Task Analysis Of Interval Laparoscopic Abdominal Cerclage
Dr. Viveka Mohan
Abdominal cerclage is necessary when the standard transvaginal cerclage fail or anatomical abnormalities preclude the vaginal placement. In 1965, Benson and Durfee described an abdominal approach to cerclage. The main interest of this technique is to avoid a laparotomy; thus, reducing the morbidities of laparotomy and also the recovery time post-surgery.A 5-mm non-absorbable needled polyester fiber tape (Mersilene) suture was placed laparoscopically at the level of the internal os as an interval procedure.
Indications
1) congenitally short or extensively amputated cervix, marked scarring of the cervix,
2) subacute cervicitis,
3) wide or extensive cervical conisation, and
4) one or more previous trans-vaginal cerclage failures.
Contraindications:
1)bulging membranes
2)ruptured membranes,
3)intrauterine infections,
4)vaginal blood loss,
5)intrauterine foetal death,
6)labour,
7) life-threatening maternal condition.
Pre operative steps
1) Any medical co -morbidities and absolute or relative contraindications
2) Informed consent
3) Pre- surgical checklist
Intro operative steps
1. Prophylactic antibiotics half an hour prior to surgery after test dose.
2. Connect patient for vital signs monitoring and EtCo2 monitor.
3. Induction with general anesthesia.
4. Patient in Trendelenburg position.
5. Preparation of surgical site.
6. Speculum and uterine manipulator placement
7. Make sure that all the cables and patient return plate are properly connected and the required energy sources are in working condition.
8. Pre operative checklist is reconfirmed.
Port placement and pnemoperitonium:
Using baseball diamond concept, one 10mm port is placed in the umbilicus and two 5mm ports are placed contra-laterally at distance of 7.5 cm from the umbilicus. Before inserting check the Veress needle action by pressing the blunt tip of the needle against a hard surface and checking the action of the red indicator.
Steps:
1. For the umbilical port placement, evert the umbilicus by applying two Alleys forceps on lateral margins of umbilicus.
2. Then a stab incision is given in the midline on the superior or inferior crease of the umbilicus.
3. Now, hold the Veress needle like a dart in the right hand and lift up the abdominal wall by holding suprapubically. Insert the Veress needle at a 90° angle to the abdominal wall and oblique to the peritoneum and keep the direction of the needle towards the pelvis
4. There will a sensation of initial resistance and then giving away at two places. Once the peritoneum in pierced confirm it by connecting 5ml syringe to the Veress needle and then aspirate. If nothing is aspirated, then push some saline into the cavity and then aspirate again, if the peritoneal cavity has been reached then no fluid should be aspirated back. Hanging drop test and plunger test can also be done.
5. Once the position of the needle is confirmed, attach the needle to the insufflator with initial flow rate of 1L/min with preset pressure of 12 to 15mm of Hg.
8. Once uniform dissension is achieved, enlarge the incision in a curved fashion and insert a 10mm port perpendicular to the abdominal wall by screwing movement . Now, remove the trocar and insert a 30° telescope through the cannula, into the abdominal cavity keeping the light source cable at 12’o clock position and CCD cable at 6’o clock position.
10. Once the port is inserted, the flow rate can be increased to >/= 6L/min.
11. Now to put a 5mm port 7.5 cm lateral to the umbilical port, by first making a stab wound on the skin and then inserting the port perpendicular to the skin, under the direct vision via laparoscope. Similarly, put another port 7.5 cm lateral to the umbilicus on the contra lateral side.
Procedure of laparoscopic abdominal cerclage
1)Start by inspecting the abdominal and pelvic cavities for any abnormalities, adhesions and endometriosis.
2)Inspect the uterus, fallopian tubes, ovaries, the pouch of Douglas and uterosacral ligaments for any congenital anomalies, any visible myomas, cysts, adhesions of the tube or hydrosalpinx
3)Uterus is held retroverted.The uterovesicle fold of peritoneum is dissected using atraumatic grasper and dissector(scissors,harmonic) to visualize the uterine artery .Blunt dissection is carried out atlas the upto 4 cm on either side to reach the broad ligament.
4)Uterus is anteverted and the site for needle insertion is delineated.Ideally this is the grey area, roughly 2cm above the uterosacral ligament origin,which corresponds to a point lateral to internal is of cervix and medial to uterine artery.Coagulation is done at this point which also helps to prevent excessive bleeding .
5)Mercilene tape with 2 needles with a ski configuration is introduced through 5mm port.
6)The needle is held and taken posterior to uterus.Needle is held at right angles to uterus at the grey area and brought out anteriorly medial to uterine artery on one side.Care should be taken not to injure the uterine vessels.Similarly the step is repeated on the other side .Care should be taken that the tape remains flat posteriorly.
7)The tape is pulled anteriorly from both sides.The needles are cut off and removed through 5 mm port.A surgeon’s knot is placed by first taking 2 wraps and then two single opposite throws . The knot should be tied snuggly and excessive tension is not needed.The 2 ends of the knot are cut and sutured together with absorbable suture and anchored to cervical fascia.
8)With the same absorbable suture the UV fold of peritoneum is approximated by continuous sutures and terminated by Aberdin,s knot. 9)Haemostasis is checked. Pnemoperitoneum is reverted followed by closure of all ports.