At the bottom of the uterus, the cervix serves as the mouth of the womb-the opening, for example, through which menstruation and childbirth takes place. Women who have a weak or insufficient cervix have difficulty carrying a pregnancy to term due to premature passing of the fetus that results in miscarriage. Women with this condition may experience unsuccessful pregnancies, as a result of multiple miscarriages. But cerlage surgery using robotic technology is helping to change that for more patients.
Women with cervical weakness, also called cervical incompetence, have typically suffered an injury to their cervix that has left it stretched and pliable or deficient. Others may have an incomplete cervix congenitally or due to surgery.
Gynecologists use medical history, physical exam and transvaginal ultrasound to diagnose the condition. Specialized centers have offered treatment for cervical weakness through a surgical procedure. Options for this operation have gone through an evolution in recent decades.
Standard Solutions for a Weak or Incompetent Cervix
To treat the condition, the gynecologic specialist seeks to surgically tighten the cervix. Beginning more than half a century ago, certain centers with this capability began performing this "cerlage" surgery. (The word comes from the French "circlage," meaning an encircling.) In this operation, the surgeon accesses the cervix through the vagina and stitches the cervix to give it added support. However, only the lowest part of the cervix extends into, and can be reached from, the vagina. As a result, the procedure usually required post-surgical bed rest to safeguard a delicate repair that too often failed.
This standard solution is still appropriate in some cases, including for women who are later in pregnancy. The stitching may be removed prior to delivery. (Future pregnancies may require a repeat of the procedure.)
In the past, most women who availed themselves of cerclage did so when cervical protrusion became clear during a pregnancy, typically in the second trimester. (Cervical incompetence is a major cause of second-trimester miscarriage.) Today, more women with known cervical deficiencies are seeking the surgery prior to pregnancy, in part because of new developments in the surgery.
The Transabdominal Cerclage Advantage
Led by Lourdes and a few other centers, advanced Gyn services have offered another, more dependably successful operation, over the last two decades. In this transabdominal cerlage, the surgeon makes a "bikini-cut" incision, similar to that required for a C-section, in the lower pelvis. The surgeon lifts the bladder to access the abdominal portion of the cervix (the portion above the vagina). The team places a nylon-mesh band around the upper portion of the cervix, at its junction with the rest of the uterus, firming up the cervix's function of securing the lower portion of the womb.
The band stays in place permanently. And the patient delivers all future pregnancies via C-section.
Patients who seek the procedure have often undergone failed vaginal cerlage, which may leave tears or lacerations in the lower cervix. Transbdominal cerlage has been very successful; however, the procedure requires the extended healing and recovery inherent for any open surgical procedure.
Transabdominal Cerlage as a Laparoscopic Procedure: A Challenge
Over the last decade, a small number of highly specialized centers have also offered transabdominal cerclage using the less-invasive but conventional laparoscopic approach. (Laparoscopy requires only several small, button-hole incisions for access to the pelvis for the endoscope and laparoscopic tools.)
The operation has proven difficult to perform via this approach, however. For the surgeon, visualization is limited, and positioning and adjusting the band properly is challenging. The Lourdes program has not emphasized this approach.
Robotic Surgery Changes Outcomes
Advanced centers with highly trained surgeons and the most advanced equipment, though, have recently overcome these drawbacks, successfully delivering minimally invasive transabominal cerclage via laparoscopic access. The advancement is based on robotic-assisted surgery, an approach using highly precise, remotely controlled surgical tools.
Through several laparoscopic incisions, the surgeon views the intra-abdominal area in three-dimensions. In turn, highly exacting tools, improve the surgeon's ability to position the surgical material and stitches, and to secure them without injuring the cervix—while offering visual and access advantages similar to that gained by the open-surgery approach.
The procedure returns cervical competency in a less-invasive cerlage operation that requires less time in the hospital, and results in virtually no blood loss. Patients often return home on the same day that they undergo the procedure and are active again within a day or two. Women who have received robotic transabdominal cerlage have typically gone on to achieve full-term pregnancies and deliveries (by C section).
This advancement adds an important new cerlage option. The superior dexterity and visualization via the daVinci® Surgical System at Lourdes make that new technology an excellent match for this purpose.
Cerlage that is easier to undergo is more appealing for women considering having the procedure prior to pregnancy. Lourdes' program is among the very few top most in the nation, in experience with this procedure.
Helping More Women Carry Pregnancies Successfully
A weak cervix has threatened many pregnancies in the past, in women physically incapable of carrying a baby to term because of the problem. These women and couples have lost pregnancies through serial miscarriages that have thwarted their hopes for a family.
Lourdes offers pregnancy support in the form of surgical answers to this dilemma. And, reproductive endocrinologists have increasingly supported cerlage prior to pregnancy.
The Lourdes gynecologic surgical service encourages women with indications or diagnosis of cervical weakness to seek a consultation. Careful selection for a cerlage procedure often results in overcoming cervical insufficiency.