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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


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. Joseph’s 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.


© 2009 Published by Mosby, Inc. doi: 10.1016/j.ajog.2009.07.018

Published by Mosby, Inc. doi: 10.1016/j.ajog.2009.07.018 For Editors’ Commentary, see Table of Contents closed

For Editors’ Commentary, see Table of Contents

For Editors’ Commentary, see Table of Contents closed against the increasing uterine dis- tention pressure,

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 Durfee 2 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 Novy 4 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

364.e1 American Journal of Obstetrics & Gynecology OCTOBER 2009

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


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-

Obstetrics Research


Patient demographics



Mean maternal age at cerclage, y Mean gravidity No. of live children/patient Patients with previous term pregnancy T1 loss, % (mean no. T1 loss/patient) T2 loss, % (mean no. T2 loss/patient) Patient with prior TA Patients with prior failed cerclage Patients with previous cervical surgery (cone, LEEP) Patient with DES exposure Nulligravid/primigravid patients with insufficient cervical tissue

32.6 4.6 (range, 22–42) 3.4 2.3 (range, 0–14) 0.43 (range, 0–2)


38.5% (0.8 1.8) 92.3% (1.6 1.1)





5 (7.6%)

DES, diethylstilbestrol; LEEP , loop electrosurgical excision procedure; T1 , first trimester; T2 , second trimester. Whittle. Laparoscopic cervicoisthmic cerclage. Am J Obstet Gynecol 2009.

cated ongoing infection, suppressive an- tibiotic therapy was prescribed for the remainder of the pregnancy.

Surgical preparation

The patient was prepared in the dorsal lithotomy position with a urinary cathe- ter in situ. If the patient was not preg- nant, a transcervical uterine manipula- tor was used; for the pregnant patient, a sponge on ring forcep was placed into the vaginal fornix to facilitate uterine manipulation. A traditional 4 puncture operative laparoscopy set up is used. Ini- tial abdominal entry is achieved through the closed Veress technique at the umbi- licus. 16 For cases done during preg- nancy, the gravid uterus was avoided through entry in the left upper quadrant by the closed Veress technique or through an open Hassan technique at the umbilicus. Abdominal insufflation was maintained at 12-15 mmHg using CO 2 .

Step 1: development of the paravesical and vesico- uterine spaces

The vesicouterine peritoneum was in- cised using the CO 2 laser (Coherent Inc., Santa Clara, CA) or monopolar scissors across the lower uterine segment, and a combination of sharp and blunt dissec- tion was used to reflect the bladder from the lower uterine segment and anterior cervix. Paravesical spaces were devel-

oped bilaterally through a combination

of blunt and sharp dissection.

Step 2: creation of broad ligament peritoneal windows

Anteversion of the uterus revealed a transparent posterior leaf of the broad ligament, an avascular space to create a window in the broad ligament on each side of the uterus. Fluid placement in the anterior cul-de-sac facilitated identifica- tion of the avascular space. The opening was created by a “push and spread” tech- nique through the peritoneum with a laparoscopic grasper and enlarged by stretching the opening parallel and lat- eral to the uterine vessels. Creating this window allowed for caudal displacement

of the ureters and identified the uterine

vessels at the cervico-isthmic junction.

Step 3: placement of suture material through broad ligament peritoneal window

A no. 1 Prolene (Ethicon Inc., Somer-

ville, NJ) suture on a CT-1 needle was passed into the abdomen through a 10-12 mm port on a laparoscopic needle

holder. It is critical that the needle be set

to pass from the posterior aspect of the

right 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 right sided uterine vessels.

Steps 4 and 5: right and left sided placement of cerclage at the cervico-isthmic junction

The needle was introduced medial and posterior to the uterine vessels, a small pur- chase of cervical tissue at the level of the cervico-isthmic junction is taken, and the needle is followed through anteriorly with the distal end of the suture in the cul-de- sac behind the uterus. This step anchored the suture on the right side of the uterus. The suture material and needle was passed anteriorly across the lower segment to the left side of the uterus. In a similar fashion, the needle is placed medial to the left sided uterine vessels and a small purchase of cer- vical tissue at the level of the left sided cer- vico-isthmicjunctionwas taken as the nee- dle was passed through posteriorly through the broad ligament window leav- ing the needle in the cul-de-sac and secur- ing the suture to the left side of the uterus (Figure, A and B).

