BASIC INFORMATION

Date & Time: April 11, 2026, 15:19:31 Indian Standard Time

Lecture Handout Prepared from the Teaching Session by: Dr. R. K. Mishra

SUMMARY

This lecture provides a comprehensive overview of laparoscopic cervical cerclage for postgraduate surgeons and gynecologists. Dr. R. K. Mishra elucidates the clinical significance of cervical incompetence, which affects approximately 1% of the obstetric population and is responsible for 15-20% of second-trimester miscarriages. The discussion covers the etiology, diagnosis, and management options for cervical incompetence, with a primary focus on the laparoscopic technique. The lecture details the operative steps of laparoscopic cerclage, including patient positioning, dissection of the vesicouterine fold, placement of a non-absorbable tape at the level of the internal os, and peritoneal closure. Key advantages of the laparoscopic approach, such as a more physiological placement of the cerclage high on the cervix, are contrasted with traditional vaginal methods like the McDonald and Shirodkar procedures. The session also addresses surgical pearls, potential complications, patient selection, and postoperative management, emphasizing that laparoscopic cerclage necessitates delivery by cesarean section. The procedure is presented as a straightforward and effective intervention for preventing recurrent mid-trimester pregnancy loss in appropriately selected patients.

KEY KNOWLEDGE POINTS

Cervical incompetence is a significant cause of second-trimester pregnancy loss (16-24 weeks).
Diagnosis is primarily based on obstetric history and transvaginal ultrasonography, with findings like T, Y, V, or U-shaped cervical funneling.
Laparoscopic cerclage offers a high, physiological placement of the suture at the internal os, which is mechanically superior to lower vaginal placements.
The ideal time for the procedure is in a non-pregnant patient (interval cerclage), though it can be performed in early pregnancy.
The technique involves creating windows in the broad ligament, passing a non-absorbable tape (e.g., Mersilene) around the cervix at the cervico-isthmic junction, and securing it.
Delivery following laparoscopic cerclage must be via cesarean section.
Key complications include suture disruption, chorioamnionitis, and the risk of uterine rupture if labor ensues and is not managed appropriately.

INTRODUCTION

Cervical incompetence, or cervical insufficiency, is a clinical diagnosis characterized by the inability of the uterine cervix to retain a pregnancy in the second trimester in the absence of uterine contractions. This condition is a significant contributor to obstetric morbidity, accounting for an estimated 1% of the obstetric population and 15-20% of all mid-trimester miscarriages. The etiology can be congenital (e.g., in-utero diethylstilbestrol exposure, uterine anomalies) or acquired (e.g., cervical trauma from prior procedures, inflammation, infection). Diagnosis relies on a thorough obstetric history of recurrent, painless second-trimester losses and is supported by imaging, such as transvaginal ultrasonography, which may reveal cervical shortening or funneling of the internal os. While conservative management and vaginal cerclage procedures (McDonald, Shirodkar) have been historical mainstays, laparoscopic cervical cerclage has emerged as a highly effective alternative, particularly for patients who have failed a previous vaginal cerclage or have a very short or anatomically distorted cervix. The laparoscopic approach allows for placement of the cerclage at the level of the internal os, providing superior mechanical support consistent with Pascal's principle of hydrostatic pressure.

LEARNING OBJECTIVES

To understand the pathophysiology, risk factors, and diagnostic criteria for cervical incompetence.
To compare and contrast vaginal and laparoscopic approaches to cervical cerclage.
To master the step-by-step surgical technique for performing a laparoscopic cervical cerclage, including key anatomical landmarks.
To recognize the indications, contraindications, and potential complications associated with laparoscopic cerclage and their management.

CORE CONTENT

1. Diagnosis of Cervical Incompetence

Obstetric History: The cornerstone of diagnosis is a history of recurrent, painless pregnancy losses in the second trimester (16-24 weeks). A history of previous preterm birth, forceps delivery, or vigorous cervical manipulation is also relevant.
Physical Examination: In a pregnant patient, a dilated cervix may be noted on speculum examination.
Ultrasonography (USG): Transvaginal ultrasound is the primary imaging modality.
- Normal Cervix: Appears T-shaped with a closed internal os and a length typically greater than 25 mm.
- Incompetent Cervix: Demonstrates funneling, appearing Y-shaped, V-shaped, or U-shaped. A cervical opening greater than 10 mm is considered indicative of incompetence.
Magnetic Resonance Imaging (MRI): MRI can provide superior anatomical detail compared to ultrasound but is less commonly used for routine diagnosis.

