Transvaginal sonography and fiberoptic illumination of uterine vessels for abdominal cervicoisthmic cerclage

BACKGROUND: Transabdominal cervicoisthmic cerclage is a procedure carried out to increase the fetal salvage rates in women who are poor candidates for the more usual procedure of transvaginal. cerclage or for those with previously failed vaginal procedures. Although several modifications have been applied to the original procedure in an attempt to reduce the morbidity, bleeding arising from trauma to the uterine vessels during suture placement remains problematic. CASE: Our technique involves transilluminating the uterine vessels during placement of the 5-mm-wide Mersilene (Ethicon Inc., Peterborough, Ontario, Canada) tape suture through an avascular space above the junction of the cervix and the uterine isthmus. This obviates the need to dissect or tunnel into the broad ligament. Simultaneous intraoperative transvaginal ultrasonography is used to enhance high suture placement at the isthmus and monitor the fetoplacental unit. We have used this technique in a series of five women with cervical incompetence for seven pregnancies. All but one procedure resulted in live term births. There were no major complications. CONCLUSION: Simultaneous intraoperative ultrasonography and uterine vessel transillumination simplified suture placement during abdominal cerclage, and reduced the amount of dissection and bleeding.