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Robot-assisted laparoscopic cervical cerclage as an interval procedure


Robot-assisted abdominal cerclage performed in the pregnancy interval has the advantages of operating on the non-gravid uterus. This is the first report of two women with cervical insufficiency, who underwent robot-assisted abdominal cerclage in the pregnancy interval and delivered two healthy infants.

Case 1

A 28-year-old woman gravida 4 Para 0 presented with a history of cervical insufficiency following three mid-trimester miscarriages, two at 16 weeks and one at 17 weeks. The last two mid-trimester miscarriages presented with painless rupture of membranes and cervical shortening was demonstrated on ultrasound in one. She also had one early miscarriage at 6 weeks. There was no patient history of cervical instrumentation, cervical surgery, congenital abnormality or uterine anomaly. There was also no history of thrombophilia, translocation or maternal family history of recurrent miscarriage. She was appropriately counselled and offered an interval robot-assisted abdominal cerclage (Interval RA-AC).

The procedures were carried out using the da Vinci System. The ports were sited as per Fig. 1.

Fig. 1

Port sites. 1. Camera port 12 mm (port 3). 2. Assistance port 12 mm — suction and needle insertion (port 4). 3. Three da Vinci trochars (ports 1, 2 and 5): Maryland grasper (port 1, robot arm 3), monopolar scissors (port 2, robot arm 1), gyrus bipolar patient left lower (port 5, robot arm 2). For suturing, we change the monopolar scissors for a needle grasper (port 2, robot arm 1)

The procedure was performed as previously described [1, 2] using steep Trendelenburg position, uterine manipulation with a size 10 Hagar dilator in order to prevent over-tightening of the cervix, bladder reflection (Fig. 2) and broad ligament fenestration bilaterally (Fig. 3). A one Ethibond (Ethicon Inc., Johnson & Johnson, USA) suture was placed medial to the uterine artery bilaterally (Fig. 4) and tied posteriorly (Fig. 5). She was discharged without complication later that day and remained well. She subsequently became spontaneously pregnant. Her pregnancy was uncomplicated and she delivered a healthy female infant (weighing 2.58 kg) by elective caesarean section (CS) at 37 weeks gestation. There were no intraoperative difficulties. The suture was neither visualised nor felt at CS, and it was presumably deep in the substance of the myometrium. The cerclage remains in place for subsequent pregnancies.

Fig. 2

Bladder reflection

Fig. 3

Left broad ligament fenestration

Fig. 4

Suture placed medical to uterine artery

Fig. 5

Knot tying posteriorly

Case 2

A 33-year-old woman primagravida, presented at 20 weeks with concern regarding an increase in cervical mucus. There was no personal history of previous instrumentation, surgery or congenital abnormality of the cervix including a collagen disorder, or maternal family history of recurrent miscarriage. Speculum examination revealed dilatation of the cervix approximately 3–4 cm in the absence of pain and uterine activity. Fetal viability was confirmed and the absence of infection and uterine activity checked, before an attempted rescue transvaginal cervical cerclage was performed with initial good effect and she was admitted for complete bed rest. However, a week later she laboured spontaneously and delivered a non-viable fetus at 21 weeks. Cervical insufficiency was attributed as the cause of the miscarriage. She was appropriately counselled and offered RA-AC. This was performed using a one Prolene (Ethicon Inc, Johnson & Johnson, USA) suture in this instance in the same fashion as previously, and she was discharged home the next morning. She spontaneously became pregnant and delivered a healthy female infant (weighing 2.72 kg) by elective CS at 37 weeks after an uncomplicated pregnancy. Again, there were no intra-operative difficulties. The suture was felt during the CS and remains in place for future pregnancies.


Cervical insufficiency is a recognised cause of second-trimester miscarriage. Although there is no accepted definition, the term infers a structural weakness of the cervix, either congenital or acquired in nature [3]. It classically presents as painless progressive dilatation of the cervix resulting in second or early third trimester loss and is a retrospective diagnosis after exclusion of other causes. It is reported to complicate approximately 1% of the obstetric population [4] and contributes to 8% of recurrent second trimester losses [5].

