For more than a decade, the capacity to perform cervicoisthmic cerclage by laparoscopy has provided a minimally invasive alternative for some women to the often-complicated traditional abdominal approach that was first reported in 1965.

With a laparoscopic cerclage performed by 12 weeks’ gestation, patients for whom conventional vaginal cerclage has failed or is not possible have had successful deliveries without the extended midline incision, considerable hospital stays, or significant risks to the mother and fetus that are associated with the conventional abdominal approach.

Laparoscopic cerclage is a highly innovative procedure that has offered hope and delivered good outcomes. Still, one has to ask, are we really achieving all we can for our patients?

Does it not make sense to intervene earlier – before pregnancy – in certain high-risk women with anatomically altered or deficient cervices and/or with previous failures of conventional vaginal cerclages for cervical incompetence?

The notion of “interval cerclage” as opposed to interventional or “rescue” cerclage is an idea whose time has come. There are significant numbers of women who would substantially benefit from the insertion of a cervicoisthmic cerclage in the nonpregnant state – when the surgeon is not constrained by the contents, size, or fragility of the gravid uterus or challenged by the marked pelvic vascularity and other physiological changes of pregnancy.

The pregnant women who have undergone laparoscopic cervicoisthmic cerclage under our care have experienced failures of conventional vaginal cerclages, and many have suffered repeated second-trimester losses.

These high-stakes cases involving patients who are desperate for a successful pregnancy have led us to believe that one failure is enough – or, in the cases of patients who have other clear risk factors such as anatomically altered cervices, that one failure is too many.

As we move further into the era of reproductive technology and extended reproductive years, pregnancies are increasingly high-stakes experiences with a limited number of assisted cycles. Women do not have time to spare and do not want to take risks. Older women seeking to have a child not only are more likely to have had in vitro fertilization and other fertility treatments, they also are more likely to have had a loop electrosurgical excision procedure (LEEP), cone biopsy, or other procedure that has been associated with cervical incompetence. Many of these women are possible candidates for interval cerclage.

This type of cerclage requires a new thought process – a new mind-set – as well as new and creative collaboration between skilled laparoscopic surgeons and the perinatologists who are following and counseling these patients.

By working in teams, with the perinatologist cultivating a relationship with an experienced laparoscopic surgeon, specialists can work together to bring the option of interval cerclage into discussions with patients who have poor obstetric histories due to cervical incompetence or serious risk factors associated with poor pregnancy outcomes, and then see the procedure through when it is deemed worthwhile and desirable.

In our experience, once we met each other and became aware of each other’s interests and expertise, it seemed only natural to collaborate and offer these patients interval laparoscopic cerclage.

The Benefits

Ironically, we have shifted in the last 5-10 years from early-pregnancy cerclage based largely on history toward cerclage that is performed based on ultrasound measurement of cervical length during pregnancy. Cervical change rarely occurs before 12-14 weeks’ gestation, which means that by the time of “discovery” of a short cervical length, cerclage is all the more difficult and risky to perform.

The advantages to an interval approach to cerclage are numerous: The surgeon does not have to contend with the burden of an intrauterine pregnancy associated with the increased pelvic vascularity of pregnancy (up to 25% of the maternal circulation moves through the pelvis at this time) or the increased uterine size, which can be constraining, particularly for a laparoscopic approach.

Beyond 12-14 weeks, in fact, it becomes almost impossible with a laparoscopic approach to gently manipulate the uterus to see both the front and back of the lower uterine segment. Avoiding interventions close to the gravid uterus, of course, is always desirable. And with an interval cerclage, healing is typically completed by the time pregnancy occurs.

For a surgeon with advanced laparoscopic experience, the laparoscopic approach to a cervicoisthmic cerclage is generally much easier and safer than a “true” transvaginal cervicoisthmic cerclage.

Some experienced surgeons – though very few – have performed classical cervicoisthmic cerclage transvaginally during early pregnancy in the belief that a higher cerclage placement is more effective than a lower one. When the stitch is placed high at the level of the cervicoisthmic junction – or even higher – and above the level of the cardinal ligaments, the stitch is less likely to slip down along the cervix. It is supported from underneath by the cardinal ligaments.

