Laparoscopic cervical cerclage is a minimally invasive surgical technique designed to prevent premature birth in women with cervical incompetence, a condition where the cervix starts to dilate and efface before the pregnancy reaches term. This condition can lead to late miscarriage or preterm birth if not properly managed. The procedure involves placing a stitch around the cervix to reinforce it and keep it closed during pregnancy, thereby reducing the risk of spontaneous preterm birth. This essay provides a comprehensive tutorial on the surgical approach, patient selection, preoperative preparation, intraoperative technique, postoperative care, and potential complications associated with laparoscopic cervical cerclage.

Patient Selection and Preoperative Preparation

The selection of patients for laparoscopic cervical cerclage is critical and involves a thorough assessment of the patient's obstetric history, including any previous preterm births or second-trimester losses, as well as an examination of the cervix via ultrasound or physical examination. Ideal candidates are those with a history of cervical incompetence, especially those who have failed a previous vaginal cerclage or for whom a vaginal approach is not feasible due to anatomical reasons.

Preoperative preparation includes counseling the patient about the procedure, its risks, and benefits, and obtaining informed consent. Preoperative antibiotics may be administered to reduce the risk of infection, and the patient is advised to fast for a specified period before the surgery.

Intraoperative Technique

The laparoscopic cervical cerclage procedure is performed under general anesthesia. The patient is placed in the lithotomy position, and a urinary catheter is inserted to decompress the bladder. The abdomen and vagina are prepped and draped in a sterile fashion.

Pneumoperitoneum is established, and trocars are placed strategically to allow for optimal access to the cervix. A laparoscope is inserted through the umbilical port to visualize the pelvic anatomy. The surgeon identifies the cervix and uses laparoscopic instruments to carefully dissect the vesico-uterine peritoneum to expose the cervix's anterior and posterior aspects.

A non-absorbable suture, typically made of Mersilene, Ethibond, or Prolene, is then used to place a purse-string or McDonald-type stitch around the cervix, just below the level of the vaginal reflection. Care is taken to avoid the uterine arteries and to ensure that the stitch is placed at an adequate depth to provide support without compromising cervical tissue.

Once the cerclage is in place, the suture is tied, and the knot is buried to prevent it from irritating the surrounding tissues. The peritoneum is then closed over the cerclage to protect it and to reduce the risk of adhesion formation. The laparoscope and instruments are removed, and the incisions are closed.

Postoperative Care

After the procedure, the patient is monitored for any immediate complications such as bleeding or signs of infection. Pain management is provided, and the patient is usually advised to rest and avoid strenuous activities for a specified period. Follow-up appointments are scheduled to monitor the pregnancy and the position of the cerclage via ultrasound.

Potential Complications

While laparoscopic cervical cerclage is generally safe, it is not without risks. Complications can include bleeding, infection, bladder or bowel injury, preterm premature rupture of membranes (PPROM), and cerclage failure leading to preterm birth. The risk of these complications can be minimized with proper surgical technique and careful patient selection.

Conclusion

Laparoscopic cervical cerclage is a valuable surgical technique for the prevention of preterm birth in women with cervical incompetence. It offers the benefits of minimally invasive surgery, including reduced postoperative pain, shorter hospital stays, and quicker recovery times. However, the success of the procedure depends on careful patient selection, meticulous surgical technique, and thorough postoperative care. With advancements in laparoscopic technology and technique, laparoscopic cervical cerclage continues to be a critical tool in the management of cervical incompetence, offering hope to many women at risk of preterm birth.