Laparoscopic abdominal cerclage during pregnancy: Report on two cases using a McCartney tube

Introduction

Trans abdominal cerclage during pregnancy in case of cervical insufficiency in women with repeated premature deliveries can be difficult. The enlarged pregnant uterus decreases visualisation of the surgical field, and manipulation of the soft corpus may harm the pregnancy. In addition, the uterine vasculature is more pronounced, which can lead to heavy blood loss. Therefore, an abdominal cerclage is preferably performed either before pregnancy or via laparotomy during pregnancy (Foster et al. 2011; Burger et al. 2012). However, a number of successful laparoscopic abdominal cerclages performed during pregnancy have been reported, providing the patient with the benefits of fast recovery and reduced length of hospital stay (Darwish and Hassan 2002; Ades et al. 2014; Tulandi et al. 2014). We introduced the McCartney tube to this procedure to mobilise the uterus and facilitate surgery by optimising the surgical field. McCartney and Obermair (2004) used different from most uterine manipulators, this device has no intra-uterine part that may harm the intra uterine pregnancy.

Case reports

The first case is a 41-year-old female. Her first three pregnancies were uneventful with term deliveries. In her fourth pregnancy, she had a premature delivery at 24 weeks and in her fifth pregnancy, she had a premature delivery at 23 weeks and 4 days of gestation after a vaginal cerclage at 16 weeks. Both infants deceased due to prematurity. She underwent a laparoscopic transabdominal cerclage in her sixth pregnancy at 14 weeks of gestation.

The second case is a 33-year-old female. In her first two pregnancies, she gave birth spontaneously at 20 and 16 weeks of gestation, respectively. In her third pregnancy, she underwent an elective cerclage at 12 weeks gestation. Despite this, she lost her baby at 18 weeks. In her fourth pregnancy, she underwent a laparoscopic transabdominal cerclage at 11 weeks of gestation. Both patients underwent an uneventful caesarean section at 39 weeks of gestation.

Surgical procedure

Under general anaesthesia, the patient was placed in dorsal lithomy position. A Foley catheter was placed into the bladder. After an open incision at the umbilicus, a 10 mm trocar was inserted with a 30° scope. After this, a 10 mm suprapubic trocar and two lateral 5 mm trocars were inserted. A McCartney tube (4.5 cm diameter) was inserted vaginally, and the pregnant uterus was manipulated cranially, which created a clear view of the vesicouterine fold. The vesicouterine peritoneum was opened with monopolar scissors and the bladder was partially dissected off the cervix. After opening the anterior fold of the broad ligament on both sides, there was a clear exposure of the vasculature of the uterus.

The blunt, curved needles of the 5 mm Mercilene tape were straightened and inserted anteriorly in the cervix, medial from the uterine artery just below the level of the internal ostium, on both sides. Visualisation of the posterior side of the uterus was facilitated by the gentle use of a 10 mm finger retractor. The knot of the Mercilene tape was tied posteriorly. Foetal cardiac activity was confirmed before and after the procedure by ultrasound. No tocolytic agents were given.

In both cases there was an adequate cervical length of more than 3 cm measured by transvaginal ultrasound. The procedures lasted 140 and 83 min, respectively, both with <100 mL blood loos.

Discussion

We found that manipulation of the pregnant uterus with a McCartney tube greatly improved the vision of the surgical field. The use of a McCartney tube during laparoscopic abdominal cerclage has not been described before in the literature. Other techniques have been reported to mobilise the pregnant uterus: Darwish and Hassan (2002) made use of digital vaginal manipulation and Whittle et al. (2009) used a sponge on ring forceps placed in the vaginal fornix. Yet, we think that the McCartney tube is more effective for this purpose.

We used a slightly modified technique for the cerclage, as described by Cho et al. (2003). In their series, the needle was driven from a posterior-to-anterior direction, and the knot secured on the anterior side. We preferred the anterior-to-posterior direction, with the tape knotted on the posterior side. This direction provided better visualisation of the course of the uterine arteries, and we felt that the needle could be placed more securely in the cervix, just medial of the vessels. This also maximises the amount of cervical tissue caught into the cerclage, which might be in favour of the success rate in terms of term deliveries.

Conclusion

Laparoscopic abdominal cerclage during pregnancy is a challenging procedure, and use of a McCartney tube for uterine manipulation may increase its feasibility.

Disclosure statement

All authors have no conflicts of interests to declare.