Robot-Assisted Transabdominal Cervical Cerclage With the Hugo RAS System: Surgical Technique and Perioperative...

Cervical insufficiency, the inability of uterine cervix to retain pregnancy in absence of labor, is a major cause of preterm births and stillbirths. Therapeutic options include expectant management, progesterone, pessaries, or surgical cerclage [1]. Minimally invasive approaches provide several advantages over laparotomy, including decreased blood loss, lower post-operative pain, shorter hospital stay and faster recovery while achieving comparable or improved obstetric outcomes [2,3]. Robotassisted transabdominal cerclage (RA-TAC) is gaining popularity due to the enhanced three-dimensional visualization, improved dexterity and precision in performing fine dissection and knot-tying [4]. This video article demonstrates our RA-TAC technique and setup in a complex patient using the Hugo™ RAS system (Medtronic, Minneapolis, MN, USA) [5].

Step-by-step explanation of surgical technique of RA-TAC in a 40-year-old, BMI 36 kg/m² patient, with unfavorable obstetric history and desire for further pregnancy.

Academic Hospital, IRCCS Policlinico di S. Orsola Bologna, Italy.

All possible therapeutic strategies and related complications have been discussed with the patient. Considering her strong desire for pregnancy, her surgical and obstetric history- including prior preterm deliveries despite vaginal cerclage (2020-2021)- and her BMI, a preconceptional RA-TAC was planned. A "straight" port placement in a "compact" docking configuration was installed. Surgery was performed under general anesthesia in 49 minutes. There were no intraoperative or postoperative complications. After 15 months, the patient successfully delivered a healthy 2896g male infant via elective cesarean section at 36+6 weeks, with no need for perinatal care; the cerclage was removed and bilateral salpingectomy was performed.

Robotic-assisted surgery represents a feasible option for transabdominal cerclage, particularly in patients with obesity or intra-abdominal adhesions. Surgeon ergonomics, three-dimensional visualization, unrestricted range of motion, improved tremor control are key-advantages in procedures demanding maximal precision. While current literature lacks strong evidence demonstrating superiority of robotic-assisted over laparoscopic cerclage, this video illustrates technique, feasibility and potential benefits of RA-TAC.