The normal cervix can be anatomically represented by the letter Y. Then imagine it becoming the letter V, and then the letter U. This is the type of change that an incompetent cervix undergoes. If we can prevent, as much as possible, the formation of the V, then these changes are less likely to occur.

Although there is no scientific evidence, per se, to support this “higher is better” belief, it makes intrinsic sense, and there are data to suggest better outcomes with this higher stitch placement. Our experience, moreover, shows that the vast majority of patients with previous failed cerclages had the conventional vaginal procedure, a simple Mersilene purse-string stitch placed low in the cervical stroma, not approximating the internal os where deformities typically are.

The problem is that transvaginal insertion of a cervical suture high at the level of the cervicoisthmic junction is complex and fraught with the risk of complications because the high stitch placement involves mobilizing and climbing up under the bladder, in close proximity to the vasculature of the uterus. Some surgeons have had success, but in general, what needs to be done exceeds the skills and experience of most.

In patients who are pregnant, traditional abdominal cervicoisthmic cerclage – the other alternative – has been associated with severe complications, such as hemorrhage and pregnancy loss. (Our sense is that few of these surgeries are performed because the stakes are so high and the risks so real.) Patients who are not pregnant still face an extended midline incision and a considerable hospital stay.

With laparoscopy, we can achieve the higher is better principle less invasively with more ease and superior precision. Compared with the vaginal or laparotomic approach, the laparoscopic method provides less trauma to the gravid uterus and unparalleled visual and mechanical access to the key anatomical structures either incorporated or potentially injured during cervicoisthmic cerclage. Placing the stitch precisely at the correct level is the most important element of this procedure.

Moreover, laparoscopic placement of the tape may reduce the recognized incidence of postoperative chorioamnionitis by removing the presence of a foreign body in the vagina. A first-trimester loss can usually be evacuated using conventional techniques, while elimination of more-advanced gestations can be simply facilitated by removing the stitch laparoscopically.

Whereas patients undergoing laparoscopic cervicoisthmic cerclage still must have a laparotomy at the end, because the cerclage is a permanent suture and necessitates delivery by cesarean section, morbidity and mortality risks are cut in half compared with patients undergoing two traditional abdominal surgeries.

Success rates after cervical cerclage are high, up to 87%. The interpretation of outcome is complex, however, because of the conflicting indications for treatment and differing timing of the procedure (before or during pregnancy). Quality research comparing approaches in patients with high-risk indications has been difficult to conduct as well, in part because patients who have had recurrent pregnancy failures are reluctant to participate in such studies.

Much of the available data, moreover, is confounded by a multiplicity of high-risk factors and variables related to recurrent pregnancy loss.

Dr. Brill’s Technique

Patients are placed in a modified dorsal lithotomy position, and a No. 12 Foley catheter is inserted for bladder drainage. When the patient is pregnant, I perform an assiduous pelvic exam to assess for advanced cervical dilation.

In gravid patients, the largest cervical cup from a disassembled KOH colpotomizer is used to laparoscopically delineate the vaginal fornices and atraumatically manipulate the cervix and lower uterine segment by using two ring forceps secured opposite one another to the outer ring.

Fetal heart tones are documented before the laparoscopic procedure is initiated. The risk of incidental trauma to the gravid uterus is minimized by using open laparoscopy to attain peritoneal access.

The intra-abdominal pressure is strictly limited to 12 mm Hg, and all patients are placed in a maximally tolerated Trendelenburg position. I then determine the feasibility of the procedure based on an assessment of anatomical access and ready mobility of the gravid uterus.

Two 5-mm midquadrant ports are placed under direct vision, each lateral to the respective epigastric arteries and slightly below the level of the umbilicus. A 10-mm port is carefully introduced in the midline, one to two finger breadths above the pubic ramus.

The vesicouterine peritoneum is dissected transversely using either a monopolar spatula electrode or the 5-mm curved Harmonic shears. The uterus is mobilized using the pericervical cup and a 5-mm blunt probe.