Cervical cerclage is a surgical technique for the management of cervical insufficiency whereby a suture is placed around the cervix, as close as possible to the internal os, enclosing it and thus reinforcing the cervix mechanically at the level of the internal os which is therefore physiologic [6]. A non-absorbable suture such as silk, monofilament or 5-mm Mersilene tape is used according to the surgeon’s preference [7]. Indication for cerclage can be based on the patient’s history, length of the cervix as measured using ultrasound, or as a rescue procedure. The recent 2011 guidelines on cervical cerclage from the Royal College of Obstetricians and Gynaecologist (RCOG), state that for women who have had three or more second trimester loss or preterm births, a history indicated cerclage should be offered [7]. The procedure is usually performed transvaginally as an elective procedure between 12 and 14 weeks gestation. For women who decline cerclage, ultrasound surveillance is useful to monitor cervical length as not all women develop a short cervix during pregnancy with a history of cervical insufficiency [7, 8]. Ultrasound indicated cerclage is recommended in cases of cervical length shortening during incidental surveillance. This is done usually between 14 to 25 weeks gestation, where the cervix is less than 25 mm in measurement and is only recommended in women with a history of second trimester loss or spontaneous preterm delivery [7]. A more recent meta-analysis by Berghella et al. [9] in 2011 also identified a reduction in preterm birth, perinatal morbidity and mortality with cerclage using these criteria.

A rescue cerclage is the term used to describe a cerclage performed in cases of premature cervical dilatation and exposed fetal membranes into the vagina, the presence of which may or may not be clinically obvious. The RCOG recommends the involvement of a senior clinician in the decision to perform such a cerclage depending on the particular case, as its appropriate use can delay delivery up to 5 weeks compared with expectant management/bed rest alone [7]. Early complications of transvaginal cerclage include abdominal pain, vaginal bleeding, bladder injury, and premature pre-labour rupture of membranes and premature labour (presumably caused by manipulation of the cervix during the procedure). The risk of rupture of membranes is increased in the instance of a rescue cerclage with concurrent effacement, dilatation of the cervix and prolapsing membranes and the procedure is not recommended due to the high chance of cerclage failure if there is advanced dilation of the cervix or if membranes beyond the external os [7]. Late complications include subclinical or clinical chorioamnionitis and preterm delivery, uterine rupture or difficulty in cerclage removal [10, 11].

Shirodkar [12] first proposed cervical cerclage in 1955, whereby a suture is placed transvaginally at the level of the internal os, after a circular incision in the cervix and after dissecting the bladder free. In 1957, McDonald [13] simplified the procedure to a simple purse string suture placed around the cervix, which is technically easier to perform and associated with less bleeding. In a study comparing the two procedures, there was no significant difference found in outcome using the two techniques despite an increased cervical length achieved measured by ultrasound using the Shirodkar suture, being placed nearer to the cervicoisthmic junction [14].

Benson and Durfee [15] first described the transabdominal cervical suture, placed during laparotomy at the level of the cervicoisthmic junction, in 1965. It involves a laparotomy and insertion of a suture enclosing the internal os above the level of the cardinal and uterosacral ligaments. Abdominally placed cerclage can be performed in early pregnancy around 12 weeks or in the pre-pregnancy interval (interval cerclage). Interval cerclage is better where possible, due to the technical advantage of operating on the non-pregnant uterus and unaffected fertility associated with the procedure. First trimester miscarriages can still be managed using dilatation and curettage. Second trimester intra-uterine death requires a hysterotomy. The suture remains in place until term, necessitating delivery of the infant by CS, and remains in place for future pregnancies. This type of cerclage is considered in women following failed transvaginal cerclage, or where extensive surgery has left very little cervical tissue or there is a congenitally short cervix and therefore transvaginal cervical cerclage is impossible [7, 11, 16, 17]. This procedure can improve fetal survival rate from 70% to 95% through prolonging gestation [1820]. Although transabdominal cerclage is associated with a higher risk (3%) of serious operative complications (bleeding requiring transfusion, injury to the bowel, bladder or uterine artery), a study by Zaveri et al in 2002 showed that when performed following previous failed transvaginal cerclage, there was a reduced risk of perinatal death and delivery <24 weeks [17]. A higher incidence of complications, ranging from 7% [15] to 25% [21], has been described elsewhere in the literature. However, no randomised controlled trials have been performed comparing the transvaginal versus the transabdominal approach.

