Laparoscopic Abdominal Cerclage in a Patient With a Müllerian Anomaly

INTRODUCTION: Cerclage is the recommended treatment in cases of cervical insufficiency. It can be performed transvaginally or transabdominally. Transabdominal cerclage may be indicated after failed transvaginal cerclage, in patients with prior cervical surgery that would make a transvaginal approach technically difficult, such as a large conization or trachelectomy, or patients with congenital uterine anomalies. In patients with müllerian anomalies undergoing a cerclage placement, it is critical to properly identify the anatomy for surgical planning and patient counseling of the cerclage method. OBJECTIVE: The objectives of this video are to describe and review transabdominal cerclage indications and surgical technique, and to illustrate a needleless laparoscopic abdominal cerclage placement in a patient with a history of a müllerian anomaly, and important related considerations. METHODS: 33-year-old G2P0201 previously diagnosed with a dydelphic uterus and duplicated cervices. She had a failed history-indicated transvaginal cerclage during her second pregnancy, and was referred to our practice for transabdominal cerclage placement. Preoperative MRI was obtained. RESULTS: MRI revealed a complete septate uterus with duplicated cervices. Laparoscopy revealed endometriosis, which was excised. A needleless laparoscopic transabdominal cerclage was placed after careful dissection of the uterine vessels at the level of the internal cervical os, and creation of a tunnel medial to them. Mercilene suture was used. CONCLUSIONS: Transabdominal cerclage may be the preferred approach in patients with congenital uterine anomalies, as a transvaginal approach might increase the risk of failure. MRI can be useful in the proper recognition of the uterine anomaly, which can help guide decision-making and surgical planning. During cerclage placement, proper dissection and identification of the colpotomizer cup, and skeletonization of the uterine vessels allows for safe placement of suture material. A needleless approach is a safe technique that could help decrease the risk of injury to surrounding structures and placement of suture material within cervical stroma.