Step 6: the cerclage knot secured

The cerclagewas tied by either an extracor- poreal or intracorporeal knot at the poste- rior aspect of the uterus. The tension of the suture can be adjusted over a transcervical 5 mm Hegar dilator in the nonpregnant patient. The suture placement should sit at the level of the internal cervical os, above the uterosacral ligaments, the knot at the posterior aspect of the uterus (Figure, C and D). At the conclusion of the procedure, the laparoscopic ports are removed, the gas evacuated, and the abdominal wall and skin are repaired in the usual fash- ion. No tocolytic agents were adminis- tered during or post procedurefor gravid patients. Perioperative antibiotics were administered at the discretion of the pri- mary surgeon. Nonpregnant patients were discharged home from the postop- erative recovery area; pregnant patients were admitted overnight for observation and a pelvic ultrasound to confirm fetal viability.


Sixty-five patients underwentlaparoscopic cervico-isthmic cerclage during the study period; patient demographics are pre- sented in Table 1. Thirty-one patients un- derwent cerclage placement in the first or

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Pregnancy outcomes following laparoscopic cervico-isthmic cerclage placement




Perioperative pregnancy loss

n 2



n 1


n 1


n 1

Delivery 24 wk with NND

n 6

Delivery 24 wk

n 54

Mean GA if pregnancy lasted 12 wk

34.4 5.4 wk (17-39 wk)

Mean GA if pregnancy lasted 24 wk

35.8 2.9 wk (24.5-39 wk)

Distribution of GA at delivery

24 28 wk

n 2


32 wk

n 5


36 wk

n 10



n 53

NND with delivery 24 wk

n 1


No. of NICU admissions

n 12

No. with long-term sequelae of prematurity

n 0

Weeks of pregnancy gained: 13.2

Mean GA at delivery in last pregnancy

prior to cerclage:

19.7 8.0 wk

Mean GA at first delivery



32.9 8.8 wk

Fetal salvage rate 6.5-fold improvement

No. of liveborn children at last pregnancy prior to cerclage:



No. of liveborn children at first pregnancy 12 wk postcerclage 53/60 (88.3%)

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.

Whittle. Laparoscopic cervico-isthmic cerclage. Am J Obstet Gynecol 2009.


second trimester ( 16 weeks’ gestation) and 34 patients were not pregnant at the time of the surgery. Seven cases were con- verted to laparotomy due to either compli- cations arisingfrom uterine vessel bleeding (n 5) or impaired surgical visibility (n 2) due to morbid obesity; 6 of these pa-

tients were pregnant. Two patients experi- enced a perioperative pregnancy loss; both cases had been converted to laparotomy due to bleeding requiring uterine vessel li- gation and 1 of the cases was 16 weeks’ gestation. No other immediate surgical complications related to laparoscopy oc-


Details of pregnancy failure

No. of cerclage failures


Mean GA at failure

20.7 / 2.9w (17–23)


Reason for failure


n 3

Cervical dilatation clinical chorioamnionitis

n 2

Preterm labor

n 2

Placental pathology

Acute stage II/III chorioamnionitis

n 6

PPROM , premature preterm ruptured membranes

Whittle. Laparoscopic cervico-isthmic cerclage. Am J Obstet Gynecol 2009.


364.e3 American Journal of Obstetrics & Gynecology OCTOBER 2009

curred. All patients delivering after 24 weeks of gestation underwent cesarean section with the cerclage left intact; no op- erative complications of this surgery oc- curred. Six patients had the cerclage re- moved at the time of delivery and a tubal ligation performed. The cerclage was re- movedin 1 patient at the time of delivery at term as it was no longer intact, and 1 pa- tient had the cerclage removed postpar- tum through a posterior colpotomy as it had eroded through the posterior fornix into the vagina. Sixty-seven pregnancies have occurred in this study cohort and 8 patients remain nonpregnant. The overall pregnancy suc-

cess rate defined as number of live births

per number of pregnancies is 80.6%; de- tails of pregnancy outcomes are presented in Table 2. Three pregnancieswere aborted in the first trimester (1 patient had a termi- nation due to fetal trisomy 21); all 3 cases were managed by dilatation and curettage through the cerclage.Themean gestational age at delivery for all remaining pregnan- cieswas34.4 5.4weeks (17.0 –39.0wk);1 patient experienced an intrauterine fetal demise unrelated to the indication for the cerclage. Cerclage failure was defined as delivery prior to neonatal viability between 13 and23 6weeks of gestation;6 patients experienced a cerclage failure with a mean gestational age at presentation of 20.7 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 clinical consequences of acute or subacute chorioamnionitis and occurred in women with a history of recurrent second trimes- ter loss. Each patient was managed with a posterior colpotomy for cerclage removal followed by a vaginal delivery; all patients received intravenous antibiotics due to the clinical diagnosis of chorioamnionitis, and 1 patient was septic with a positive blood culture for Escherichia coli. The mean gestational age at delivery if the pregnancy continued past viability was 35.8 2.9 weeks (range, 24.5–39.0 wk) (Table 4). The net number of weeks of pregnancy gained for those patients who had experienced a previous pregnancy loss was 13.5 weeks of gestation with a 6.5-fold increase in the number of liveborn chil- dren compared with the pregnancy imme- diately preceding the cerclage. Twelve ba-

