Dr. Kwadwo Asare OWUSU-ANSAH, MD FWACS 

KORLE BU TEACHING HOSPITAL, ACCRA, GHANA

INTRODUCTION       

Cervical shortening has been associated with recurrent mid-trimester pregnancy loss as well as increased risk of spontaneous preterm birth.

The association between cervical dysfunction and pregnancy loss was first described by Riverius in 1658, and thoroughly effective interventions to this problem have proven somewhat elusive even though vaginal cerclage initially by Lash, Shirodkar, and MacDonald in the 1950s has achieved some success over the years. However, the evidence supports transabdominal cerclage first described by Benson and Durfee in 1965 as a more effective intervention, especially in a non-pregnant woman. Emerging evidence now shows that laparoscopy has better obstetric outcomes than laparotomy when used to place the stitch.

INDICATIONS

1. Recurrent mid-trimester pregnancy losses due to cervical factor
2. Recurrent spontaneous preterm births
3. Failed Vaginal Cerclage.

ADVANTAGES:

Very useful in cases of previously failed vaginal cerclage

DISADVANTAGES

1. More expensive

2. Elective cesarean delivery is mandatory.

TIMING

1. Pre pregnant state

2. Between 14 to 16 weeks of gestation

TASK ANALYSIS

1. Pre-operative Evaluation

2. Equipment checks

3. Port placement

4. Intraoperative steps

PRE-OPERATIVE EVALUATION

1. Relevant history and physical examination should be done as well as routine checklist for major surgery applied to rule out any potential co-morbidities.

1. Investigations such as Full blood count, Blood Urea Electrolytes, ECG, Chest X-ray, ECHO and Coagulation profile done 
2. Mandatory anesthetic review
3. Informed consent 
4. Bowel preparation (done the previous night)
5. All equipment tested before surgery.
6. Antibiotics are given at induction of anesthesia.

EQUIPMENT/HARDWARE 

1. Telescope 10mm, 30 degree
2. Electrosurgical Unit (Monopolar) or Harmonic Scalpel 
3. Atraumatic Grasper, Scissors, Maryland Dissector, Needle holder
4. Sutures: Mersilene tape 5mm, Vicryl # 0, #3/0.

TEAM MEMBERS 

1. Obstetrician-gynecologist with competencies in minimal access surgery.
2. 2 Assistants 
3. Anesthesiologist 
4. Scrub Nurse

SURGICAL TEAM POSITIONING

Surgeon: Left side of the patient’s abdomen

1st Assistant: Controls camera, stands slightly behind and to the right of the surgeon.

2nd Assistant: Controls the uterine manipulator stands in between the slightly abducted legs of the patient.

Anesthesiologist: At the head of the patient

Scrub Nurse: slightly behind and to the left of the surgeon

PATIENT POSITIONING: Initially supine, and then steep Trendelenburg with lithotomy position to help bowel fall away from the pelvis

Anesthesia: General

PORT POSITIONING: Using a baseball diamond concept, 3 Ports are used; one 10mm optical port and two 5mm ports, each 7.5cm from the optical port in contralateral setup.

ABDOMINAL ENTRY (Closed Access Technique)

A stab incision is made at the inferior crease of the umbilicus, and the Veress needle held like a dart is advanced through the anterior abdominal wall, which is lifted at an angle of 90 degrees till two clicks are felt. The correct placement of the Veress needle is confirmed with saline and the hanging drop test, and then insufflation with medical grade CO2 is started at an initial flow rate of 1L/min and preset pressure of 15mmHg. Once the preset pressure is achieved the Veress needle is removed and the stab incision enlarged by the Scandinavian technique to 11mm to allow placement of the 10mm port.

PRIMARY PORT PLACEMENT

The primary port is introduced by the surgeon holding the 10mm trocar and cannula like a pistol and advancing it slowly with continuous screwing movements initially perpendicular to the abdominal wall and the later directed towards the anus till a give is felt. The correct trocar placement is confirmed by briefly pressing the valve on the cannula to hear the hissing sound of escaping the gas. Once this is confirmed, the trocar is removed and the gas pipe of the insufflator connected to the 10mm port, and the preset pressure adjusted to 12 mmHg, which would be the working pressure. 

The continuous monitoring of the carbon dioxide pressure is done by the Quadro manometric microprocessor-controlled insufflator device.

A 10mm 30-degree telescope with the focus and white balancing already adjusted are then introduced into the abdomen via the 10mm port. A panoramic view and initial inspection of the abdomen is done starting with the point of primary port entry and adjacent area then to the right paracolic gutter, appendix, large bowel, stomach, omentum, transverse colon then to the pelvis, the uterus, ovaries, tubes, bladder, round ligament, median, medial and lateral umbilical ligaments, triangles of pain, doom and trapezoid of disaster are all inspected, any pathology seen should be noted and recorded. The uterine manipulator is then fixed, especially if not pregnant (Nathanson’s Liver retractor may help if pregnant) and the mobility of the uterus is then demonstrated by full range manipulation by the assistant, and any areas of adhesion or limited mobility is noted if there is a history of previous surgery or infections.

