TIPS AND TRICKS: PRE-CONCEPTIONAL LAPAROSCOPIC CERVICAL CERCLAGE MADE EASIER AND SAFER WITH TITIZ UTEROVAGINAL MANIPULATOR

Dr Hasan Titiz, FRANZCOG

Evin Women’s Health

Brisbane, AUSTRALIA

ABSTRACT

INTRODUCTION

Cervical incompetence or cervical insufficiency is one of the causes of preterm birth. Incidence is 0.1-1 % of all pregnancies(1). Traditionally cervical cerclage is placed vaginally, but sometimes it is not possible to do vaginally.

Then it needs to be inserted abdominally either by laparotomy or laparoscopy. Laparoscopic cervical cerclage is indicated when vaginal cerclage has failed or vaginal  cerclage is not possible  due to  deficient or  short cervix from previous cervical surgery. Although laparoscopic cervical cerclage has a good success rate(90-100% live birth)(1), it has risk of injury to bladder, sigmoid colon and uterine vessels(1). It is also important to put the suture in the right place, which is at the internal cervical os (cervico-isthmic junction) and medial to the uterine vessels. Therefore it can be a challenging operation, especially when the uterus is bulky and more vascular due to adenomyosis or fibroids.

CASE

A 32 year old woman, G0P0, with the surgical history of cone biopsy presented with the history of infertility. On vaginal examination, there was no vaginal portion of the anterior cervix and there was only 0.5 cm of vaginal portion of the posterior cervix. After extensive counselling, the decision has made to do pre-conceptional laparoscopic abdominal cerclage. This video demonstrates tips and tricks on: 1.How to determine anatomic relations between bladder, uterine vessels, cervico-vaginal junction and cervico-isthmic part of uterus. 2.How Titiz utero-vaginal manipulator helps to dissect the bladder and uterine arteries and veins safely. 3.To determine where and how to pass the sutures.

RESULT

Patient was discharged same day and did not have any post-operative complications. Patient had transvaginal ultrasound one week after the operation. Tape was shown to be at the internal cervical os level.

CONCLUSION

Titiz utero-vaginal manipulator can make pre-conceptional laparoscopic abdominal cerclage safer and easier.

REFERENCES

1.Tulandi T et al. Pre and post-conceptional  abdominal cerclage by laparotomy or laparoscopy J Minim Invasive Gynecol 2014;21:987-983.