Obstetrics Research


Effect of timing and indication for cerclage on pregnancy outcome

Indication for cervico-isthmic cerclage

Previous T2 loss / cone biopsy

31.2 / 7.8 w (17–38 w)

Previous failed vaginal cerclage / cone biopsy

34.1 / 5.3 w (20–38 w)

Nulliparous with prior cone biopsy

1 delivery at 34 w

3 delivery at 37 w

Timing of cerclage: mean GA at delivery for pregnancies 12 w

Cerclage placed in pregnancy

32.9 / 8.8 w

Cerclage placed nonpregnant

34.5 / 4.9 w

Pregnancy failures (perioperative loss, IUFD, delivery 24 w, NND)

Cerclage placed in pregnancy

n 7

Cerclage placed nonpregnant

n 2

IUFD , intrauterine fetal demise; NND, neonatal death. Whittle. Laparoscopic cervico-isthmic cerclage. Am J Obstet Gynecol 2009.

bies were admitted to the neonatal intensive care unit, 1 baby died due to ex- treme prematurity, and no other long- term sequelae of prematurity were re- ported. Nine patients have had a second term ( 37 weeks) pregnancy with the same cerclage in situ, and 1 patient has had 3 term pregnancies. Two patients had a twin gestation at the time of cerclage place- ment in the first trimester; both patients delivered healthy children after 34weeks of gestationwith nolong-term complications of preterm birth. Overall, the timing of cerclage place- ment did not influence the gestational age at delivery but cerclage failure did occur more often when the cerclage was placed during that pregnancy (Table 4). The indi- cation for cerclage did not affect the gesta- tional age at delivery, butin the small num- ber of patients for whom the cerclage was placed due to insufficient cervical tissue there was no cerclage failure (Table 4). Table 5 presents the outcome of previ- ously published retrospective cohorts of cervico-isthmic cerclage placed by both laparotomy and laparoscopy with an op- erative complication rates of 0-25% and fetal survival rates between 60-100%.


Cervical incompetence, defined as preg- nancy loss following painless cervical di- latation, has been traditionally treated

with a cerclage placed in the vaginal por- tion of the cervix in the subsequent preg- nancy. 1 This therapeutic intervention is based on the assumption that the struc- tural integrity of the cervical tissue has insufficient strength to act as a barrier to delivery against the increasing intrauter- ine pressure of the growing gestational sac. 1 When this vaginal cerclage fails to hold the cervix closed or cannot be placed due to insufficient cervical tissue, an alternative approach is the placement of a cerclage at the cervico-isthmus of the uterus. Conventionally, this type of cer- clage is placed in the first trimester of pregnancy through a laparotomy; how- ever, with the advent of minimally inva- sive surgery, placement by laparoscopy has been described in case reports and series ( Table 5 ). 7-30 The purpose of this study was to describe the surgical tech- nique for the laparoscopic cervico-isth- mic cerclage, its associated obstetric out- comes, and compare these outcomes with the traditional laparotomy ap- proach using previously reported co- horts that describe both rates of opera- tive complications and fetal survival.

Surgical considerations

The advantages of a minimally invasive approach are well established; we pro- vide evidence that this approach confers similar if not a slightly improved rate of

perioperative complications as the cer- vico-isthmic cerclage placed by laparot- omy (10% vs 0-25%, respectively; Table

5 ). The main complication of either ap-

proach was excessive blood loss—in our series no patient required a blood trans- fusion. The second most common com- plication was the conversion to laparot- omy due to surgical visibility—such a complication should be considered in the context that 58 women were spared a laparotomy by having the cerclage placed laparoscopically. Since the cer- clage is placed similar to a “noose” in the area of the cervical isthmus, a potential complication is compression of the uter- ine vessels leading to compromised uter- ine blood flow and subsequent fetal de- mise; our perioperative losses could be attributed to uterine vessel compression but may also be in part due to specific vessel ligation to arrest excessive bleed- ing. The reported perioperative loss rate by us and others did not occur with any greater incidence using the laparoscopic approach and likely is a risk of this type of cerclage regardless of the surgical ap- proach. As the uterine size increases it does become a technically more chal- lenging procedure; although we reported only 2 cases of cerclage placement in the second trimester, 1 was complicated by conversion andfetal loss. In addition, the conversion to laparotomy did occur more frequently when the patient was pregnant. Placement of this cerclage us- ing a vaginal approach with tissue dissec- tion similar to that of a vaginal hysterec- tomy has recently been described; this technique may be advantageous for women who present in the late first or early second trimester. 31 A #1 Prolene suture was chosen in this study with the rationale based on ease of handling for placement and removal compared with the traditional 5 mm Mersilene tape; this rationale is similarly supported by Rust et al 32 in the choice of suture material for a vaginal cerclage. The successful results we present support the use of this type of suture material in regard to its integrity and strength. Concerning the technique for knot tying, since the Roeder knot strength has been determined to be equivalent to the intracorporeal knot,