The bladder is then minimally dissected off the lower uterine segment to reveal native pubocervical fascia and the course of the uterine vessels. With a combination of blunt and sharp dissection, an adequate surgical window is created medial to each set of uterine vessels at the level of the isthmus (Figure 1).

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 (Figure 2).

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 (Figures 3 and 4).

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 (Figure 5).

Dr. Brill is director of minimally invasive gynecology, reparative pelvic surgery, and training at the California Pacific Medical Center, San Francisco, and is former president of the AAGL. Dr. Katz is chief of perinatal services at the medical center. Neither Dr. Brill nor Dr. Katz reported any disclosures that are relevant to the content of this article.

Copyright (c) 2009 Elsevier Global Medical News. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

首例经腹子宫颈峡部环扎术方法报告于1965年，但这种传统术式往往导致一些并发症，近十余年来，腹腔镜子宫颈峡部环扎术的引入提供了一种微创的替代手术方式。

在妊娠12周时进行腹腔镜子宫颈峡部环扎术，可使无法进行常规阴道环扎术或手术失败的患者成功分娩，并且不必扩大中线切口、不必长期住院、避免常规经腹术式对母体及胎儿的巨大风险。

腹腔镜环扎术是一种高度改良的手术，大大改善了患者预后，为此类患者的生育成功带来了新的希望。但是扪心自问，我们能为患者做到的仅此而已吗？

对某些有解剖学异常、宫颈缺陷和/或曾因宫颈机能不全行常规阴道环扎术失败的高危妇女，是否可以提前干预，即在孕前行子宫颈环扎术？

 “孕前环扎术”是相对于孕期或“补救性”环扎术的概念，当前的治疗已进入这一时代。大量妇女将从在非妊娠状态接受子宫颈峡部环扎术中获得巨大益处，因为在非妊娠状况下，手术操作不必受到妊娠子宫内容物、大小或脆性的限制，也不再会因为明显的盆腔充血和其他妊娠期生理变化而使手术难度加大。

在我们的医疗机构中，接受腹腔镜子宫颈峡部环扎术的妊娠妇女已经历过常规阴道环扎术的失败，并且其中有很多人发生反复孕中期流产。

这些急切盼望一次成功妊娠的高风险病例使我们深切地感受到：一次失败已经足够，并且在那些具有明确的风险因素如宫颈解剖异常的患者中，一次失败都不应该发生。

当我们进入到一个辅助生殖技术和延长生育期的时代，因为辅助周期的次数有限，妊娠的代价也越来越高。女性没有时间、也不希望承担妊娠失败的风险。年龄偏大女性的妊娠不仅更多需要体外受精和其他辅助生殖治疗的帮助，同时也更多发生在已经接受了宫颈电环切除术（LEEP）、宫颈锥形切除术或其他与宫颈机能不全相关的手术操作之后。很多这样的妇女可能适用孕前环扎术。

这种环扎术需要一种新的思维过程，即一种新的意识状态，同时也需要技术精湛的腹腔镜手术医生与围产医学专家的创造性合作，后者要负责对患者的随访和咨询。

在对有因宫颈机能不全导致的不良产科病史或有与不良妊娠预后相关的严重风险因素的患者的治疗讨论中，围产医学专家与经验丰富的腹腔镜手术医生团队协作，共同将孕前环扎术作为一种选择，当认为适用这种手术时，将对其进行全面的分析讨论。

在我们的经验中，一旦围产医学专家与手术医生会面，并相互了解各自的兴趣和专长，就会自然地联手合作为这些患者进行孕前腹腔镜环扎术。

益处

很有讽刺意味的是，在过去的5~10年间，我们一直在是否进行孕早期环扎术问题上犹豫不决。因为手术的确定在很大程度上是取决于妊娠期间对宫颈长度的超声测定。宫颈的变化很少发生在妊娠12~14周之前，也就是说在“发现”宫颈长度缩短时，正是施行环扎术最困难和最危险的时候。

