Robot-assisted laparoscopic cervical cerclage as an interval procedure

A 28-year-old woman gravida 4 Para 0 presented with a history of cervical insufficiency following three midtrimester miscarriages, two at 16 weeks and one at 17 weeks. The last two mid-trimester miscarriages presented with painless rupture of membranes and cervical shortening was demonstrated on ultrasound in one. She also had one early miscarriage at 6 weeks. There was no patient history of cervical instrumentation, cervical surgery, congenital abnormality or uterine anomaly. There was also no history of thrombophilia, translocation or maternal family history of recurrent miscarriage. She was appropriately counselled and offered an interval robot-assisted abdominal cerclage (Interval RA-AC). The procedures were carried out using the da Vinci System. The ports were sited as per Fig. 1. The procedure was performed as previously described [1, 2] using steep Trendelenburg position, uterine manipulation with a size 10 Hagar dilator in order to prevent over-tightening of the cervix, bladder reflection (Fig. 2) and broad ligament fenestration bilaterally (Fig. 3). A one Ethibond (Ethicon Inc., Johnson & Johnson, USA) suture was placed medial to the uterine artery bilaterally (Fig. 4) and tied posteriorly (Fig. 5). She was discharged without complication later that day and remained well. She subsequently became spontaneously pregnant. Her pregnancy was uncomplicated and she delivered a healthy female infant (weighing 2.58 kg) by elective caesarean section (CS) at 37 weeks gestation. There were no intraoperative difficulties. The suture was neither visualised nor felt at CS, and it was presumably deep in the substance of the myometrium. The cerclage remains in place for subsequent pregnancies.