The First Robotic Abdominal Cervical Cerclage in Pregnancy

In a groundbreaking procedure, robotically assisted, ultrasound-guided laparoscopic surgery was performed successfully to tighten an incompetent cervix, according to a report in the Journal of Minimally Invasive Gynecology.¹
   
Sami Kilic, MD, chief of minimally invasive gynecology and research at the Univesity of Texas Medical Branch at Galveston performed the first ever robotic abdominal cerclage placement under ultrasound guidance that successfully tightened a cervix that was too short to sustain a pregnancy in December 2011. Traditionally, abdominal cerclage surgery involves a laparotomy and a long recovery period. Using robotic technology, this new procedure, which took 2 hours, required only 3 small abdominal entry points. The patient was discharged after an overnight stay in the hospital and reported a return to normal activity after just 2 days.
   
Using the da Vinci Si system, the surgeon was able to view the surgical field and the ultrasound image in real time simultaneously. This dual-screen technology offers “unsurpassed visualization,” which minimizes the surgeon’s physical movements and decreases the risks of a surgical error.¹ For a cervical cerclage to be effective, the stitches must be placed precisely so that neither the amniotic sac nor major blood vessels in the mother are punctured. Ultrasound guidance improves needle placement accuracy, thus reducing potential for injuries. In addition, the use of the vaginal ultrasound probe allowed for manipulation of the uterus to improve visualization without placing excessive pressure on the gravid uterus, explained the surgeons.¹
   
At a 2-week postsurgical follow-up examination, an ultrasonographic scan showed that the cervical cerclage had been placed correctly and precisely. The patient, who was 35 years old and pregnant with her second child, proceeded to have an otherwise uncomplicated pregnancy until she went into labor at 36 weeks. In her first pregnancy, she also required abdominal cerclage early in her pregnancy because of an incompetent cervix. This first surgery was performed by Dr Kilic as well but was a traditional abdominal cerclage, which left her with a prolonged and painful recovery period and months of residual tenderness at the incision site.    

This new robotic procedure with dual visualization not only is effective but also allows for a significantly faster recovery period, offering patients an alternative to the traditional, more invasive cerclage that requires a laparotomy.

Pertinent Point:
- This case study describes the successful placement of a cerclage in a pregnant women with an incompetent cervix using robotically assisted, ultrasound-guided laparoscopic surgery, which allows for real-time visualization of the surgical field and the ultrasound image simultaneously.
 

References:

1. Walsh TM, Borahay MA, Fox KA, Kilic GS. Robotic-assisted, ultrasound-guided abdominal cerclage during pregnancy: overcoming minimally invasive surgery limitations? J Minim Invasive Gynecol. March 15, 2013. [Epub ahead of print.]