Transabdominal cervical cerclage
- Errol R Norwitz, MD, PhD, MBA
Errol R Norwitz, MD, PhD, MBA
- Professor and Chair
- Department of Obstetrics and Gynecology
- Tufts Medical Center and Tufts University School of Medicine
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 can be performed prior to conception  or in early pregnancy. Preconception placement provides optimum exposure and reduces risks of excessive bleeding and injury to the pregnancy. Placement of the cerclage after the first trimester 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 randomized trials have compared outcomes with preconception versus postconception cerclage. A review of 14 studies of abdominal cerclage published between 1990 and 2013 and involving a total of 678 patients reported live birth rates were similar whether abdominal cerclage was performed before or during pregnancy .
Open transabdominal approach — We use an open approach. It is usually performed with the patient in the supine position, but may be done with the woman in a modified lithotomy position if intraoperative transvaginal manipulation of the uterus or transvaginal ultrasound examination of the cervix is necessary .
- Norwitz ER, Lee DM, Goldstein DP. Transabdominal cervicoisthmic cerclage: Placing the stitch before conception. J Gynecol Tech 1997; 3:53.
- Novy MJ. Transabdominal cervicoisthmic cerclage: a reappraisal 25 years after its introduction. Am J Obstet Gynecol 1991; 164:1635.
- Novy MJ. Transabdominal cervicoisthmic cerclage for the management of repetitive abortion and premature delivery. Am J Obstet Gynecol 1982; 143:44.
- Herron MA, Parer JT. Transabdominal cerclage for fetal wastage due to cervical incompetence. Obstet Gynecol 1988; 71:865.
- Fick AL, Caughey AB, Parer JT. Transabdominal cerclage: can we predict who fails? J Matern Fetal Neonatal Med 2007; 20:63.
- Umstad MP, Quinn MA, Ades A. Transabdominal cervical cerclage. Aust N Z J Obstet Gynaecol 2010; 50:460.
- Burger NB, Einarsson JI, Brölmann HA, et al. Preconceptional laparoscopic abdominal cerclage: a multicenter cohort study. Am J Obstet Gynecol 2012; 207:273.e1.
- Tulandi T, Alghanaim N, Hakeem G, Tan X. Pre and post-conceptional abdominal cerclage by laparoscopy or laparotomy. J Minim Invasive Gynecol 2014; 21:987.
- Norwitz ER, Goldstein DP. Transabdominal cervicoisthmic cerclage: Learning to tie the knot. J Gynecol Tech 1996; 2:49.
- Göçmen A, Sanlıkan F. Two Live Births following Robotic-Assisted Abdominal Cerclage in Nonpregnant Women. Case Rep Obstet Gynecol 2013; 2013:256972.
- Walsh TM, Borahay MA, Fox KA, Kilic GS. Robotic-assisted, ultrasound-guided abdominal cerclage during pregnancy: overcoming minimally invasive surgery limitations? J Minim Invasive Gynecol 2013; 20:398.
- Moore ES, Foster TL, McHugh K, et al. Robotic-assisted transabdominal cerclage (RoboTAC) in the non-pregnant patient. J Obstet Gynaecol 2012; 32:643.
- Fechner AJ, Alvarez M, Smith DH, Al-Khan A. Robotic-assisted laparoscopic cerclage in a pregnant patient. Am J Obstet Gynecol 2009; 200:e10.
- Wolfe L, DePasquale S, Adair CD, et al. Robotic-assisted laparoscopic placement of transabdominal cerclage during pregnancy. Am J Perinatol 2008; 25:653.
- Katz M, Abrahams C. Transvaginal placement of cervicoisthmic cerclage: report on pregnancy outcome. Am J Obstet Gynecol 2005; 192:1989.
- Golfier F, Bessai K, Paparel P, et al. Transvaginal cervicoisthmic cerclage as an alternative to the transabdominal technique. Eur J Obstet Gynecol Reprod Biol 2001; 100:16.
- Witt MU, Joy SD, Clark J, et al. Cervicoisthmic cerclage: transabdominal vs transvaginal approach. Am J Obstet Gynecol 2009; 201:105.e1.
- Deffieux X, De Tayrac R, Louafi N, et al. Novel application of polypropylene sling: transvaginal cervicoisthmic cerclage in women with high risk of preterm delivery. J Minim Invasive Gynecol 2006; 13:216.
- Debbs RH, DeLa Vega GA, Pearson S, et al. Transabdominal cerclage after comprehensive evaluation of women with previous unsuccessful transvaginal cerclage. Am J Obstet Gynecol 2007; 197:317.e1.
- Foster TL, Moore ES, Sumners JE. Operative complications and fetal morbidity encountered in 300 prophylactic transabdominal cervical cerclage procedures by one obstetric surgeon. J Obstet Gynaecol 2011; 31:713.
- Hawkins E, Nimaroff M. Vaginal erosion of an abdominal cerclage 7 years after laparoscopic placement. Obstet Gynecol 2014; 123:420.
- Madueke-Laveaux OS, Platte R, Poplawsky D. Unique complication of a Shirodkar cerclage: remote formation of a vesicocervical fistula in a patient with the history of cervical cerclage placement: a case report and literature review. Female Pelvic Med Reconstr Surg 2013; 19:306.
- Ruan JM, Adams SR, Carpinito G, Ferzandi TR. Bladder calculus presenting as recurrent urinary tract infections: a late complication of cervical cerclage placement: a case report. J Reprod Med 2011; 56:172.
- Hortenstine JS, Witherington R. Ulcer of the trigone: a late complication of cervical cerclage. J Urol 1987; 137:109.
- Martin A, Lathrop E. Controversies in family planning: management of second-trimester losses in the setting of an abdominal cerclage. Contraception 2013; 87:728.
- Zaveri V, Aghajafari F, Amankwah K, Hannah M. Abdominal versus vaginal cerclage after a failed transvaginal cerclage: a systematic review. Am J Obstet Gynecol 2002; 187:868.
- Lotgering FK, Gaugler-Senden IP, Lotgering SF, Wallenburg HC. Outcome after transabdominal cervicoisthmic cerclage. Obstet Gynecol 2006; 107:779.
- Sumners JE, Moore ES, Ramsey CJ, Eggleston MK. Transabdominal cervical cerclage in triplet pregnancies and risk of extreme prematurity and neonatal loss. J Obstet Gynaecol 2011; 31:111.
- INDICATIONS AND CONTRAINDICATIONS
- Open transabdominal approach
- Other approaches
- - Laparoscopic approach
- - Transvaginal approach
- POSTOPERATIVE CARE
- Management of the cerclage after cesarean delivery
- MANAGEMENT OF FETAL DEMISE
- SUMMARY AND RECOMMENDATIONS