Effectiveness of Abdominal Cerclage Placed via Laparotomy or Laparoscopy: Systematic Review

doi:10.1016/j.jmig.2011.07.009

Journal of Minimally Invasive Gynecology

Volume 18, Issue 6, November–December 2011, Pages 696-704

https://doi.org/10.1016/j.jmig.2011.07.009 Get rights and content

Abstract

Preterm delivery remains a primary cause of neonatal morbidity and mortality. One cause of preterm birth is cervical incompetence. In women with a shortened or absent cervix or in those in whom previous vaginal cerclage failed, abdominal cerclage may be recommended. We performed a systematic literature search of PubMed, EMBASE, and the Cochrane database. Thirty-one eligible studies were selected. Six studies (135 patients) reported on the laparoscopic approach, and 26 (1116 patients) on the abdominal approach. Delivery of a viable infant at 34 weeks of gestation or more varied from 78.5% (laparoscopic) to 84.8% (abdominal). Second-trimester fetal loss occurred in 8.1% (laparoscopic) vs 7.8% (abdominal), with no reported third-trimester losses (laparoscopic) vs 1.2% (abdominal). We conclude that abdominal cerclage is associated with excellent results as treatment of cervical incompetence, with high fetal survival rates and minimal complications during surgery and pregnancy. Further studies are needed to differentiate which method is superior.

Section snippets

Search Strategy

An extensive search was performed for relevant studies on abdominal cerclage placed at laparoscopy or laparotomy. A relevant study was defined as an article that described either surgical or pregnancy outcomes after placement of an abdominal cerclage. In January 2011, the bibliographic databases MEDLINE (1965–2011), EMBASE (1965–2011), and the Cochrane Database of Systematic Reviews were searched using the key words “Cerclage” or “Uterine cervix cerclage” and “Laparoscopic surgery” or

Included Articles

The search strategy yielded 238 studies in EMBASE, 162 in PubMed, and 1 in the Cochrane Library. Subsequently, the titles and abstracts of these articles were checked to exclude irrelevant studies. We identified 110 potentially relevant articles, and examined 106 full articles and 4 abstracts (Fig. 1). These 106 articles and 4 abstracts were reviewed thoroughly, after which 79 articles were excluded, primarily because of the study design (case reports, n = 46). All references of all full

Discussion

This is the first systematic review reporting on surgical and pregnancy outcome of abdominal cerclage placed at laparotomy or laparoscopy. In this review, we made an effort to define firm inclusion and exclusion criteria so that reliable conclusions could be drawn about treatment of cervical incompetence. This was hard to maintain because there are no current standardized criteria, nomenclature, indications, or sufficient detailed data to ensure this. Indications for placement of an abdominal

Conclusion

Abdominal cerclage, placed laparoscopically or via laparotomy, is associated with excellent perinatal outcomes in patients with a poor obstetrical history. However, due to the limited number of patients included in this review and the lack of study methods, we cannot clearly differentiate which method is superior to the other.

References (39)

R. Simcox et al.
Cervical cerclage in the prevention of preterm birth
Best Pract Res Clin Obstet Gynecol
(2007)
M.U. Witt et al.
Cervicoisthmic cerclage: transabdominal vs transvaginal approach
Am J Obstet Gynecol
(2009)
R. Al-Fadhli et al.
Laparoscopic abdominal cerclage
Obstet Gynecol Clin North Am
(2004)
J.F. Carter et al.
Abdominal cerclage for the treatment of recurrent cervical insufficiency: laparoscopy or laparotomy?
Am J Obstet Gynecol
(2009)
W.L. Whittle et al.
Laparoscopic cervico-isthmic cerclage: surgical technique and obstetric outcomes
Am J Obstet Gynecol
(2009)
R. Simcox et al.
Cervical cerclage: a review
Int J Surg
(2007)
S.M. Althuisius et al.
Final results of the Cervical Incompetence Prevention Randomized Cerclage Trial (CIPRACT): therapeutic cerclage with bed rest versus bed rest alone
Am J Obstet Gynecol
(2001)
G. Nicolet et al.
Laparoscopic cervico-isthmic cerclage evaluation [in French]
Gynecol Obstet Fertil
(2009)
C.H. Cho et al.
Laparoscopic transabdominal cervicoisthmic cerclage during pregnancy
J Am Assoc Gynecol Laparosc
(2003)
H.S. Liddell et al.
Laparoscopic cervical cerclage: a series in women with a history of second trimester miscarriage
J Minim Invasive Gynecol
(2008)

F. Dawood et al.

Prospective obstetric outcome following preconceptual transabdominal cerclage

Int J Gynecol Obstet

(2009)

P.W.J. Van Dongen et al.