Disadvantages to an abdominal cerclage placed at laparotomy include longer hospitalisation and greater patient recovery time. As yet there is inadequate evidence to suggest the benefit of abdominal cerclage using laparoscopy compared with laparotomy [22]. Laparoscopic surgery is associated with less post-operative pain, a quicker recovery time and shorter hospital stay, smaller scars, reduced infections and reduced scarring. However, conventional laparoscopy requires additional training. Dexterity is limited by the fulcrum effect of the straight stick laparoscopic technique producing counter-intuitive movement of the instruments and by the two dimensional field of view. It is heavily dependent on manually held and operated instruments and the surgeon is reliant on an assistant.

Robot-assisted laparoscopy has been in use following FDA approval of the use of the da Vinci robot for gynaecological surgery in 2005. The robot-assisted approach overcomes many problems associated with laparoscopy and has several advantages. Compared with laparoscopy, it allows easier broad ligament dissection, visualisation of the vasculature and knot tying [1].

The first ever Interval robot-assisted abdominal cerclage (Interval RA-AC) using the da Vinci robot was performed in 2007 [2] and described a successful cerclage using a 5-mm Mersilene ligature as a day procedure but with no reported pregnancy outcome. RA-AC has also been performed successfully during pregnancy [1, 23] at 12 weeks gestation again using a Mersilene tape. Bleeding and trauma were reportedly minimised to the gravid uterus by using the suction irrigator to hydro dissect the plane between the bladder and cervicouterine junction. Successful pregnancy and delivery of a healthy infant was reported in this case [1].

In our two reported cases, we performed interval RA-AC’s as recommended, in accordance with recent guidelines with operating on the non-pregnant uterus advantageous with minimal blood loss and trauma [7]. We found that broad ligament fenestration and suture placement was straightforward using the da Vinci robot, as has been previously reported [1, 2]. We had a similarly favourable outcome using Ethibond and Prolene sutures instead of the described 5-mm Mersilene band. The procedure was done as a ‘day case’ and neither woman required further analgesia post-operatively. Both were delivered at term after uncomplicated pregnancies and no operative difficulties were encountered at CS.

To our knowledge, these are the first two reported cases of interval robot-assisted laparoscopic abdominal cervical cerclage with a successful pregnancy and neonatal outcome. We found that the improved surgical view with optional magnification, ease of manipulation of instruments and comfort and independence for the surgeon, affords a more advantageous surgical experience compared with conventional laparoscopy that is of benefit to both the patient and the surgeon. This is an important development in the placement of transabdominal cervical cerclage.


  1. 1.

    Fechner AJ, Alvarez M, Smith DH, Al-Khan A (2009) Robotic-assisted laparoscopic cerclage in a pregnant patient. Am J Obstet Gynecol 200(2):e10–e11

    PubMed  Article  Google Scholar 

  2. 2.

    Barmat L, Glaser G, Davis G, Craparo F (2007) Da Vinci-assisted abdominal cerclage. Fertil Steril 88(5):1437, e1–e3

    PubMed  Article  Google Scholar 

  3. 3.

    Rust OA, Atlas RO, Jones KJ, Benham BN, Balducci J (2000) A randomized trial of cerclage versus no cerclage among patients with ultrasonographically detected second-trimester preterm dilatation of the internal os. Am J Obstet Gynecol 183(4):830–835, Epub 2000/10/18

    PubMed  Article  CAS  Google Scholar 

  4. 4.

    McDonald IA (1980) Cervical cerclage. Clin Obstet Gynaecol 7(3):461–479, Epub 1980/12/01

    PubMed  CAS  Google Scholar 

  5. 5.

    Drakeley AJ, Quenby S, Farquharson RG (1998) Mid-trimester loss—appraisal of a screening protocol. Hum Reprod 13(7):1975–1980, Epub 1998/09/18

    PubMed  Article  CAS  Google Scholar 

  6. 6.

    McComiskey M, Hunter D (2009) Long-term sequelae of abdominal cervical cerclage and a minimally invasive approach to resolution. Gynecol Surg 6:53–55

    Article  Google Scholar 

  7. 7.

    Shennon A, To M. Royal College of Obstetricians and Gynaecologists. Cervical Cerclage. Green-top Guideline No. 60. May 2011

  8. 8.

    Berghella V, Mackeen AD (2011) Cervical length screening with ultrasound-indicated cerclage compared with history-indicated cerclage for prevention of preterm birth: a meta-analysis. Obstet Gynecol 118(1):148–155

    PubMed  Article  Google Scholar 

  9. 9.

