Two patients had a ine pressure of the growing gestational does become a technically more chal-
twin gestation at the time of cerclage place- sac.1 When this vaginal cerclage fails to lenging procedure; although we reported
ment in the first trimester; both patients hold the cervix closed or cannot be only 2 cases of cerclage placement in the
delivered healthy children after 34 weeks of placed due to insufficient cervical tissue, second trimester, 1 was complicated by
gestation with no long-term complications an alternative approach is the placement conversion and fetal loss. In addition, the
of preterm birth. of a cerclage at the cervico-isthmus of the conversion to laparotomy did occur
Overall, the timing of cerclage place- uterus. Conventionally, this type of cer- more frequently when the patient was
ment did not influence the gestational age clage is placed in the first trimester of pregnant. Placement of this cerclage us-
at delivery but cerclage failure did occur pregnancy through a laparotomy; how- ing a vaginal approach with tissue dissec-
more often when the cerclage was placed ever, with the advent of minimally inva- tion similar to that of a vaginal hysterec-
during that pregnancy (Table 4). The indi- sive surgery, placement by laparoscopy tomy has recently been described; this
cation for cerclage did not affect the gesta- has been described in case reports and technique may be advantageous for
tional age at delivery, but in the small num- series (Table 5).7-30 The purpose of this women who present in the late first or
ber of patients for whom the cerclage was study was to describe the surgical tech- early second trimester.31 A #1 Prolene
placed due to insufficient cervical tissue nique for the laparoscopic cervico-isth- suture was chosen in this study with the
there was no cerclage failure (Table 4). mic cerclage, its associated obstetric out- rationale based on ease of handling for
Table 5 presents the outcome of previ- comes, and compare these outcomes placement and removal compared with
ously published retrospective cohorts of with the traditional laparotomy ap- the traditional 5 mm Mersilene tape; this
cervico-isthmic cerclage placed by both proach using previously reported co- rationale is similarly supported by Rust
laparotomy and laparoscopy with an op- horts that describe both rates of opera- et al32 in the choice of suture material for
erative complication rates of 0-25% and tive complications and fetal survival. a vaginal cerclage. The successful results
fetal survival rates between 60-100%. we present support the use of this type of
Surgical considerations suture material in regard to its integrity
C OMMENT The advantages of a minimally invasive and strength. Concerning the technique
Cervical incompetence, defined as preg- approach are well established; we pro- for knot tying, since the Roeder knot
nancy loss following painless cervical di- vide evidence that this approach confers strength has been determined to be
latation, has been traditionally treated similar if not a slightly improved rate of equivalent to the intracorporeal knot,

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TABLE 5
Cumulative results of cervico-isthmic cerclage placed during pregnancy by laparotomy and cervico-isthmic
cerclage placed by laparoscopy in both pregnant and nonpregnant patients
Cerclage placed by laparotomy: Patient Pregnancy Intraoperative complicationa Fetal survival
study and year no. no. rate, % rate, %
Benson and Durfee 1965 10 13 Not reported 82
................................................................................................................................................................................................................................................................................................................................................................................
Watkins 1972 2 2 Not reported 100
................................................................................................................................................................................................................................................................................................................................................................................
Mahran 1978 10 10 0 70
................................................................................................................................................................................................................................................................................................................................................................................
Olsen and Tobiassen 1982 17 17 Not reported 88
................................................................................................................................................................................................................................................................................................................................................................................
Novy 1982 16 22 Not reported 95
................................................................................................................................................................................................................................................................................................................................................................................
Wallenberg and Lotgering 1987 13 16 0 94
................................................................................................................................................................................................................................................................................................................................................................................
Herron and Parer 1988 8 13 Not reported 85
................................................................................................................................................................................................................................................................................................................................................................................
Van Dongen et al 1991 14 16 14.2 96
................................................................................................................................................................................................................................................................................................................................................................................
Novy 1991 20 21 0 90
................................................................................................................................................................................................................................................................................................................................................................................
Cammarano et al 1995 23 29 21.7 93
................................................................................................................................................................................................................................................................................................................................................................................
Anthony et al 1997 13 15 7.6 87
................................................................................................................................................................................................................................................................................................................................................................................
Craig and Fliegner 1997 4 5 25 60
................................................................................................................................................................................................................................................................................................................................................................................
Turnquest et al 1999 11 12 0 83
................................................................................................................................................................................................................................................................................................................................................................................
Davis et al 2000 40 40 0 97
................................................................................................................................................................................................................................................................................................................................................................................
Lotgering et al 2006 101 101 5 93.5
................................................................................................................................................................................................................................................................................................................................................................................
Debbs et al 2007 75 75 4 96
................................................................................................................................................................................................................................................................................................................................................................................
Scibetta et al 1998 1 1 0 100
................................................................................................................................................................................................................................................................................................................................................................................
Lesser et al 1998 1 1 0 100
................................................................................................................................................................................................................................................................................................................................................................................
Mingione et al 2003 11 12 9 83
................................................................................................................................................................................................................................................................................................................................................................................
Cho et al 2003 20 19 0 95
................................................................................................................................................................................................................................................................................................................................................................................
Gallot et al 2003 3 2 0 100
................................................................................................................................................................................................................................................................................................................................................................................
Ghomi et al 2006 1 1 0 100
................................................................................................................................................................................................................................................................................................................................................................................
Aboujaoude et al 2007 1 1 0 Not reported
................................................................................................................................................................................................................................................................................................................................................................................
Agdi et al 2008 1 1 0 100
................................................................................................................................................................................................................................................................................................................................................................................
Reid et al 2008 2 0 0 100
................................................................................................................................................................................................................................................................................................................................................................................
Current study 65 67 10.7 80
................................................................................................................................................................................................................................................................................................................................................................................
a
Intraoperative complications include: cystotomy, bleeding 500c, bleeding requiring transfusion, perioperative pregnancy loss, ruptured fetal membranes.
Whittle. Laparoscopic cervico-isthmic cerclage. Am J Obstet Gynecol 2009.

