The normal cervix can be anatomically represented by the letter Y. Then imagine it becoming the letter V, and then the letter U. This is the type of change that an incompetent cervix undergoes. If we can prevent, as much as possible, the formation of the V, then these changes are less likely to occur.
Although there is no scientific evidence, per se, to support this “higher is better” belief, it makes intrinsic sense, and there are data to suggest better outcomes with this higher stitch placement. Our experience shows that the vast majority of patients with previous failed cerclages had the conventional vaginal procedure, a simple Mersilene purse-string stitch placed low in the cervical stroma, not approximating the internal os where deformities typically are.
The problem is that transvaginal insertion of a cervical suture high at the level of the cervicoisthmic junction is complex and fraught with the risk of complications because the high stitch placement involves mobilizing and climbing up under the bladder, in close proximity to the vasculature of the uterus. Some surgeons have had success, but in general, what needs to be done exceeds the skills and experience of most.
In patients who are pregnant, traditional abdominal cervicoisthmic cerclage—the other alternative—has been associated with severe complications, such as hemorrhage and pregnancy loss. (Our sense is that few of these surgeries are performed because the stakes are so high and the risks so real.) Patients who are not pregnant still face an extended midline incision and a considerable hospital stay.
With laparoscopy, we can achieve the higher is better principle less invasively with more ease and superior precision. Compared with the vaginal or laparotomic approach, the laparoscopic method provides less trauma to the gravid uterus and unparalleled visual and mechanical access to the key anatomical structures either incorporated or potentially injured during cervicoisthmic cerclage. Placing the stitch precisely at the correct level is the most important element of this procedure.
Moreover, laparoscopic placement of the tape may reduce the recognized incidence of postoperative chorioamnionitis by removing the presence of a foreign body in the vagina. A first-trimester loss can usually be evacuated using conventional techniques, while elimination of more-advanced gestations can be simply facilitated by removing the stitch laparoscopically.
Whereas patients undergoing laparoscopic cervicoisthmic cerclage still must have a laparotomy at the end, because the cerclage is a permanent suture and necessitates delivery by cesarean section, morbidity and mortality risks are cut in half compared with patients undergoing two traditional abdominal surgeries.
Success rates after cervical cerclage are high, up to 87%. The interpretation of outcome is complex, however, because of the conflicting indications for treatment and differing timing of the procedure (before or during pregnancy). Quality research comparing approaches in patients with high-risk indications has been difficult to conduct as well, in part because patients who have had recurrent pregnancy failures are reluctant to participate in such studies.
Much of the available data, moreover, is confounded by a multiplicity of high-risk factors and variables related to recurrent pregnancy loss.
Dr. Brill's Technique
Patients are placed in a modified dorsal lithotomy position, and a No. 12 Foley catheter is inserted for bladder drainage. When the patient is pregnant, I perform an assiduous pelvic exam to assess for advanced cervical dilation.
In gravid patients, the largest cervical cup from a disassembled KOH colpotomizer is used to laparoscopically delineate the vaginal fornices and atraumatically manipulate the cervix and lower uterine segment by using two ring forceps secured opposite one another to the outer ring.
Fetal heart tones are documented before the laparoscopic procedure is initiated. The risk of incidental trauma to the gravid uterus is minimized by using open laparoscopy to attain peritoneal access.
The intra-abdominal pressure is strictly limited to 12 mm Hg, and all patients are placed in a maximally tolerated Trendelenburg position. I then determine the feasibility of the procedure based on an assessment of anatomical access and ready mobility of the gravid uterus.
Two 5-mm midquadrant ports are placed under direct vision, each lateral to the respective epigastric arteries and slightly below the level of the umbilicus. A 10-mm port is carefully introduced in the midline, one to two finger breadths above the pubic ramus.
The vesicouterine peritoneum is dissected transversely using either a monopolar spatula electrode or the 5-mm curved Harmonic shears. The uterus is mobilized using the pericervical cup and a 5-mm blunt probe.
The bladder is then minimally dissected off the lower uterine segment to reveal native pubocervical fascia and the course of the uterine vessels. With a combination of blunt and sharp dissection, an adequate surgical window is created medial to each set of uterine vessels at the level of the isthmus (