Transabdominal cerclage

Eur J Obstet Gynecol Reprod Biol

(1991)

T. McElrath et al.

Trans-abdominal vs. trans-vaginal cerclage: a comparison of cervical length, incidence of funneling and odds of delivery <36 weeks

Am J Obstet Gynecol

(2009)

M.U. Witt et al.

Cervicoisthmic cerclage: transabdominal vs transvaginal approach

Am J Obstet Gynecol

(2009)

A. Gesson-Paute et al.

Transabdominal cervico-isthmic cerclage in the management of cervical incompetence in high risk women

J Gynecol Obstet Biol Reprod (Paris)

(2007)

K.M. Groom et al.

Preconception transabdominal cervicoisthmic cerclage

Am J Obstet Gynecol

(2004)

G. Davis et al.

Patients with a prior failed transvaginal cerclage: a comparison of obstetric outcomes with either transabdominal or transvaginal cerclage

Am J Obstet Gynecol

(2000)

G.S. Anthony et al.

Transabdominal cervico-isthmic cerclage in the management of cervical incompetence

Eur J Obstet Gynecol Reprod Biol

(1997)

C.L. Cammarano et al.

Validity of indications for transabdominal cervicoisthmic cerclage for cervical incompetence

Am J Obstet Gynecol

(1995)

Cited by (69)

