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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_207_библиотеки_им_акад_М_И_Перельмана
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GENERAL PRINCIPLES
Definition
Cervical insufficiency is defined as the inability of the cervix to retain a pregnancy in the second trimester.
1
This is due to a
presumed weakness of cervical tissue that leads to painless cervical dilation with a resulting delivery of a live fetus (usually
previable) in the second trimester.
2
A laparoscopic abdominal cerclage is usually indicated in cases of prior failed vaginal
cerclage, or in a patient with cervical anatomic limitations such as prior cervical procedures, injuries, or congenital cervical
abnormalities.
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Differential Diagnosis
Preterm labor
Uterine infection
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Nonoperative Management
Nonsurgical treatments such as bed rest, pelvic rest, and modified activity have not been proven effective and their use is
discouraged.
1
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IMAGING AND OTHER DIAGNOSTICS
Physical exam of the cervix can identify patients in whom a vaginal cerclage may not be suitable due to prior cervical injury or
surgical treatment. Measurement of cervical length by transvaginal ultrasound can be used as part of the decision-making
process, though patient history can often provide the most information regarding indications for placement.
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PREOPERATIVE PLANNING
Preoperative assessment with a transvaginal ultrasound should be performed to evaluate for the presence of uterine
abnormalities that could contribute to preterm labor such as a didelphys, unicornuate, bicornuate, or uterine septum.
Preoperative cervical length should also be recorded.
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SURGICAL MANAGEMENT
It is preferable to place a laparoscopic transabdominal cerclage in the nonpregnant state prior to conception. It can be
placed in the first trimester, though this can be more difficult due to limitations of uterine manipulation, increased risks if a
uterine vascular injury were to occur, and possible risk of fetal exposure to anesthetic agents.
The cerclage is placed with a Mersilene 5-mm tape 12′′ (Ethicon Inc., Somerville, NJ), double-armed, on a BP-1 needle
(blunt point, 65 mm) (Product code RS21). This needle is a ½ circle and prior to use, two heavy needle drivers are used to
straighten it. By holding the two needle drivers close to each other on the needle, the curvature is removed one small
segment at a time. All but the distal 1 cm is straightened, forming a ski configuration (Fig. 2.2.1). The suture is soaked in
iodine solution prior to use as a deterrent to bacteria.
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Positioning
The patient is placed in a standard dorsal lithotomy position as for other basic laparoscopy procedures.
Figu re 2 .2.1. Suture needle straight ened into “ ski” configuration.
If nonpregnant, a uterine manipulator is placed. A manipulator that has the ability to flex the uterus can be beneficial.
Appropriate intrauterine manipulators include the ClearView
®
(Clinical Innovations, Murray, UT), HUMI
®
(Cooper
Surgical, Trumbull, CT), ZUMI™ (Cooper Surgical, Trumbull, CT), or Kronner Manipujector
®
(Cooper Surgical, Trumbull,
CT).
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Approach
An abdominal cerclage can be placed through a laparotomy incision, but laparoscopic placement is equally successful
3,4
and
associated with a faster recovery and less patient morbidity.
For a laparoscopic approach, the procedure can be performed with or without robotic assistance. In most cases, placement
of the cerclage requires two 5-mm ports in addition to an umbilical camera port. An additional port may be needed if the
uterus is not freely mobile, or if bleeding is encountered.
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Procedures and Techniques
Video of a laparoscopic abdominal cerclage placement
The following steps to perform a laparoscopic abdominal cerclage procedure can be viewed in an unedited video of the
procedure (Video 2.2.1 ).
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Opening of vesi couterine fold of peritoneum
Open the peritoneum at the vesicouterine fold with monopolar scissors (Te ch Fig. 2.2.1). Enter the vesicouterine space,
dissecting the bladder away from the lower uterine segment enough to allow for visualization of the cervix and localization
of the cervix–uterine junction (Tech Fig. 2.2.2).
Te ch Fig ure 2.2.1. Opening of vesicouterine fold of peritoneum.
Te ch Fig ure 2.2.2. Exposing the cervix at the level of t he int ernal os.
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