Shiber Linda-Dalal, Lang Thomas, Pasic Resad
Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, University of Louisville, Louisville, KY.
Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics and Gynecology, University of Louisville, Louisville, KY.
J Minim Invasive Gynecol. 2015 Jul-Aug;22(5):715-6. doi: 10.1016/j.jmig.2015.03.007. Epub 2015 Mar 18.
To review the indications, rationale, and technique for abdominal cerclage, specifically focusing on a laparoscopic approach to this procedure during the first trimester of pregnancy.
This is an educational video directed toward gynecologic surgeons. Patient consent was obtained for use of surgical video footage, and Institutional Review Board exemption was granted. A patient case is discussed and a step-by-step description of the technique used to perform laparoscopic cerclage in the first trimester of pregnancy is demonstrated using surgical footage.
The estimated incidence of cervical insufficiency affecting pregnancy is as high as 1%. Cervical cerclage placement is the treatment for this condition. Although most cerclages are placed transvaginally via the Shirodkar or McDonald technique, abdominal cerclage is necessary in women with a previous failed transvaginal cerclage or in those with minimal cervical tissue accessible vaginally [1,2]. Both laparoscopic and robotic approaches to this procedure have been developed, allowing patients to enjoy a more rapid recovery as well as to avoid an unnecessary laparotomy[3-6]. The observational studies reporting outcomes for laparoscopic-assisted abdominal cerclage quote fetal survival rates of >85%, which is comparable to the rates for abdominal cerclage[7-18]. Complication rates are low, also congruent with the laparotomic approach[12-18].
The patient, a 35-year-old gravida 3, para 1, 0, 1, 1, at 11 weeks gestation, had a history of a full-term vaginal delivery followed by an excisional procedure for cervical dysplasia, and then an early second trimester pregnancy loss. She was referred for laparoscopic-assisted abdominal cerclage after a severely shortened cervix was noted on examination. Laparoscopic cerclage placement was uncomplicated, with minimal blood loss encountered. The patient did well in the immediate postoperative period and was discharged home on postoperative day 1. The remainder of the pregnancy was uneventful, and she delivered via scheduled cesarean section at term.
With proper patient selection and operative planning, the technique of laparoscopic cerclage is both safe and advantageous in terms of faster recovery. Obstetric outcomes are equivalent, if not superior, to an open abdominal approach to this procedure.
回顾腹部宫颈环扎术的适应证、理论依据及技术，特别关注妊娠早期该手术的腹腔镜入路。
这是一部面向妇科外科医生的教学视频。已获得患者同意使用手术视频片段，并获得机构审查委员会的豁免。讨论了一个患者病例，并使用手术视频展示了妊娠早期进行腹腔镜宫颈环扎术所用技术的分步描述。
影响妊娠的宫颈机能不全的估计发病率高达1%。宫颈环扎术是针对这种情况的治疗方法。虽然大多数宫颈环扎术是通过希罗德卡尔或麦克唐纳技术经阴道进行的，但对于既往经阴道宫颈环扎术失败的女性或阴道可触及宫颈组织极少的女性，腹部宫颈环扎术是必要的[1,2]。该手术的腹腔镜和机器人入路均已开发出来，使患者能够更快恢复，同时避免不必要的剖腹手术[3 - 6]。报告腹腔镜辅助腹部宫颈环扎术结果的观察性研究显示胎儿存活率>85%，这与腹部宫颈环扎术的存活率相当[7 - 18]。并发症发生率低，也与剖腹手术方法一致[12 - 18]。
患者为35岁孕妇，孕3产1，0，1，1，妊娠11周，有一次足月阴道分娩史，随后因宫颈发育异常接受了切除手术，然后在妊娠中期早期流产。检查发现宫颈严重缩短后，她被转诊接受腹腔镜辅助腹部宫颈环扎术。腹腔镜宫颈环扎术操作顺利；术中出血极少。患者术后即刻情况良好，术后第1天出院。妊娠剩余时间顺利，她足月时通过择期剖宫产分娩。
通过适当的患者选择和手术规划，腹腔镜宫颈环扎术在恢复更快方面既安全又有利。产科结局即使不优于开放性腹部手术方法，也与之相当。