the posterior location of our knot place- attributable to the cerclage, the true cer- that cervical incompetence is a complex
ment favors the Roeder knot especially clage success rate should be defined by the disease that cannot be treated solely with
with the bulky pregnant uterus.33 We pregnancies lost at the time of surgery (2 the placement of a cerclage either vagi-
conclude that the laparoscopic approach cases) and the number of live, take home nally or at the cervico-isthmus; multiple
for the placement of the cervico-isthmic babies (58 cases) after the first trimester is etiologies lead to a common final pathway
cerclage confers a similar rate of periop- completed. By this definition, the rate of of undesired cervical dilatation and efface-
erative complications as the traditional cerclage success was 89%, making the ob- ment. Cervical incompetence should be
laparotomy and is best completed non- stetric outcome after laparoscopic cervico- described in 2 main categories: mechanical
pregnant or early in the first trimester. isthmic cerclage comparable to that of the and functional. Mechanical incompetence
Obstetric considerations abdominal approach and to that reported implies that the cervical components do
In our series, the fetal survival rate was by others using a laparoscopic approach not have the strength to maintain the
80.6%; however, taking into account that 3 (Table 5). structure of the cervix through gestation.1
losses were in the first trimester and that 1 Based on the failures that occurred in Postulated risk factors include: cervical
patient suffered an intrauterine demise not our series, what has become apparent is structural anomalies due to in utero dieth-

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FIGURE

A, Laparoscopic intraabdominal view of the placement of the suture to pass from the posterior aspect of the broad ligament window through anteriorly to
prepare the trailing suture length for the final step; in this step the needle and suture sit lateral to the uterine vessels. B, Laparoscopic intraabdominal view
of the placement of the suture through both peritoneal broad ligament windows in preparation for the knot tying. C, Laparoscopic intraabdominal view of
the suture placement in the sit at the level of the internal cervical os, above the uterosacral ligaments, the knot at the posterior aspect of the uterus. D,
Schematic representation of cervico-isthmic cerclage placement (blue) medial to the uterine vessels and above the uterosacral ligaments.
Whittle. Laparoscopic cervicoisthmic cerclage. Am J Obstet Gynecol 2009.

ylstilbestrol exposure, overdilatation of the
cervix during pregnancy termination, cer-
vical trauma from conization or loop elec-
trosurgical excision procedures, congeni-
tal mullerian anomalies, obstetric trauma
including cervical lacerations, prolonged
second stage of labor, precipitous deliv-
ery.1 Each risk factor describes a type of
damage to the anatomic elements of the
cervix and should be the defining indica-
tion(s) for the cervico-isthmic cerclage re-
gardless of the surgical approach.
Given that each of the cerclage failures
we reported in our series occurred in
women who presented with symptoms
and signs consistent with chorioamnioni-
tis, we propose that these patients may
have an underlying pathology resulting in
prematurity that is not solely attributable
to mechanical cervical failure. A similar
proposal has been suggested by Drakely et
al,34 who reported a 5% dual pathology
rate in women with second trimester preg-
nancy loss. Functional incompetence is the
premature triggering of the cervical ripen-
ing process that occurs at term; postulated
risk factors include subacute or acute in-
fection of the genitourinary tract and/or
uterine cavity, abnormal placental devel-
opment, suspension of the antiinflamma-
tory effects of progesterone, and preterm
labor.1 Each risk factor describes a proin-
flammatory environment that promotes
cervical ripening for which a cervical cer-
clage will not suspend. The patients for
whom the cerclage failed in this present
pregnancy each presented with a clear in-
fectious/inflammatory process and each
had experienced a previous pregnancy loss
with a similar presentation. Himes and
Simhan35 have reported that placental in-
flammatory lesions including acute cho-
rioamnionitis are associated with a signifi-
cant risk of recurrent spontaneous
preterm birth. Furthermore, Edmondson

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Research Obstetrics
et al36 reported that chronic endometritis 4. Novy MJ. Transabdominal cervicoisthmic
leading to chronic deciduitis plays a role in cerclage for the management of repetitive abor-
tion and premature delivery. Am J Obstet Gy-
the etiology of preterm labor and prema- necol 1982;1:44-54.
ture ruptured membranes. Detailed exam- 5. Lotgering FK, Gaugler-Senden IP, Lotgering
ination of the past obstetric history and SF, Wallenburg HC. Outcome after transab-
placental pathology(ies) is imperative to dominal cervicoisthmic cerclage. Obstet Gy-
identify risk factors for pregnancy loss, in necol 2006;107:779-84.
6. Scibetta JJ, Sanko SR, Phipps WR. Laparo-
particular a history of recurrent infectious/ scopic transabdominal cervicoisthmic cer-
inflammatory preterm birth, that are not clage. Fertil Steril 1998;69:161-3.
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