Cervical insufficiency, also known as cervical incompetence, is a condition where the cervix painlessly dilates and shortens during pregnancy, often leading to recurrent mid-trimester pregnancy losses or preterm births. One of the effective interventions for this condition is cervical cerclage, a surgical procedure that reinforces the cervix with sutures to help it remain closed during pregnancy. While the conventional approach to cerclage is via the vaginal route, laparoscopic cervical cerclage has emerged as a valuable minimally invasive alternative, particularly in women for whom vaginal cerclage is not feasible or has failed.

Understanding Cervical Cerclage

Cervical cerclage is typically performed between 12–14 weeks of gestation or in the pre-pregnancy period for women with recurrent pregnancy losses. It can be done via different approaches:

Transvaginal Cerclage (McDonald or Shirodkar techniques).

Transabdominal Cerclage (TAC), performed either via laparotomy or laparoscopy.

Laparoscopic cervical cerclage is a form of transabdominal cerclage that uses minimally invasive techniques, offering reduced morbidity and faster recovery compared to open abdominal procedures.

Indications for Laparoscopic Cervical Cerclage

Laparoscopic cerclage is usually considered in:

Women with a history of failed vaginal cerclage.

Severe cervical shortening or congenital absence of cervix.

High or severely damaged cervix due to trauma, conization, or trachelectomy.

Anatomical abnormalities that make vaginal placement technically impossible.

Advantages of the Laparoscopic Approach

Laparoscopic cervical cerclage offers several benefits:

Minimally invasive: Smaller incisions, less postoperative pain, and better cosmesis.

Improved visualization: Magnified view of pelvic anatomy allows precise placement of the suture at the cervico-isthmic junction.

Reduced complications: Less risk of injury to bladder or ureters compared to open TAC.

Faster recovery: Shorter hospital stay and earlier return to daily activities.

Permanent option: Can be performed before pregnancy, remaining in place for future pregnancies.

Surgical Technique of Laparoscopic Cervical Cerclage
Patient Preparation and Positioning

The procedure can be done pre-pregnancy or during the first trimester of pregnancy (ideally before 14 weeks).

The patient is placed in the lithotomy position with steep Trendelenburg tilt.

General anesthesia is administered.

Creation of Pneumoperitoneum and Port Placement

Pneumoperitoneum is established using carbon dioxide.

Typically, three or four laparoscopic ports are inserted: one umbilical port for the camera and two lateral working ports.

Exposure of Cervico-Isthmic Region

The bladder is dissected and reflected downward to expose the uterovesical junction.

Care is taken to avoid injury to the uterine vessels and ureters, which run laterally.

Placement of Suture

A non-absorbable suture material such as Mersilene tape (5 mm) is commonly used.

The suture is passed around the cervico-isthmic junction at the level of the internal os.

It is carefully threaded medial to the uterine vessels on both sides.

The knot is tied anteriorly, away from the cervical canal, to minimize complications during labor.

Completion

Hemostasis is confirmed.

Ports are removed, and skin incisions are closed.

In pregnant women, fetal well-being is assessed postoperatively.

Timing of the Procedure

Interval (Preconceptional) Cerclage: Performed before pregnancy, often considered the safest and most effective because it avoids surgical risks to the fetus.

Pregnant Cerclage: Done in early pregnancy (up to 14 weeks), with higher technical challenges due to increased uterine size and vascularity.

Postoperative Care

Patients recover quickly and can usually be discharged within 24–48 hours.

Analgesics are prescribed for postoperative pain.

In pregnant women, ultrasound is used to monitor fetal viability.

Normal physical activities are gradually resumed, though heavy lifting and strenuous activities are avoided for a few weeks.

Outcomes and Success Rates

Several studies have shown that laparoscopic cervical cerclage has high success rates, with improved pregnancy outcomes in women with cervical insufficiency. Reported live birth rates are comparable to or even better than those achieved with open abdominal cerclage. Because the cerclage can remain in place, women can carry multiple future pregnancies without repeat procedures.

Risks and Complications

Although laparoscopic cerclage is generally safe, potential complications include:

Injury to the bladder, uterine vessels, or ureters.

Intraoperative bleeding.

Misplacement of the suture leading to failure.

Pregnancy-related risks, such as miscarriage or preterm contractions.

These risks are minimized when the procedure is performed by skilled laparoscopic surgeons with experience in advanced gynecologic surgery.

Conclusion

Laparoscopic cervical cerclage has emerged as a highly effective, minimally invasive option for women with cervical insufficiency, especially those with failed or contraindicated vaginal cerclage. It combines the benefits of laparoscopy—such as reduced morbidity, faster recovery, and superior visualization—with the durability and reliability of abdominal cerclage. For carefully selected patients, this approach offers excellent reproductive outcomes, improving the chances of carrying pregnancies to term. As laparoscopic techniques continue to evolve, cervical cerclage performed via this route is likely to become increasingly accessible and widely practiced in modern gynecology.