A 5-mm Mersilene tape is prepared by removing the attached curved needles, and the suture is then introduced into the posterior pelvis through the 10-mm suprapubic port. A 10-mm right-angle forceps through the suprapubic port is used to grasp and position the ligature around the lower uterine segment at the level of the isthmus by first piercing through the surgical windows in an anterior-to-posterior direction to then grasp and withdraw each end of the suture back into the vesicouterine space.
Care must be taken to confirm that the tape is flatly applied to the posterior lower uterine segment. The suture is then tied intracorporeally on the pubocervical fascia with at least five knots (
Whenever possible the vesicouterine peritoneal defect is closed with a running suture and tied extracorporeally. A vaginal exam is then performed to ensure that the suture ligature is above the level of the vaginal fornices. Fetal heart tones are once again documented.
In nongravid patients, a conventional uterine elevator is used for uterine manipulation. Conventional closed laparoscopic techniques are used for peritoneal access. Lower-quadrant trocar sites are lateral to the inferior epigastric vessels and usually at the level of the anterior superior iliac spines.
Whereas I employ the same dissection and suture ligature techniques used during the early cases of interval cerclage, more recently I have employed the classical technique using the two attached 48-mm needles to direct the Mersilene tape through the broad ligament just medial to the uterine vessels at the level of the isthmus.
After dissection of the anterior lower uterine segment to mobilize the bladder and to expose the uterine vessels, the uterus is anteverted and windows are created in the posterior broad ligament to expose the course of the uterine vessels.
The large needles still attached to the tape are introduced into the abdomen through one of the exposed lateral trocar sites by successively grasping each end of the suture several centimeters from the swedge point and then directing the needles through the abdominal wall and then into the peritoneal cavity under direct vision. Using the uterine elevator to retroflex the uterus and then expose the anterior lower uterine segment, I drive each needle medial to the uterine vessels perpendicularly to exit posteriorly as the uterus is simultaneously anteflexed to expose the broad ligament windows (
Once tightened around the lower uterine segment at the level of the isthmus, the tape ends are cut to release the needles, which are then extracted through the open suprapubic port site by reversing the maneuver used for their introduction. Care must be taken to confirm that the tape is flatly applied to the anterior lower uterine segment. The ligature ends are then tied together posteriorly by intracorporeal knot tying and are not peritonealized (
Cervical Cerclage
Cervical cerclage involves the placement of sutures, wires, or synthetic tape to mechanically increase the tensile strength of the cervix. The procedure is done either electively or emergently (rescue) to reduce the risk of cervical insufficiency and the resultant second-trimester recurrent pregnancy loss.
After reviewing the 2006 article in the American Journal of Obstetrics and Gynecology by Dr. Roberto Romero and his associates, the subsequent letter to the editors by Sietske M. Althuisius, Ph.D., and Pieter Hummel, Ph.D., and the author's reply, debate still lingers about whether credit should be given to Lazare Rivière, in his 1655 article published in Latin, for the first description of cervical insufficiency. By 1678, A. Cole, N. Culpepper, and W. Rowland described this entity in their book “Practice of Physick”:“The second fault in women which hindered conception is when the seed is not retained or the orifice of the womb is so slack that it cannot rightly contract itself to keep in the seed; which is chiefly caused by abortion or hard labor and childbirth, whereby the fibers of the womb are broken in pieces one from another and the inner orifice of the womb overmuch slackened.”
Three hundred years later, in an 1865 letter to the editor of the Lancet, G.T. Gream described a patient who had previously undergone cervical surgery “as a cure for dysmenorrhea and sterility.” Gream wrote: “She had arrived at about the fourth month of pregnancy; telling me—without, however, attributing her pregnancy to the operation—that the uterus had 6 years before been operated upon; and so complete had been the division of the cervix that the finger could readily be introduced into the uterine cavity, and the membranes of the ovum could be touched, as they can be sometimes during the last days of gestation. … According to prognostications, abortion resulted but a few weeks afterwards, from the inability of the uterus to retain its contents.”