ACCESSORY PORTS PLACEMENT

After inspection, two 5mm accessory ports are placed through the 

anterior abdominal wall in contralateral configuration through the stab incision made at the transilluminated points on the abdomen to avoid the inferior epigastric vessels, which should be medial to the ports.

These two ports are then advanced under direct vision and directed towards the pelvis.

ELECTROSURGICAL DISSECTION

Once all ports have been placed, the appropriate instruments are now 

introduced in this case the atraumatic grasper in the left hand and harmonic scalpel or alternatively the monopolar scissors in the right hand. With the uterus in retroverted position by the manipulator, the anterior UV fold of the peritoneum is held with the grasper in the midline and opened with the harmonic and dissected to about 3-4 cm on either side, left and right. The bladder is carefully dissected from the cervix and pushed away. The uterus is the pushed to anteverted position and about 2cm just above the arc of the uterosacral ligament posteriorly, this an avascular area through the broad ligament at the level of and lateral to the internal os and also medial to the uterine 

artery, two points; one on the left and one on the right are coagulated to create an opening to pass the needle of the Mersilene tape. The tape with needles in end ski configuration is now introduced through the 5mm port and passed first from anterior to posterior on the left side and then posterior to anterior on the right side through the coagulated area with needle of the tape held perpendicular to the needle holder. 

While this is being done on the left side and right sides, make sure to avoid injury to the bladder and uterine vessels. The needles on the Mersilene tape ends are cut and removed through the 5mm 

Port, a surgeon’s knot is then made anteriorly, and the excess Mersilene tape trimmed off. The free ends of the Mersilene tape are then fixed to the anterior cervical fascia to secure it using Vicryl #1; then the peritoneum is the closed off from left to right using the same Vicryl suture with Dundee Jamming knot in a continuous manner with Aberdeen termination.

COMPLETION

The abdomen is then inspected for any significant bleeding to rule out any injury, and if found to be satisfactory, then the CO2 gas is switched off, accessory ports removed under direct vision, telescope removed, and the valves of the primary port opened to decompress the abdomen. The telescope is then reintroduced through the primary port, and then both primary port and telescope removed together.

PORT CLOSURE

Only ports greater than 10mm are closed fully, the skin was closed with Vicryl 3/0, and a sterile dressing applied.

POSTOPERATIVE PERIOD

1. The patient is monitored in the recovery room with ¼ hourly vital signs
2. Analgesics and Antiemetics are given
3. Observe for 24 hours, then discharge home.
4. Re counseling on potential complications such as suture disruption, and chorioamnionitis
5. To continue antenatal care and counsel on elective cesarean delivery at term.

Elaboration of Steps:

Position the patient in the lithotomy position.

Administer general anesthesia.

Insert a urinary catheter to empty the bladder.

Preoperative antibiotics are administered.

Insert a uterine manipulator to improve visualization.

Insufflate the abdomen using CO2.

The laparoscope is inserted through a 10mm port at the umbilicus.

Place 2-3 additional trocars as required.

Identify the cervix.

Dissect the bladder off the anterior aspect of the cervix.

Use a monopolar or bipolar electrosurgical device to create a tunnel on the cervix.

Insert a Mersilene tape through the tunnel.

Tie the tape to form a loop around the cervix.

Tighten the tape to achieve the desired level of cervical competence.

Cut the tape ends and bury them in the cervical tissue.

Inspect the cervix and surrounding structures for any signs of bleeding.

Remove the laparoscope.

Remove the trocars.

Deflate the abdomen.

Close the incisions with sutures or staples.

Apply sterile dressing to the incisions.

The patient is awakened from anesthesia.

Extubate the endotracheal tube.

Move the patient to the post-anesthesia care unit.

Administer analgesics for pain management.

Monitor vital signs and urine output.

Check the dressing for bleeding or drainage.

Observe the patient for any signs of infection or complications.

Advise the patient to avoid strenuous activity for 2-4 weeks.

Advise the patient to avoid intercourse for 2-4 weeks.

Schedule a follow-up appointment.

Evaluate the patient's postoperative course.

Monitor for any complications, such as bleeding or infection.

Evaluate the patient's recovery of bowel and bladder function.

Adjust medication as needed.

Evaluate the healing of the incisions.

Provide the patient with a detailed report of the procedure and postoperative care.

Advise the patient on any potential complications or side effects of the procedure.

Provide the patient with instructions on follow-up appointments and monitoring.

Advise the patient on when to resume normal activities, such as driving, work, and exercise.

The patient follows up with the surgeon at regular intervals.

The surgeon evaluates the patient's healing and progress at each follow-up appointment.

The surgeon orders any necessary imaging or laboratory tests to evaluate progress.

The surgeon adjusts medications or treatment as needed.

The surgeon monitors the patient for any signs of complications or side effects.

The surgeon communicates with the patient's primary care physician to ensure continuity of care.

The surgeon provides the patient with information on any further treatment or follow-up care.

The patient continues to follow the surgeon's instructions and attend regular follow-up appointments.