    Berghella V, Rafael TJ, Szychowski JM, Rust OA, Owen J (2011) Cerclage for short cervix on ultrasonography in women with singleton gestations and previous preterm birth: a meta-analysis. Obstet Gynecol 117(3):663–671

    PubMed  Article  Google Scholar 

  10. 10.

    Drakeley AJ, Roberts D, Alfirevic Z (2003) Cervical stitch (cerclage) for preventing pregnancy loss in women. Cochrane Database Syst Rev 1:CD003253, Epub 2003/01/22

    PubMed  Google Scholar 

  11. 11.

    Simcox R, Shennan A (2007) Cervical cerclage in the prevention of preterm birth. Best Pract Res Clin Obstet Gynaecol 21(5):831–842

    PubMed  Article  Google Scholar 

  12. 12.

    Shirodkar V (1955) A new method of operative treatment for habitual abortion in the second trimester of pregnancy. Antiseptic 52:299–300

    Google Scholar 

  13. 13.

    McDonald IA (1957) Suture of the cervix for inevitable miscarriage. J Obstet Gynaecol Br Emp 64(3):346–350, Epub 1957/06/01

    PubMed  Article  CAS  Google Scholar 

  14. 14.

    Odibo AO, Berghella V, To MS, Rust OA, Althuisius SM, Nicolaides KH (2007) Shirodkar versus McDonald cerclage for the prevention of preterm birth in women with short cervical length. Am J Perinatol 24(1):55–60, Epub 2006/12/30

    PubMed  Article  Google Scholar 

  15. 15.

    Benson RC, Durfee RB (1965) Transabdominal Cervico Uterine Cerclage during Pregnancy for the Treatment of Cervical Incompetency. Obstet Gynecol 25:145–155, Epub 1965/02/01

    PubMed  CAS  Google Scholar 

  16. 16.

    Norman JE (2007) Preterm labour. Cervical function and prematurity. Best Pract Res Clin Obstet Gynaecol 21(5):791–806, Epub 2007/05/11

    PubMed  Article  Google Scholar 

  17. 17.

    Zaveri V, Aghajafari F, Amankwah K, Hannah M (2002) Abdominal versus vaginal cerclage after a failed transvaginal cerclage: a systematic review. Am J Obstet Gynecol 187(4):868–872, Epub 2002/10/22

    PubMed  Article  Google Scholar 

  18. 18.

    Debbs RH, DeLa Vega GA, Pearson S, Sehdev H, Marchiano D, Ludmir J (2007) Transabdominal cerclage after comprehensive evaluation of women with previous unsuccessful transvaginal cerclage. Am J Obstet Gynecol 197(3):317, e1–e4. Epub 2007/09/11

    PubMed  Article  Google Scholar 

  19. 19.

    Deffieux X, Faivre E, Senat MV, Fuchs F, Gervaise A, Fernandez H. Fertility outcome following transvaginal cervicoisthmic cerclage using a polypropylene sling. Int J Gynaecol Obstet.109(1):37–40. Epub 2010/01/15

  20. 20.

    Moria A, Aljaji N, Miner L (2011) Abdominal cerclage after failed transvaginal cercical cerclage. Gynecol Surg. doi:10.1007s10397-011-0691-7

  21. 21.

    Whittle WL, Singh SS, Allen L, Glaude L, Thomas J, Windrim R (2009) Laparoscopic cervico-isthmic cerclage: surgical technique and obstetric outcomes. Am J Obstet Gynecol 201(4):364, e1–e7. Epub 2009/10/01

    PubMed  Article  Google Scholar 

  22. 22.

    Carter JF, Soper DE, Goetzl LM, Van Dorsten JP (2009) Abdominal cerclage for the treatment of recurrent cervical insufficiency: laparoscopy or laparotomy? Am J Obstet Gynecol 201(1):111, e1–e4

    PubMed  Article  Google Scholar 

  23. 23.

    Wolfe L, DePasquale S, Adair CD, Torres C, Stallings S, Briery C et al (2008) Robotic-assisted laparoscopic placement of transabdominal cerclage during pregnancy. Am J Perinatol 25(10):653–655

    PubMed  Article  Google Scholar 

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The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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Correspondence to B. A. O’Reilly.

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Cronin, C., Hewitt, M., Harley, I. et al. Robot-assisted laparoscopic cervical cerclage as an interval procedure. Gynecol Surg 9, 317–321 (2012).

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  • da Vinci surgery
  • Interval cerclage
  • Laparoscopy
  • Robotic