Cervical incompetence, also known as cervical insufficiency, is a condition in which the cervix is unable to maintain its structural integrity during pregnancy, leading to painless cervical dilation and often resulting in mid-trimester pregnancy loss or preterm birth. It is estimated to affect 0.1–1% of pregnancies, but in women with recurrent second-trimester losses, the prevalence is significantly higher. One of the definitive treatments for this condition is cervical cerclage, a surgical procedure in which the cervix is reinforced with a suture to prevent premature opening.

While the traditional approach to cerclage is transvaginal, certain situations necessitate a transabdominal approach. Laparoscopic cervical cerclage (LCC) offers a minimally invasive method to place a transabdominal cerclage, providing durable cervical support and improved outcomes in selected patients.

Indications for Laparoscopic Cervical Cerclage

Laparoscopic cerclage is generally indicated in patients with:

Failed vaginal cerclage in previous pregnancies.

Severely shortened or damaged cervix, often due to trauma, conization, or trachelectomy.

Anatomic abnormalities that prevent safe vaginal cerclage placement.

History of recurrent second-trimester losses associated with cervical insufficiency.

Preconceptional cerclage is often preferred, although early first-trimester cerclage is also feasible. Laparoscopic cerclage is considered when long-term cervical reinforcement is required.

Advantages of Laparoscopic Approach

Compared to open abdominal cerclage, laparoscopy offers several benefits:

Minimally invasive: Small incisions lead to less postoperative pain and faster recovery.

Superior visualization: Magnification provided by laparoscopic cameras allows precise placement of the suture around the cervico-isthmic junction.

Reduced complications: Lower risk of infection, reduced blood loss, and minimal disruption of surrounding tissues.

Durable support: Provides reliable cervical reinforcement for current and future pregnancies.

Early mobilization: Patients typically return to normal activity within days.

Preoperative Preparation

Successful outcomes require thorough preoperative evaluation and optimization:

Assessment of cervical anatomy using ultrasound or MRI.

Evaluation of reproductive history, including previous pregnancy losses or failed cerclage.

Laboratory tests to check coagulation profile, hemoglobin, and overall health status.

Anesthesia consultation, as general anesthesia is required for laparoscopic surgery.

Patient counseling regarding the risks, benefits, and postoperative care.

Surgical Technique

Laparoscopic cervical cerclage is performed under general anesthesia with the patient in the lithotomy position and a slight Trendelenburg tilt to allow bowel displacement.

Port Placement

Typically, three to four ports are used:

Umbilical port for laparoscope.

Two lateral working ports for instruments.

Optional suprapubic port for retraction if needed.

Exposure and Dissection

The bladder is reflected downward to expose the uterovesical junction.

The uterine vessels and ureters are identified and preserved.

The cervical isthmus is exposed for accurate placement of the suture.

Suture Placement

A non-absorbable suture, often Mersilene tape, is passed around the cervico-isthmic junction.

The suture is placed medial to the uterine vessels on both sides.

The knot is tied anteriorly to avoid interference with the cervical canal and future deliveries.

Completion

Hemostasis is ensured.

Pneumoperitoneum is released, and ports are removed.

Skin incisions are closed with absorbable sutures or adhesive strips.

Postoperative Care

Patients usually recover quickly and can resume normal activities within a few days.

Analgesics are provided for mild postoperative discomfort.

If the patient is pregnant, follow-up ultrasounds monitor fetal growth and cervical integrity.

Routine monitoring includes assessment for infection, bleeding, or preterm contractions.

Outcomes and Success Rates

Laparoscopic cervical cerclage provides high success rates in preventing mid-trimester losses and preterm birth, particularly in women with prior failed transvaginal cerclage. Studies indicate:

Live birth rates significantly improve after laparoscopic cerclage.

Recurrence of cervical insufficiency in subsequent pregnancies is rare.

The procedure is safe with minimal intraoperative and postoperative complications when performed by experienced laparoscopic surgeons.

Risks and Complications

Although generally safe, potential risks include:

Injury to the bladder, uterine vessels, or ureters.

Bleeding during dissection.

Suture misplacement leading to failure.

Rare complications include infection, preterm contractions, or miscarriage if performed during early pregnancy.

Conclusion

Laparoscopic cervical cerclage is a highly effective, minimally invasive solution for women with cervical incompetence, particularly those with previous failed vaginal cerclage or significant cervical abnormalities. By providing durable cervical support and minimizing surgical morbidity, it significantly improves pregnancy outcomes. Careful preoperative planning, meticulous surgical technique, and appropriate postoperative monitoring are critical to achieving optimal results. For women at high risk of second-trimester loss, laparoscopic cerclage represents a safe and reliable method to maintain cervical integrity and promote healthy pregnancy outcomes.