Transabdominal placement of a cerclage at the cervicoisthmic junction appears to be a safe and effective procedure for reducing the incidence of spontaneous pregnancy loss in selected patients with cervical insufficiency [1-6]. Potential advantages of transabdominal over transvaginal cerclage are more proximal placement of the stitch (at the level of the internal os), decreased risk of suture migration, absence of a foreign body in the vagina that could promote infection, and the ability to leave the suture in place for future pregnancies . A disadvantage of this approach is the potential need for two laparotomies during pregnancy (one to place the cerclage and potentially another to remove it).
INDICATIONS AND CONTRAINDICATIONS
There are no studies comparing the outcome of transabdominal and transvaginal cerclage in similar populations of patients. Transabdominal cerclage is a more morbid procedure than transvaginal cerclage. It usually requires a laparotomy for placement and delivery by cesarean. For these reasons, most experts recommend reserving the transabdominal approach for women with cervical insufficiency who have either failed two or more previous transvaginal cerclages or in whom a transvaginal cerclage is technically impossible to perform due to extreme shortening, scarring, or laceration of the cervix.
Contraindications to transabdominal cerclage are similar to those for transvaginal cervical cerclage. (See "Transvaginal cervical cerclage".)
Transabdominal cerclage placement is usually performed either prior to conception  or during early pregnancy (at 11 to 14 weeks). Placement of the cerclage later in pregnancy is undesirable since the large size of the uterus makes the procedure difficult and thus may be associated with a higher risk of complications.
No studies have compared the outcome of patients who underwent surgery prior to conception versus those whose placement was in early pregnancy. Although the preconceptional approach is associated with less blood loss and avoids the risk of pregnancy-associated complications (eg, rupture of the fetal membranes), there is a theoretic risk of causing subfertility with preconceptional placement . Our preference is to perform the procedure in early pregnancy.