Cervical insufficiency, also known as cervical incompetence, is a condition in which the cervix is unable to maintain its structural integrity during pregnancy, leading to premature dilation and potential pregnancy loss, typically in the second trimester. Women with recurrent mid-trimester losses or preterm births due to cervical insufficiency often require surgical intervention to maintain pregnancy. One of the most effective treatments is cervical cerclage, a procedure that reinforces the cervix using a suture or tape. Over the years, laparoscopic cervical cerclage (LCC) has emerged as a minimally invasive alternative to traditional abdominal cerclage, combining precision with reduced morbidity.

Indications for Laparoscopic Cervical Cerclage

Laparoscopic cervical cerclage is indicated in patients with:

A history of failed transvaginal cerclage in previous pregnancies.

A short, damaged, or congenitally abnormal cervix, often due to trauma, conization, or trachelectomy.

Anatomical or pathological conditions that make vaginal cerclage unsafe or impossible.

Recurrent second-trimester pregnancy losses attributed to cervical insufficiency.

Laparoscopic cerclage can be performed preconceptionally or in early pregnancy (usually up to 12–14 weeks gestation). Pre-pregnancy placement is often preferred to minimize fetal risk.

Advantages of the Laparoscopic Approach

Compared to traditional open abdominal cerclage, laparoscopy provides:

Minimally invasive access: Small incisions reduce postoperative pain, scarring, and recovery time.

Enhanced visualization: Magnified laparoscopic views allow precise dissection and accurate suture placement at the cervico-isthmic junction.

Reduced complications: Lower risk of wound infection, bleeding, and adhesion formation.

Durable cervical support: Provides reliable reinforcement for multiple pregnancies if needed.

Early recovery: Most patients resume normal activities within a few days.

Preoperative Preparation

Proper preoperative assessment ensures optimal outcomes:

Clinical evaluation: Assess reproductive history, previous pregnancy losses, and cervical status.

Imaging: Ultrasound or MRI can help evaluate cervical anatomy and rule out anomalies.

Laboratory tests: Routine blood tests, coagulation profile, and pre-anesthesia workup.

Patient counseling: Inform about procedural risks, benefits, potential complications, and postoperative care.

Anesthesia evaluation: General anesthesia is required for laparoscopic procedures.

Surgical Technique

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

Port Placement

Umbilical port for laparoscopic camera.

Two lateral working ports for instruments.

Optional suprapubic port for retraction or assistance.

Exposure of the Cervico-Isthmic Junction

The bladder is reflected inferiorly to expose the uterovesical junction.

Uterine vessels and ureters are identified and protected.

The anterior and lateral aspects of the cervico-isthmic junction are exposed.

Suture Placement

A non-absorbable suture, typically Mersilene tape, is passed around the cervix at the isthmic level.

The suture is placed medial to the uterine vessels to avoid vascular injury.

The knot is tied anteriorly, leaving adequate cervical canal space for potential vaginal deliveries in future pregnancies.

Completion of Procedure

Hemostasis is confirmed.

Ports are removed, and skin incisions are closed using absorbable sutures or adhesive strips.

In pre-pregnancy cases, cerclage remains in place until conception occurs.

In pregnant patients, postoperative monitoring of fetal well-being is conducted.

Postoperative Care

Most patients recover rapidly and can return to normal activities within a few days.

Analgesics are provided for mild postoperative discomfort.

Pregnant patients are monitored for uterine contractions, infection, and cervical integrity.

Follow-up imaging may be used to ensure proper placement of the cerclage.

Vaginal delivery is typically not recommended; cesarean section is the preferred mode of delivery in future pregnancies.

Outcomes and Success Rates

Laparoscopic cervical cerclage has demonstrated excellent outcomes:

High live birth rates in patients with prior second-trimester losses.

Durable cervical support reduces recurrence of insufficiency in subsequent pregnancies.

Low incidence of surgical complications, especially when performed by experienced laparoscopic surgeons.

Ability to provide a long-term solution for women with anatomical limitations for transvaginal cerclage.

Risks and Complications

Although generally safe, potential complications include:

Injury to bladder, ureters, or uterine vessels.

Intraoperative bleeding during dissection.

Misplacement or slippage of suture leading to procedure failure.

Infection or, rarely, miscarriage if performed during pregnancy.

Conclusion

Laparoscopic cervical cerclage is a safe and effective surgical intervention for women with cervical incompetence who are at high risk for pregnancy loss. By combining the benefits of minimally invasive surgery with precise anatomical dissection, laparoscopic cerclage provides reliable cervical support while minimizing patient morbidity. Careful preoperative planning, meticulous surgical technique, and vigilant postoperative monitoring are essential for achieving optimal outcomes. For women with recurrent second-trimester losses or significant cervical abnormalities, laparoscopic cervical cerclage represents a highly valuable solution, improving the chances of successful pregnancy and healthy fetal outcomes.