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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:



Intraoperative complication a rate, %

Fetal survival

study and year



rate, %

Benson and Durfee 1965



Not reported


Watkins 1972



Not reported


Mahran 1978





Olsen and Tobiassen 1982



Not reported


Novy 1982



Not reported


Wallenberg and Lotgering 1987





Herron and Parer 1988



Not reported


Van Dongen et al 1991





Novy 1991





Cammarano et al 1995





Anthony et al 1997





Craig and Fliegner 1997





Turnquest et al 1999





Davis et al 2000





Lotgering et al 2006





Debbs et al 2007





Scibetta et al 1998





Lesser et al 1998





Mingione et al 2003





Cho et al 2003





Gallot et al 2003





Ghomi et al 2006





Aboujaoude et al 2007




Not reported

Agdi et al 2008





Reid et al 2008





Current study





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- ment favors the Roeder knot especially with the bulky pregnant uterus. 33 We conclude that the laparoscopic approach for the placement of the cervico-isthmic cerclage confers a similar rate of periop- erative complications as the traditional laparotomy and is best completed non- pregnant or early in the first trimester.

Obstetric considerations

In our series, the fetal survival rate was 80.6%; however, takinginto account that 3 losses were in the first trimester and that 1 patient suffered anintrauterine demise not

attributable to the cerclage, the true cer- clage success rate should be defined by the pregnancies lost at the time of surgery (2 cases) and the number of live, take home babies (58 cases) after the first trimester is completed. By this definition, the rate of cerclage success was 89%, making the ob- stetric outcome after laparoscopic cervico- isthmic cerclage comparable to that of the abdominal approach and to that reported by others using a laparoscopic approach (Table 5). Based on the failures that occurred in our series, what has become apparent is

364.e5 American Journal of Obstetrics & Gynecology OCTOBER 2009

that cervical incompetence is a complex disease that cannot be treated solely with the placement of a cerclage—either vagi- nally or at the cervico-isthmus; multiple etiologies lead to a common final pathway of undesired cervical dilatation and efface- ment. Cervical incompetence should be described in 2main categories:mechanical and functional. Mechanical incompetence implies that the cervical components do not have the strength to maintain the structure of the cervix through gestation. 1 Postulated risk factors include: cervical structural anomalies due to in utero dieth-

Obstetrics Research

FIGURE Obstetrics Research FIGURE D A, Laparoscopic intraabdominal view of the placement of the suture to Obstetrics Research FIGURE D A, Laparoscopic intraabdominal view of the placement of the suture to Obstetrics Research FIGURE D A, Laparoscopic intraabdominal view of the placement of the suture to

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. Functionalincompetenceis 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 Simhan 35 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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et al 36 reported that chronic endometritis leading to chronic deciduitis plays a role in the etiology of preterm labor and prema- ture rupturedmembranes. Detailed exam- ination of the past obstetric history and placental pathology(ies) is imperative to identify risk factors for pregnancy loss, in particular a history of recurrent infectious/ inflammatory preterm birth, that are not related to the structuralintegrity of the cer- vix. In such cases, counseling in regard to realistic expectations of the cerclage must be undertaken and potential role for chronic antibiotic and/or progesterone therapy must be explored. However, each of the patients who failed the cervico-isth- mic cerclage had a previous failed vaginal cerclage, which can cause damage to the structural integrity of the cervix, com- pounding the riskfor pregnancyloss by su- perimposing riskfor mechanicalfailure on a background of inflammatory/infectious risk factors for premature cervical ripen- ing. As such, we recommend a compre- hensive evaluation of all women prior to cervico-isthmic cerclage placement in- cluding: radiographic evaluation of the uterine cavity, thrombophilia screen, de- tailed evaluation of obstetric history espe- cially placenta pathology, cervico-vaginal swabs, and endometrial biopsy if any evi- dence of inflammatory lesions within the previous placental pathology. Patient se- lection remains the greatest challenge to and predictor of cerclage success regardless of the location of its placement. In summary, our data indicated that the cervico-isthmic cerclage placed laparo- scopically comparesfavorablywith the tra- ditional laparotomy approach in regard to operative technique, risk of complications, and obstetric outcome; in the carefully se- lected patient this cerclage may provide a reasonable alternative to achieve preg-

nancy success.



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