2. Management Options

Conservative Management: Includes bed rest, avoidance of heavy lifting, and pelvic rest (no coitus). Efficacy is debated.
Vaginal Cerclage:
- McDonald Cerclage (1963): A purse-string suture using a non-absorbable material placed around the cervix to reduce the canal diameter to 5-10 mm. The suture is typically removed around 37 weeks gestation to allow for vaginal delivery.
- Shirodkar Cerclage (1955): A more complex procedure involving mucosal dissection and placement of a Mersilene tape higher on the cervix. It is generally reserved for cases where a McDonald procedure has failed.
Laparoscopic Cerclage: An abdominal approach that places the cerclage at the cervico-isthmic junction, above the insertion of the cardinal and uterosacral ligaments.

3. Laparoscopic Cervical Cerclage: Operative Principles

3.1. Indications

History of failed transvaginal cerclage.
Anatomical limitations for vaginal placement (e.g., congenitally short cervix, extensive scarring, previous trachelectomy).
Patient preference for an interval procedure (performed when not pregnant).

3.2. Contraindications

Active vaginal bleeding.
Evidence of uterine contractions or labor.
Ruptured membranes.
Suspected chorioamnionitis.

3.3. Surgical Technique (Interval Procedure)

Patient Positioning and Uterine Manipulation: The patient is placed in the lithotomy position. A uterine manipulator is used to retrovert the uterus and push it superiorly into the abdomen, exposing the vesicouterine (UV) fold.
Peritoneal Incision: The peritoneum of the UV fold is incised transversely for approximately 3 cm on either side of the midline. This incision extends into the anterior leaf of the broad ligament. A hook, monopolar scissors, or an energy device can be used.
Bladder Dissection: The bladder is gently dissected inferiorly off the anterior aspect of the lower uterine segment and cervix until the shiny cervical fascia is clearly visible.
Creation of Posterior Windows: Bilateral "windows" are created in the avascular space of the broad ligament. The key landmark is approximately 2 cm above the uterosacral ligament insertion in the paracervical area. The peritoneum is desiccated with bipolar energy to minimize bleeding before puncture.
Tape Introduction and Placement: A non-absorbable tape (e.g., Mersilene) on a straight or straightened needle is used.
- One 5 mm port is removed, and the needle is introduced directly through the abdominal wall incision.
- The needle is passed from posterior to anterior through the created avascular window on one side of the uterus. The assistant drops the uterus to facilitate the needle's passage.
- The needle is retrieved anteriorly, and the tape is passed across the anterior aspect of the cervix, deep to the dissected bladder flap.
- The needle is then passed from anterior to posterior through the window on the contralateral side.
Knot Tying: The tape is tied posteriorly with an intracorporeal surgeon's knot (double-throw followed by two alternating single throws). The tension should be firm but not overly tight, cinching the cervix at the internal os.
Anterior Fixation: The knot and the anterior loop of the tape are secured to the anterior cervical fascia at the 12 o'clock position using an absorbable suture (e.g., Vicryl). This prevents the tape from migrating and aids in its identification during a subsequent cesarean section.
Peritoneal Closure: The incised vesicouterine peritoneum is closed over the tape using a continuous absorbable suture. This prevents adhesion formation.

3.4. Procedure in a Pregnant Patient

Uterine manipulation must be avoided. A fan retractor, Nathanson liver retractor, or gentle elevation with a suction-irrigator can be used to elevate the gravid uterus.
The procedure is more challenging due to increased vascularity and the size of the uterus.
It is optimally performed before 14-16 weeks of gestation.

