Page 31 - World Journal of Laparoscopic Surgery

WJOLS

Transabdominal Cervical Cerclage: Laparoscopy or Laparotomy
Table 1: List of studies comparing the route advocated, time of placement, and outcome
Selected studies Sample size Route advocated Time of placement Outcome
Ades et al 1 69 51 Laparoscopy Nonpregnant and during pregnancy 98% viable pregnancy in laparoscopy
18 Laparotomy 100% viable pregnancy in laparotomy
Ades et al 7 64 Laparoscopy Nonpregnant and during pregnancy 95.8% viable pregnancy
Umstad et al 8 22 Laparotomy Nonpregnant and during pregnancy 91% deliveries > 34 weeks
Thuezen et al 9 45 Laparotomy Nonpregnant 97% deliveries > 34 weeks
Davis et al 10 40 Laparotomy During pregnancy 90% deliveries > 33 weeks
Whittle et al 6 65 Laparoscopy Nonpregnant and during pregnancy 89% deliveries on 35.8 ± 2.9 weeks
Carter et al 5 19 12 Laparoscopy Nonpregnant and during pregnancy 75% viable pregnancy in laparoscopy
7 Laparotomy 71% viable pregnancy in laparotomy
Nicolet et al 11 5 Laparoscopy Nonpregnant 100% term deliveries
Reid et al 12 2 Laparoscopy Nonpregnant 100% deliveries > 34 weeks
Liddell et al 13 10 Laparoscopy Nonpregnant 100% deliveries in third trimester
Kjøllesdal et al 14 1 Laparoscopy Nonpregnant 100% term delivery
Al-Fadhli, Tulandi 15 2 Laparoscopy Nonpregnant 100% deliveries > 34 weeks
Mingione et al 4 11 Laparoscopy Nonpregnant 100% deliveries > 34 weeks
Gallot et al 16 2 Laparoscopy Nonpregnant 100% term deliveries
Cho et al 17 20 Laparoscopy During pregnancy 95% live born infants

were selected for review and the included studies are laparoscopy group perforation of the bladder was noted
tabulated in Table 1. 5-17 From these 15 articles, 132 patients in one patient. The laparoscopic TAC confers a similar
underwent laparotomy and 245 patients underwent rate of perioperative complications as the laparotomy and
laparoscopy for transabdominal cervical cerclage. The is best finished in nonpregnant or in the first trimester.
procedure was performed in both the pregnant as well The operating time in the laparoscopic group was
as in the nonpregnant state. more compared to the laparotomy but did not have
5
Carter et al compared a prospective cohort of patients any statistical significance and in some studies the
1
undergoing laparoscopic cerclage with a historical control laparoscopic cerclage was concomitantly performed with
group of patients who underwent a laparotomy for TAC other surgeries. The laparoscopy group had significantly
and there was no difference in outcome for viable pregnan- lower surgical morbidity, which was contributed mainly
cies (75% in laparoscopy and 71% in the laparotomy group). by a reduced hospital stay. Most laparoscopy cases were
6
A similar study outline is seen in a study of Whittle et al classified as outpatient procedures and were performed
with a larger sample size. Sixty-five patients underwent a with oral analgesia only, with the patient leaving the
laparoscopic TAC either before or during pregnancy. The hospital on the same day. The difference in blood loss
outcomes were compared with the traditional laparotomy was also not clinically significant and no patient required
approach using previously reported cohorts. The success transfusion.
rate in this study was 89% with a mean gestational age of
35.8 ± 2.9 weeks, which is a comparable obstetric outcome DISCUSSION
with the laparotomy approach.
Also from the selected studies the success rate Aside from the more complexity in the procedure of a
of live pregnancies after 33 weeks ranges from 71 to TAC, there are some points of interest when utilizing this
100% in the laparotomy group and 75 to 100% in the method rather than the transvaginal cerclage, i.e., high
laparoscopy group with a mean success rate of 89.8% situation of the suture, no slippage of the cerclage, absence
in the laparotomy group and 96% in the laparoscopic of the suture material inside the vagina that could bring
procedures. It can be concluded from these studies that about infection and preterm labor, and the advantage to
3
the laparoscopic approach for TAC is as effective as the leave the tape in situ between pregnancies. To utilize
laparotomy approach and can be safely performed during this method laparoscopically, the surgeon needs ability
pregnancy also. in laparoscopic suturing. In contrast with laparotomy,
In one of the case series with 11 cases, a small bowel laparoscopy outcomes are less or no hospitalization, less
4
injury was reported and two uterine vessel injuries postoperative torment, and quicker recovery. 18,19
were reported in two studies. 16,17 In a prospective cohort Laparoscopic cervical cerclage can be performed dur-
1
study by Ades et al, four cases in the laparotomy group ing pregnancy or as an interval procedure in nonpreg-
and one case in the laparoscopy arm had complications. nant women. It is performed under general anesthesia.
In the laparotomy group, three cases had intraoperative In a nonpregnant woman, a dilator may be initially
hemorrhage and one wound infection and in the inserted into the cervix through the vagina for uterine
World Journal of Laparoscopic Surgery, May-August 2016;9(2):78-81 79