V.N. Shirodkar, professor of midwifery and gynecology at Grant Medical College in Bombay, India, is credited with the introduction of cervical cerclage into modern obstetric practice in 1955. The need was based on his finding that “some women abort[ed] repeatedly between the fourth and seventh month and no amount of rest and treatment with hormones seemed to help them in retaining the product of conception.” This was immediately followed by Ian McDonald's report from the Royal Melbourne Hospital on his cerclage experience in 70 patients in 1957.
In this edition of Master Class in Gynecologic Surgery, I have asked Dr. Andrew I. Brill, director of minimally invasive gynecology, reparative pelvic surgery, and training at the California Pacific Medical Center, San Francisco, and former president of the AAGL, as well as Dr. Michael Katz, clinical professor of obstetrics, gynecology, and reproductive sciences, University of California, San Francisco, and chief of perinatal services at California Pacific Medical Center, to discuss interval cervicoisthmic cerclage, with an emphasis on a laparoscopic approach.
Dr. Brill coauthored the first report on a laparoscopic preconceptional cervicoisthmic cerclage in a woman with repeated midtrimester cervical cerclage failure for the Journal of Minimally Invasive Gynecology. Despite being an experienced vaginal surgeon and having extensive experience in classical transvaginal cervicoisthmic cerclage, upon observing Dr. Brill's laparoscopic technique, Dr. Katz became familiar with the benefits of this approach. It is our intent that after reading this edition of the Master Class in Gynecologic Surgery, you will, too.
Dr. Brill's Experience
Over the last 5 years, I have performed laparoscopic cervicoisthmic cerclage under general anesthesia in 23 patients who had documented histories consistent with cervical incompetence.
There have been 18 successful deliveries (at a mean gestational age of 36.6 weeks) with a fetal salvage rate of 78% (18/23), compared with 7.3% (6/82) during all of the patients' previous intrauterine pregnancies. In 12 of the 23 cases (52%), the cerclage was performed preconceptionally as an interval procedure. In the remaining 11, cerclage was performed during early pregnancy (at a mean gestational age of 12 weeks). Three of the cases were ultimately completed laparotomically—two secondary to pelvic adhesions and the other secondary to bleeding. In the 11 pregnant patients, only two losses occurred intraoperatively—one secondary to advanced cervical dilation and one for undetermined reasons 10 days postoperatively.