SURGICAL PEARLS

Ideal Timing: Perform the cerclage as an interval procedure in a non-pregnant patient for the easiest and safest dissection.
Anatomical Landmark: The target for needle passage is the avascular paracervical space, approximately 2 cm superior to the uterosacral ligament insertion. Desiccating this area with bipolar energy before needle passage helps identify the plane and achieve hemostasis.
Needle Passage: Hold the needle perpendicular to the tissue and have the assistant "drop" the uterus to allow the needle to pass passively from posterior to anterior. This minimizes trauma and risk to vessels.
Tape Tension: The goal is firm apposition, not strangulation. Intracorporeal knot tying naturally prevents over-tightening.
Anterior Fixation Suture: Do not cut the Vicryl suture after fixing the tape. Use the same suture as a "starter knot" to begin the continuous closure of the peritoneum.
Safety: Always use a needle holder, not a grasper, to control the needle. When tying the knot, pull on the tape itself, not the needle, to avoid accidental injury.

COMPLICATIONS AND THEIR MANAGEMENT

Intraoperative
- Hemorrhage: Bleeding from the uterine vessels can occur. It is often minor (needle prick) and resolves with a hematoma or upon tying the cerclage knot. Correct landmark identification minimizes this risk.
- Bladder or Ureter Injury: Rare, but possible during dissection. Careful identification of planes is crucial.
Early Postoperative
- Suture Disruption: Can occur if the knot is not secure.
- Infection/Chorioamnionitis: A significant risk, particularly if the procedure is performed with subclinical infection.
Late Postoperative (During Pregnancy)
- Preterm Premature Rupture of Membranes (PPROM).
- Preterm Labor: If labor ensues, an emergency cesarean section is required. In cases of preterm fetal demise in the third trimester, a hysterotomy may be necessary for delivery.
- Uterine Rupture: A catastrophic risk if the patient labors to full dilatation with the cerclage in situ. This underscores the need for planned cesarean delivery.

MEDICOLEGAL AND PATIENT SELECTION CONSIDERATIONS

Informed Consent: The patient must understand unequivocally that laparoscopic cerclage mandates delivery by cesarean section for all subsequent pregnancies as long as the tape is in place.
Delivery Planning: The patient must be counseled to present to a hospital capable of performing a cesarean section at the first sign of labor or at a pre-determined gestational age (e.g., 37 weeks). It is preferable for the operating surgeon to perform the cesarean section, as they are aware of the precise location of the tape.
Patient Communication: The patient must be educated on the risks, including uterine rupture, and the importance of close obstetric follow-up. The tape's presence should be clearly documented in her medical records.
Removal: The tape can be left in place for future pregnancies or removed during cesarean section if the patient has completed her family.

SUMMARY AND TAKE-HOME MESSAGES

Laparoscopic cervical cerclage is a highly effective procedure for preventing second-trimester pregnancy loss due to cervical incompetence, especially after a failed vaginal cerclage.
The key advantage is the high placement of the tape at the cervico-isthmic junction, providing mechanically superior support to the cervix.
The procedure is technically straightforward, involving minimal dissection primarily within the peritoneal folds, and can be performed in under 30 minutes by an experienced surgeon.
Absolute commitment to cesarean delivery is non-negotiable and must be a central part of patient counseling.
Proper patient selection, meticulous surgical technique focusing on key anatomical landmarks, and comprehensive postoperative planning are essential for successful outcomes.

MULTIPLE CHOICE QUESTIONS (MCQs)

What is the primary advantage of laparoscopic cervical cerclage over a vaginal McDonald cerclage?

a) It allows for vaginal delivery.

b) It can be performed without anesthesia.

c) It places the suture higher, at the level of the internal os.

d) It uses an absorbable suture.

Answer: c
According to the lecture, what percentage of second-trimester miscarriages are attributed to cervical incompetence?

a) 1-2%

b) 5-10%

c) 15-20%

d) 30-40%

Answer: c
Which of the following is a contraindication for performing a cervical cerclage?

a) History of a previous cesarean section

b) A non-pregnant state (interval procedure)

c) Active uterine contractions

d) Bicornuate uterus

Answer: c
During laparoscopic cerclage, where is the Mersilene tape knot tied?

a) Anteriorly, over the bladder

b) Posteriorly, behind the cervix

c) Laterally, in the broad ligament

d) Inside the cervical canal

Answer: b
What is the mandatory mode of delivery for a patient with a laparoscopic cervical cerclage in situ?