孕前环扎术方法具有很多优势：手术医生不再需要克服宫内妊娠相关的盆腔充血（这个时候高达25%的母体血液循环转移到盆腔）或子宫增大造成的手术难题，这些变化对手术，尤其是对腹腔镜操作会造成极大限制。

事实上，在妊娠12~14周之后，已几乎不可能再用腹腔镜方法对子宫进行轻柔操作以观察子宫下段的前面和后面。而靠近妊娠子宫的操作往往是不可避免的。如采用孕前环扎术，则当妊娠发生时，通常创面已经完全愈合。

对于一个腹腔镜手术技术高超的医生而言，子宫颈峡部环扎术的腹腔镜方法通常要比“真正的”经阴道子宫颈峡部环扎术容易操作和安全得多。

一些很有经验的手术医生（尽管数量非常少）进行了经典的孕早期经阴道子宫颈峡部环扎术，他们相信高位环扎较低位环扎更有效。当缝合位置高于子宫颈峡部鳞柱细胞交接部，甚至更高，达到高于子宫主韧带的水平时，缝线沿宫颈滑脱就很少发生。原因是缝扎受到其下方主韧带的支撑。

正常宫颈的解剖可以用字母“Y”形象地表示，然后请想象“Y”向字母“V”，然后向“U”的演变，这就是宫颈机能不全经历的变化。如果可以预防，尽可能保持“V”的形态，以后的变化就不太可能发生了。

尽管本身没有任何科学证据支持“越高越好”的观点，直观感觉和一些资料提示高位缝扎的预后更好。并且，我们的经验中显示绝大多数既往环扎失败的患者接受的是常规经阴道环扎手术，采用的是单纯Mersilene荷包缝合，缝合处位于宫颈间质较低的位置，但不接近于发生畸形的典型部位——宫颈内口。

这种手术的问题在于在子宫颈峡部鳞柱细胞交接部的高度水平进行经阴道宫颈缝合的难度很大，并且导致并发症的风险很大，因为高位缝合将会导致膀胱位置变动，并且需要在膀胱下方向上操作，非常接近子宫血管的位置。一些手术医生可能有过成功案例，但一般而言，多数医生不可能具备进行这种手术的技能和经验。

在妊娠妇女中，传统的经腹子宫颈峡部环扎术（另一种手术选择）可能导致严重并发症，如出血和流产(在我们的印象中很少进行这样的手术，因其代价过高，并且风险过大)。即使是未妊娠妇女也会面临扩大中线切口和住院时间延长的风险。

通过腹腔镜，我们可以更加轻松和准确地以微创方式达到越高越好的要求。与阴道和经腹手术相比，腹腔镜手术对妊娠子宫的损伤更小，且无论是对完好的还是可能在子宫颈峡部环扎过程中受损的关键解剖结构，都可以提供无与伦比的视觉和操作路径。在正确的水平精确地进行缝合是进行这种手术的核心要素。

并且，腹腔镜置入环扎带可能通过移除阴道内出现的异物降低术后绒毛膜羊膜炎的发生率。孕早期流产通常可采用常规负压吸引的方法吸出，当需要清除更大孕周的妊娠产物时，仅需使用腹腔镜拆除缝线辅助清除。

尽管患者接受的是腹腔镜子宫颈峡部环扎术，但最终还必须进行开腹手术，因为环扎是永久性的缝合，所以必须以剖宫产的方式分娩，与接受两种传统腹部手术的患者相比，腹腔镜子宫颈峡部环扎术患者的病死率风险减半。

子宫颈环扎术后的成功率高达87%。但是因为治疗适应证的不统一和手术时机的分歧（孕前或孕时），使对手术预后的解释非常困难。对有高危适应证的患者进行手术方法比较的质量研究也很难进行，一部分原因是有反复妊娠失败史的患者不愿意参与这样的研究。

