Alex Ades

Laparoscopic transabdominal cervical cerclage: A 6-year experience

Cervical cerclage has been used as a treatment for cervical insufficiency for over 60 years. Transabdominal cerclage is indicated for cervical insufficiency not amenable to a transvaginal procedure, or following previous failed vaginal cerclage. A laparoscopic approach to abdominal cerclage offers the potential to reduce the morbidity associated with laparotomy.

Transabdominal cervical cerclage

Background:  Transabdominal cervical cerclage has been performed via laparotomy for over four decades. A laparoscopic approach has recently been developed and offers the potential for lower morbidity.

Porous diaphragm syndrome: haemothorax secondary to haemoperitoneum following laparoscopic hysterectomy.

The porous diaphragm syndrome is associated with the presence of diaphragmatic fenestrations creating peritoneopleural communications. Such defects may occur in conditions associated with a rise on intra-abdominal pressure including laparoscopic surgery. Thoracic complications of laparoscopic surgery may occur as a result. A 48-year-old woman underwent a total laparoscopic hysterectomy for heavy menstrual bleeding. The postoperative period was complicated by haemoperitoneum resulting in haemothorax secondary to porous diaphragm syndrome. Surgeons and anaesthetists should be aware of the possibility of serious thoracic complications related to laparoscopic surgery.

Experience with laparoscopic transabdominal cervico-isthmic cerclage.

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Laparoscopic Removal of Abdominal Cerclage and Vaginal Delivery at 21 Weeks

Introduction: Transabdominal cerclage (TAC) is a procedure for cervical insufficiency in women in whom transvaginal cerclage cannot be performed. In recent years, laparoscopic transabdominal cerclage has gained favor by eliminating the need for laparotomy and reducing surgical morbidity. Case Description: We present a case of laparoscopic removal of a TAC in a 27-year-old woman with uterus didelphys, who presented with fetal death in utero at 21 weeks 3 days. Conclusion: This successful, minimally invasive technique eliminated the need for hysterotomy and the potential corresponding morbidity associated with the operation and allowed for normal spontaneous vaginal delivery.

Spontaneous combined bladder and uterine rupture in pregnancy

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Removal of copper-bearing IUDs in asymptomatic patients

I read with interest Dr Isabel Draper’s letter1 regarding difficult intrauterine device (IUD) insertions published in the January 2008 issue of this Journal. I agree with Dr Draper’s views and would like to share my experience on this subject. I am an instructing doctor and do two IUD/intrauterine system (IUS) training clinics every week. One training clinic is at The Palatine Centre in Manchester and the other is a Gynaecology Tier 2 clinic in Stockport with facilities for on-site ultrasound scanning for difficult IUD/IUS insertions/removals. On an average five patients are seen in each clinic for IUD/IUS insertions. Nearly 30% of patients I see are under the age of 25 years and nulliparous. In my experience I have found that insertion of TT380 Slimline®, TCu380®, QuickLoad® or TSafe 380A®, which are current recommended gold standards, can be at times difficult and painful to insert in this group of patients. I agree with the author’s comments that insertion of the IUS can also be challenging in this group of women. I find the following methods helpful in reducing the discomfort associated with IUD/IUS insertions. 1 Injection of local anaesthetic directly into the cervix (intracervical block) at the 3, 6, 9 and 12 o’clock position is very effective. A 27gauge dental syringe is used to inject 3% Mepivacaine (Scandonest®) or Articaine® with adrenaline (Septanest®), which is available in cartridges. In order to divert the women’s attention I usually ask the patient to cough at the time of injection. 2 Anaesthetic gel such as Instillagel® (lidocaine 2% and chlorhexidine gluconate solution 0.25%) used with Instillaquill® applied on the ectocervix and directly into the endocervical canal takes up to 5 minutes to work. Therefore I rely on its lubricant properties in enhancing ease of uterine instrumentation. 3 Topical application of lidocaine ointment (5%) on the ectocervix. There is a lack of randomised controlled trials investigating the use of topical or intracervical anaesthesia during IUD/IUS insertions. Methods used to aid clinicians in dilating the cervical os if resistance is encountered are listed below. 1 A plastic disposable graduated uterine sound and dilator is available from Durbin Sales. Dilatation up to 5.5 mm can be achieved with this disposable plastic instrument that has a graduated cervical dilator at one end and a sound at the other end. It is marked at 1 cm intervals, and the dilator end is tapered with gradual increase in width to 5.5 mm and has a gentle curve. In my experience it is easy to use compared to the metal Hegars dilators. 2 Vaginal use of misoprostol (200 μg) inserted 3 hours prior to IUD/IUS insertion softens the cervix. This may cause some vaginal bleeding and cramps, and due to the risk of teratogenicity should be used during a period or a reliable method of contraception should be advised during that cycle. Previous Caesarean section is a risk factor for perforation.2 Risk of perforation is directly proportional to the degree of difficulty encountered during insertion, clinician experience and technique. I can foresee that these potential difficult cases will be referred to specialist clinics or will be done by experienced practitioners. I share Dr Draper’s concerns about trainees who would have to learn in this environment and the need for more training sessions to enable them to achieve adequate skills.

Laparoscopic transabdominal cerclage: Outcomes of 121 pregnancies

Cervical insufficiency is a significant cause of morbidity and mortality. Cervical cerclage is one option in the management of cervical insufficiency.

Successful laparoscopic transabdominal cerclage in uterus didelphys

The incidence of uterus didelphys is around 3/10 000 women. It is a class III Müllerian duct anomaly resulting from a complete non-fusion of the paired Müllerian ducts between the 12th and 16th weeks of gestation. Although the prevalence of cervical insufficiency in women with uterus didelphys is unknown, the incidence of cervical insufficiency in women with Müllerian anomalies has been reported as high as 30%. We present a case of successful pregnancy outcome following a laparoscopic transabdominal cerclage in a woman with uterus didelphys and cervical insufficiency. The case demonstrates that laparoscopic transabdominal cerclage can be performed successfully in women with uterus didelphys and a satisfactory obstetric outcome can be achieved.