a) Vaginal delivery after suture removal at 37 weeks

b) Forceps-assisted vaginal delivery

c) Cesarean section

d) Water birth

Answer: c
What is the purpose of fixing the cerclage tape to the anterior cervical fascia at the 12 o'clock position?

a) To make the tape absorbable

b) To prevent tape migration and aid in identification during cesarean section

c) To secure the bladder to the uterus

d) To completely occlude the cervix

Answer: b
When performing a laparoscopic cerclage in a pregnant patient, what instrument should NOT be used?

a) Bipolar forceps

b) Uterine manipulator

c) Fan retractor

d) Suction-irrigator

Answer: b
What is the key anatomical landmark for creating the posterior window for needle passage?

a) The sacral promontory

b) The round ligament

c) The avascular space approximately 2 cm above the uterosacral ligament insertion

d) The infundibulopelvic ligament

Answer: c
Which ultrasound finding is most characteristic of an incompetent cervix?

a) A T-shaped internal os

b) A cervical length of 4 cm

c) Funneling of the cervix (Y, V, or U-shape)

d) Posterior shadowing from the cervix

Answer: c
The surgical technique described involves incising which peritoneal structure?

a) The peritoneum over the sigmoid colon

b) The vesicouterine (UV) fold and anterior broad ligament

c) The peritoneum of the pelvic sidewall over the ureter

d) The falciform ligament

Answer: b
According to Dr. Mishra, what is the ideal timing for performing a laparoscopic cervical cerclage?

a) During the third trimester

b) In a non-pregnant patient (interval cerclage)

c) At 24 weeks of gestation

d) During active labor

Answer: b
What is the recommended management if a patient with a laparoscopic cerclage goes into preterm labor?

a) Attempt to stop labor with tocolytics and remove the stitch vaginally

b) Allow labor to proceed for a vaginal delivery

c) Perform an emergency cesarean section

d) Administer epidural anesthesia and await full dilatation

Answer: c
What is a potential catastrophic complication if a patient with a cerclage labors to full dilatation?

a) Bladder injury

b) Suture erosion

c) Uterine rupture

d) Chorioamnionitis

Answer: c
The first throw of the intracorporeal surgeon's knot for securing the tape should be a:

a) Single throw

b) Double throw

c) Triple throw

d) Slip knot

Answer: b
What historical procedure is considered a precursor to the laparoscopic technique, often utilizing a Mersilene tape placed vaginally after mucosal dissection?

a) McDonald cerclage

b) Hegar dilatation

c) Shirodkar cerclage

d) Wertheim's hysterectomy

Answer: c
How is the bladder handled during the initial dissection?

a) It is incised to drain urine.

b) It is filled with methylene blue.

c) It is dissected inferiorly off the cervix.

d) It is left undisturbed.

Answer: c
What is the recommended action after securing the anterior fixation suture (Vicryl)?

a) Cut the suture immediately.

b) Use the same suture to begin closing the peritoneum.

c) Tie ten additional knots for security.

d) Remove the suture and leave the tape unfixed.

Answer: b
What action facilitates the passage of the needle from posterior to anterior through the broad ligament window?

a) Pushing the uterus up with the manipulator

b) Asking the assistant to "drop" the uterus

c) Increasing the pneumoperitoneum pressure

d) Angling the needle posteriorly

Answer: b
Congenital cervical incompetence has been associated with maternal exposure to which substance?

a) Penicillin

b) Aspirin

c) Diethylstilbestrol (DES)

d) Folic acid

Answer: c
After the cerclage is complete, what structure prevents the tape from migrating inferiorly in the posterior cul-de-sac?

a) The bladder

b) The round ligaments

c) The uterosacral ligaments

d) The sigmoid colon

Answer: c

MOTIVATIONAL MESSAGE FROM DR. R. K. MISHRA

The scalpel is an instrument of decision. Each movement is a commitment, each suture a promise. Cultivate the discipline to make your decisions deliberate and your promises steadfast, for in this commitment lies the foundation of surgical excellence and the trust of your patient.

My best wishes are with you as you continue on your path of learning and service.