另一方面，现有资料中多数因受到高危因素和反复流产相关变量的多样性的干扰而致混乱，难以解释。

Brill医生的手术方法

患者采取改良肾背位式，并插入12号Foley导尿管排空膀胱。如患者已妊娠，为了评估宫颈扩张的程度，尽认真进行盆腔检查。

在妊娠患者中，从拆开的KOH阴道切开器中选取最大的子宫颈杯，在腹腔镜手术中使用这种子宫颈杯描绘出阴道穹隆的形状，并使用两叶卵圆钳相互向相反方向抵住外侧，以保证在子宫颈和子宫下段操作中不发生损伤。

在开始腹腔镜手术操作前记录胎心率。使用开放式腹腔镜经腹膜进入，以尽可能降低对妊娠子宫意外损伤的风险。

将腹腔内压力严格控制于12 mmHg以下，并且将所有患者置于最大可耐受的Trendelenburg（头低足高）体位。然后，通过评估解剖入路和妊娠子宫的可移动性决定手术操作是否可行。

在直视下于象限中心置入2根直径5mm的通道，每根通道均位于相应的腹壁动脉外侧，并略低于脐水平。小心地将一根直径10mm的通道引入中线位置，并位于耻骨支上方一至两指的宽度。

使用单极抹刀电极或5mm Harmonic弯剪刀横向切开膀胱子宫腹膜。使用子宫颈杯和一个5mm钝头探测器松动子宫。

然后将膀胱最低限度地与子宫下段分开，以显露耻骨宫颈筋膜的原貌和子宫血管的走行。采用钝性分离与锐性分离相结合的方法，在子宫峡部水平两侧子宫血管中间构建一个足以进行操作的外科窗口。

移走与5 mm Mersilene缝合带相连接的弯针，通过10mm的耻骨上通道将缝线引入盆腔后侧。通过耻骨上通道使用10mm直角钳进行抓持，并在前后方向首次刺穿外科窗，然后抓住缝线的每一端退回到膀胱子宫间隙，藉此将结扎带置于子宫下段周围子宫颈峡部水平。

必须注意确保结扎带水平地置于子宫下段后侧。然后在耻骨宫颈筋膜上体内结扎缝线，至少结扎5次（图1）。

 

图1   孕12w的子宫。显露耻骨宫颈筋膜后，用Mersilene带结扎。

在可能的时候，使用连续缝合和体外结扎关闭膀胱子宫腹膜的缺损。然后进行阴道检查保证缝线的线结在阴道穹隆水平以上。再一次记录胎心率。

在非妊娠患者中，使用常规举宫器进行子宫操作。经腹膜进入时使用常规封闭式腹腔镜技术。下腹部套管针穿刺的位置在腹壁下血管的外侧，并通常位于髂前上棘的水平。

我在早期进行的孕前环扎术病例中使用相同的切开和缝合结扎技术，而在最近，我采用了古典技术，使用两根48mm的连接针引导Mersilene带在子宫颈峡部水平恰好位于两侧子宫血管中间的位置通过阔韧带。

切开子宫下段前面以松动膀胱并暴露子宫血管后，将子宫前倾，构建阔韧带后的窗口以暴露子宫血管的走行。

在距渐缩点数厘米处逐个连续抓住缝线的每一端，然后在直视下将仍然连接于带子的大针经一个暴露于外侧的套管针孔穿过腹壁进入腹膜腔。

使用举宫器将子宫后曲，暴露出子宫下段的前面，将子宫前屈以暴露阔韧带窗的同时，操作使每根位于两侧子宫血管中间的针垂直从后面退出。

一旦将带子在子宫颈峡部水平围绕子宫下段拉紧，切断带子末端以便将针取出。按照引入时相反的手法将针通过开放的耻骨上通道取出。必须注意确保带子水平地围绕子宫下段的前面。体内打结将结扎线的末端在子宫下段后面系在一起，并且不覆盖腹膜。

Brill医生是三藩市加利福尼亚太平洋医学中心的微创妇科、盆腔修补外科及培训部门主任，并为AAGL前任主席。Katz医生是该医学中心的围产医学部门主管。Brill 和Katz均没有任何与本文内容相关的信息披露。

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