A Retrospective Study Comparing Laparoscopic Transabdominal Cerclage: Pre-Pregnancy Versus in Pregnancy With Their Reproductive Outcomes and Safety
2024, Journal of Obstetrics and Gynaecology Canada
To compare the efficacy of laparoscopic transabdominal cerclage (TAC) pre-pregnancy and laparoscopic TAC in pregnancy in treating cervical insufficiency.
A retrospective analytical study comparing outcomes of laparoscopic TAC pre-pregnancy with laparoscopic TAC in pregnancy. A total of 178 patients who underwent laparoscopic TAC at our hospital were enrolled in the study. In total, 122 patients underwent interval cerclage, and 56 patients underwent cerclage during pregnancy.
A total of 178 patients who met the inclusion criteria were included in the analysis. Second-trimester abortions decreased by 50%, with an overall increase in full-term live births (32.53%) in patients undergoing laparoscopic TAC pre-pregnancy. The fetal survival rate was around 90% and 85% with laparoscopic TAC pre-pregnancy and laparoscopic TAC in pregnancy, respectively. Although the obstetric outcomes of laparoscopic TAC pre-pregnancy and in pregnancy were comparable, laparoscopic TAC pre-pregnancy was safer than laparoscopic TAC in pregnancy due to the complications associated with the procedure during pregnancy.
Laparoscopic TAC pre-pregnancy yielded better reproductive outcomes than laparoscopic TAC in pregnancy and was associated with fewer perioperative complications.
Comparer l’efficacité du cerclage transabdominal (CTA) laparoscopique prégestationnel et du CTA laparoscopique pendant la grossesse dans le traitement de l’incompétence du col.
Une étude analytique rétrospective a été effectuée pour comparer les issues du CTA laparoscopique prégestationnel au CTA laparoscopique pendant la grossesse. Au total, 178 patientes ayant subi un CTA laparoscopique dans notre hôpital ont été incluses dans l’étude. De ce nombre, 122 ont subi un cerclage prégestationnel et 56 ont subi un cerclage pendant la grossesse.
Au total, 178 femmes enceintes répondant aux critères d’inclusion ont été incluses dans l’analyse. On observe une réduction de 50 % des avortements spontanés du deuxième trimestre et une augmentation du nombre de naissances vivantes à terme (32,53 %) dans le groupe du CTA laparoscopique prégestationnel. Le taux de survie fœtale était d’environ 90 % et 85 % respectivement avec le CTA laparoscopique prégestationnel et le CTA laparoscopique pendant la grossesse. Quoique les issues obstétricales soient comparables entre les deux, le CTA laparoscopique prégestationnel s’est avéré plus sécuritaire en raison des complications associées à l’intervention pendant la grossesse.
Le CTA laparoscopique prégestationnel a donné de meilleures issues reproductives que le CTA laparoscopique pendant la grossesse et est associé à moins de complications périopératoires.
Favorable surgical and obstetrical outcomes in pre- and postconceptional laparoscopic abdominal cerclage: a large multicenter cohort study
2024, American Journal of Obstetrics and Gynecology MFM
Cervical incompetence is an important cause of extremely preterm delivery. Without specialized treatment, cervical incompetence has a 30% chance of recurrence in a subsequent pregnancy. Recently, the first randomized controlled trial showed significant superiority of abdominal cerclage compared with both high and low vaginal cerclage in preventing preterm delivery at <32 weeks of gestation and fetal loss in patients with a previous failed vaginal cerclage.
This study aimed to assess surgical and obstetrical outcomes in patients with pre- and postconceptional laparoscopic abdominal cerclage placement. Furthermore, it also aimed to perform subgroup analysis based on the indication for cerclage placement in order to identify patients who benefit the most from an abdominal cerclage.
A retrospective multicenter cohort study with consecutive inclusion of all eligible patients from 1997 onward in the Dutch cohort (104 patients) and from 2007 onward in the Boston cohort (169 patients) was conducted. Eligible patients had at least 1 second- or third-trimester fetal loss due to cervical incompetence and/or a short or absent cervix after cervical surgery. This includes loop electrosurgical excision procedure, conization, or trachelectomy. Patients were divided into the following subgroups based on the indication for cerclage placement: (1) previous failed vaginal cerclage, (2) previous cervical surgery, and (3) other indications. The third group consisted of patients with a history of multiple second- or early third-trimester fetal losses due to cervical incompetence (without a failed vaginal cerclage) and/or multiple dilation and curettage procedures. The primary outcome measure was delivery at ≥34 weeks of gestation with neonatal survival at hospital discharge. Secondary outcome measures included surgical and obstetrical outcomes, such as pregnancy rates after preconceptional surgery, obstetrical complications, and fetal survival rates.
A total of 273 patients were included (250 in the preconceptional and 23 in the postconceptional cohort). Surgical outcomes of 273 patients were favorable, with 6 minor complications (2.2%). In the postconceptional cohort, 1 patient (0.4%) had hemorrhage of 650 mL, resulting in conversion to laparotomy. After preconceptional laparoscopic abdominal cerclage (n=250), the pregnancy rate was 74.1% (n=137) with a minimal follow-up of 12 months. Delivery at ³34 weeks of gestation occurred in 90.5% of all ongoing pregnancies. Four patients (3.3%) had a second-trimester fetal loss. The indication for cerclage in all 4 patients was a previous failed vaginal cerclage. The other subgroups showed fetal survival rates of 100% in ongoing pregnancies, with a total fetal survival rate of 96%. After postconceptional placement, 94.1% of all patients with an ongoing pregnancy delivered at ³34 weeks of gestation, with a total fetal survival rate of 100%. Thus, second-trimester fetal losses did not occur in this group.
