Laparoscopic interval isthmocervical cerclage with cardiac tape in a patient with previous cervical amputation

To show the technique of interval laparoscopic isthmocervical cerclage using cotton cardiac tape.

Case report (Canadian Task Force Classification III).

A private practice hospital in Brasília, Brazil.

A 36-year-old female patient with primary infertility for 2 years caused by previous amputation of the cervix because of intraepithelial neoplasia. There was no other suspected factor for infertility. Before undergoing in vitro fertilization, she was referred for interval cerclage because of anticipated cervical insufficiency during an eventual pregnancy. The patient's clinical history was unremarkable, except for the fact that she had developed secondary dysmenorrhea since the amputation, which prompted her to undergo cervical dilatation on 2 occasions. During the physical examination, we noted the absence of the exocervix, a mobile and normal-sized uterus and adnexa, and no pain. Informed consent was obtained from the patient for this case report. The local institutional review board considered this report exempt from approval.

The procedure was performed according to the technique described by Pereira et al. We incised the visceral peritoneum in the anterior cul-de-sac and developed the vesicouterine space for complete exposure of the uterine isthmus. Then, we incised the posterior leaf of both broad ligaments superiorly to the uterosacral ligaments and medially to the ureter and uterine vessels. We aimed to identify the bifurcation of the uterine artery and to create a "window" between them and the isthmus to place the cerclage tape. For this purpose, we used a 5-mm 36-cm blunt tip retractor for gastric banding (ref 30623G; Karl Storz, Tuttlingen, Germany) to transfix the broad ligament, anteriorly to posteriorly, under direct vision. We tied 2-0 Vicryl (Ethicon, Sommerville, NJ) sutures to the tips of 0.3 × 80 cm cotton cardiac tape (reference FAB-46; Ethicon) and pulled both edges of the tape through the windows in the broad ligament. The final position of the tape was inferior and medial to the main ascending branch of the uterine artery, right over the isthmus, and without any vessels interposed between them. This is to avoid any possible compression and congestion with uterine progressive enlargement as pregnancy proceeds. We then made 6 square knots in the anterior cul-de-sac and adjusted the tension-free tape firmly enough to give the uterine corpus support during pregnancy evolution. Finally, we closed the visceral peritoneum with a 3-0 PDS running suture (Ethicon).

The surgery lasted 70 minutes, and bleeding was minimal. The patient was discharged the following day. She is currently undergoing her 18th week of pregnancy resulting from in vitro fertilization treatment, and we wait for her obstetric results.

Cotton cardiac tape is feasible for laparoscopic cerclage and can be used as an alternative to the commonly used Mersilene tape (Ethicon). Laparoscopy safely allows tape placement medial to the uterine vessels. Additional cases are necessary to establish the obstetric effectiveness of cotton cardiac tape for laparoscopic cerclage.