Pre- and postconceptional laparoscopic abdominal cerclage is a safe procedure with favorable obstetrical outcomes in patients with increased risk of cervical incompetence. All subgroups showed high fetal survival rates. Second-trimester fetal loss only occurred in the group of patients with a cerclage placed for the indication of previous failed vaginal cerclage, but was nevertheless rare even in this group.
Society for Maternal-Fetal Medicine Consult Series #65: Transabdominal cerclage
2023, American Journal of Obstetrics and Gynecology
Cerclage is the mainstay of treatment for cervical insufficiency. Although transabdominal cerclage may have advantages over transvaginal cerclage, it is associated with increased morbidity and the need for cesarean delivery. In this Consult, we review the current literature on the benefits and risks of transabdominal cerclage and provide recommendations based on the available evidence. The following are Society for Maternal-Fetal Medicine recommendations: (1) we recommend that transabdominal cerclage placement be offered to patients with a previous transvaginal cerclage placement (history or ultrasound indicated) and subsequent spontaneous singleton delivery before 28 weeks of gestation (GRADE 1B); (2) we recommend maternal-fetal medicine consultation for counseling patients who may be candidates for transabdominal cerclage and those who have undergone transabdominal cerclage (Best Practice); (3) we suggest that both laparoscopic transabdominal cerclage and open transabdominal cerclage are acceptable and the decision of approach may depend on gestational age, technical feasibility, available resources, and expertise (GRADE 2B); (4) we suggest that transabdominal cerclage can be performed before pregnancy or in the first trimester of pregnancy with similar fetal outcomes. If a patient with an indication for transabdominal cerclage presents after the first trimester of pregnancy, transabdominal cerclage can still be considered before 22 weeks of gestation (GRADE 2C); (5) we recommend that routine transvaginal cervical length screening not be performed for patients with a transabdominal cerclage in situ (GRADE 1C); (6) we suggest that for individuals at risk of recurrent spontaneous preterm birth, including those with a transabdominal cerclage in situ, a risk-benefit discussion of supplemental vaginal progesterone be undertaken with shared decision-making (GRADE 2C); (7) we suggest that pregnancy loss be managed with dilation and curettage or dilation and evacuation with a transabdominal cerclage in situ or via usual obstetrical management after laparoscopic removal of the transabdominal cerclage, depending on gestational age and resources available (GRADE 2C); and (8) we suggest cesarean delivery between 37 0/7 and 39 0/7 weeks of gestation for patients with a transabdominal cerclage in situ (GRADE 2C).
The effectiveness of transabdominal cerclage placement via laparoscopy or laparotomy: a systematic review and meta-analysis
2023, American Journal of Obstetrics and Gynecology MFM
Citation Excerpt :
In addition, we provided new data, based on the most recent literature, on the different placement techniques and timing of an abdominal cerclage. Burger et al23 reported that most transabdominal cerclages were placed by AC.23 This was reflected in the limited number of inclusions in the LC group.
Failure or technical impossibility to place a prophylactic transvaginal cerclage in women with cervical insufficiency justifies the need for an abdominal cerclage. In this systematic review and meta-analysis, we studied the obstetrical and surgical outcomes of laparoscopic and open laparotomy abdominal cerclage approaches performed before (interval) or during pregnancy.
We performed a systematic literature search in PubMed, Embase, and the Cochrane Library for studies on laparoscopic and open laparotomy abdominal cerclage placement in February 2022.
All studies on laparoscopic or open laparotomy placement of an abdominal cerclage with at least 2 patients that reported on our primary outcomes were included.
All included studies were assessed for quality and risk of bias with an adjusted Quality in Prognosis Study tool. Random effects meta-analyses were performed for the primary outcomes, namely fetal survival and gestational age at delivery.
Our search yielded 83 studies with a total of 3398 patients; 1869 of those underwent laparoscopic cerclage placement and 1529 underwent open laparotomy placements. No studies directly compared the 2 cerclage approaches. The survival (overall, 91.2%) and gestational age at delivery (overall, 36.6 weeks) were not statistically different between the approaches. For the procedure during pregnancy, the laparoscopic group showed significantly less blood loss >400 mL (0% vs 3%), a slightly lower procedure-related fetal loss (0% vs 1%), a shorter hospital stay but a longer operation duration than the open laparotomy group. For the interval cerclages, the laparoscopic group showed significantly fewer wound infections (0% vs 3%) and a shorter hospital stay than the open laparotomy group, but showed comparable offspring preterm birth and survival rates.
Based on indirect comparisons, the laparoscopic and open laparotomy abdominal cerclage placements at interval or during pregnancy produced similar outcomes in terms of survival and gestational age at delivery. There are some small differences in perioperative care, surgical complications, interventions, and complications during pregnancy. This implies that both methods of abdominal cerclage placement have high success rates and thus we cannot conclude that one of the methods is superior for the placement of an abdominal cerclage.
Efficacy of laparoscopic and trans-abdominal cerclage (TAC) in patients with cervical insufficiency: A systematic review and meta-analysis
2022, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
One previous systematic review and meta-analysis demonstrated that laparoscopic cerclage is more effective than open TAC for improving the survival rate [72]. Another recent systematic review comparing these two procedures demonstrated that the two procedures have the same effect on pregnancy outcomes [73]. A previously published meta-analysis compared laparoscopy and open TAC and showed that both methods significantly decrease the fetal loss rate; however, the results favored the laparoscopy over laparotomy in improving gestational age >34 weeks [74].
Cervical insufficiency (CI) may result in preterm delivery. We sought out to perform this review and analysis to compare the efficacy of laparoscopic and open transabdominal cerclage (TAC) in patients suffering with CI.
Our search included PubMed, Scopus, MEDLINE, ClinicalTrials.Gov, Cochrane and Web of Science. We analyzed the data with Open Meta-Analyst Software as well as Review Manager Software. We included observational and randomized controlled trials that included patients with CI that underwent laparoscopic cerclage or TAC.
We included a total of 43 studies. Laparoscopic and TAC had a positive effect by increasing gestational age (GA); for the laparoscopic group (mean deviation (MD)) = 14.86 weeks (W), 95% CI [10.67, 19.05], P < 0.001) and TAC (MD = 12.79 W, 95% CI [10.97, 14.61], P < 0.001). Furthermore, improvements in all outcomes assessed (total fetal survival rate, neonatal weight, and prevention of delivery at a gestational age of<24 weeks) were all significant with the exception of the prevention of all preterm deliveries<37 weeks; for both laparoscopic at (RR = 0.116, 95% CI [-0.006, 0.238], P = 0.063) and TAC at (MD = 1, 95% CI [0.45, 2.24], P = 1), and for prevention of deliveries<34 weeks for the laparoscopic group (RR = 0.446, 95% CI [-0.323, 1.215], P = 0.256) only.
Although limited data prevented pregnancy and prepregnancy subgroups as well as a head-to-head comparison, we still found that in patients suffering from CI, both TAC and laparoscopic approaches to cerclage revealed a positive effect in preserving the pregnancy.
Complications of Laparoscopic and Transabdominal Cerclage in Patients with Cervical Insufficiency: A Systematic Review and Meta-analysis
2021, Journal of Minimally Invasive Gynecology
Cervical insufficiency is a defect of the cervix that leads to failure to preserve a full-term intrauterine pregnancy. Laparoscopic cerclage and open transabdominal cerclage (TAC) are effective ways to manage patients with cervical insufficiency. We performed this systematic review and meta-analysis to investigate the complications of laparoscopic cerclage and open TAC in the management of cervical insufficiency.
We searched PubMed, Cochrane, Scopus, and Web of Science using our search strategy and screened the results for our criteria. We extracted the results reported and analyzed them using Open Meta-Analyst (OpenMeta[Analyst], Brown School of Public Health, Providence, RI) and Review Manager (Cochrane Collaboration, London, United Kingdom) software.
We included all randomized controlled and observational trials performed on patients with cervical insufficiency undergoing open TAC or laparoscopic cerclage that matched our search strategy. We excluded letters to the editor, reviews, meetings/conference abstracts, non-English or nonhuman studies, and instances where the full text was not available.
We included a total of 33 trials. Both interventions of laparoscopic cerclage and open TAC were associated with significantly less total fetal loss (laparoscopic cerclage, relative risk [RR] 0.03; 95% confidence interval [CI], 0.01–0.08; p <.001, and open TAC, RR 0.19; 95% CI, 0.07–0.51; p <.009). The overall blood loss in open TAC was 110.589 mL (95% CI, 93.737–127.44; p <.001), and in laparoscopic cerclage, it was 24.549 mL (95% CI, 9.892–39.205; p = .001). In addition, open TAC had a positive effect regarding incidence of hemorrhage >400 mL (RR 0.077; 95% CI, 0.033–0.122; p <.001). Preterm premature rupture of membranes was significant in the open TAC (RR 0.037; 95% CI, 0.019–0.055; p <.001) and laparoscopic cerclage groups (RR 0.031; 95% CI, 0.009–0.053; p = .006).
Laparoscopic cerclage may be safer than open TAC in the management of cervical insufficiency because we found a statistically significant lower incidence of fetal loss, blood loss, and rate of hemorrhage in the laparoscopic cerclage group. Clinically, this evidence may help support favoring a laparoscopic approach over an open one in appropriate patients, although it is unclear whether this benefit is limited to cerclages placed either before pregnancy or placed in the first-trimester or both.

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Review ArticleEffectiveness of Abdominal Cerclage Placed via Laparotomy or Laparoscopy: Systematic Review

Abstract

Section snippets

Search Strategy

Included Articles

Discussion

Conclusion

Best Pract Res Clin Obstet Gynecol

Am J Obstet Gynecol

Obstet Gynecol Clin North Am

Am J Obstet Gynecol

Am J Obstet Gynecol

Int J Surg

Am J Obstet Gynecol

Gynecol Obstet Fertil

J Am Assoc Gynecol Laparosc

J Minim Invasive Gynecol

Int J Gynecol Obstet

Eur J Obstet Gynecol Reprod Biol

Am J Obstet Gynecol

Am J Obstet Gynecol

J Gynecol Obstet Biol Reprod (Paris)

Am J Obstet Gynecol

Am J Obstet Gynecol

Eur J Obstet Gynecol Reprod Biol

Am J Obstet Gynecol

Review Article
Effectiveness of Abdominal Cerclage Placed via Laparotomy or Laparoscopy: Systematic Review