Robotic-assisted transabdominal cerclage (RoboTAC) in the non-pregnant patient

The effectiveness of transabdominal cerclage placement via laparoscopy or laparotomy: a systematic review and meta-analysis

OBJECTIVE

Failure or technical impossibility to place a prophylactic transvaginal cerclage in women with cervical insufficiency justifies the need for an abdominal cerclage. In this systematic review and meta-analysis, we studied the obstetrical and surgical outcomes of laparoscopic and open laparotomy abdominal cerclage approaches performed before (interval) or during pregnancy.

DATA SOURCES

We performed a systematic literature search in PubMed, Embase, and the Cochrane Library for studies on laparoscopic and open laparotomy abdominal cerclage placement in February 2022.

STUDY ELIGIBILITY CRITERIA

All studies on laparoscopic or open laparotomy placement of an abdominal cerclage with at least 2 patients that reported on our primary outcomes were included.

METHODS

All included studies were assessed for quality and risk of bias with an adjusted Quality in Prognosis Study tool. Random effects meta-analyses were performed for the primary outcomes, namely fetal survival and gestational age at delivery.

RESULTS

Our search yielded 83 studies with a total of 3398 patients; 1869 of those underwent laparoscopic cerclage placement and 1529 underwent open laparotomy placements. No studies directly compared the 2 cerclage approaches. The survival (overall, 91.2%) and gestational age at delivery (overall, 36.6 weeks) were not statistically different between the approaches. For the procedure during pregnancy, the laparoscopic group showed significantly less blood loss >400 mL (0% vs 3%), a slightly lower procedure-related fetal loss (0% vs 1%), a shorter hospital stay but a longer operation duration than the open laparotomy group. For the interval cerclages, the laparoscopic group showed significantly fewer wound infections (0% vs 3%) and a shorter hospital stay than the open laparotomy group, but showed comparable offspring preterm birth and survival rates.

CONCLUSION

Based on indirect comparisons, the laparoscopic and open laparotomy abdominal cerclage placements at interval or during pregnancy produced similar outcomes in terms of survival and gestational age at delivery. There are some small differences in perioperative care, surgical complications, interventions, and complications during pregnancy. This implies that both methods of abdominal cerclage placement have high success rates and thus we cannot conclude that one of the methods is superior for the placement of an abdominal cerclage.

A four step strategy for robot assisted abdominal cerclage placement prior to pregnancy

OBJECTIVE

To demonstrate a simple, stepwise strategy for robot-assisted abdominal cerclage placement before pregnancy.

DESIGN

Demonstrative video presentation. Surgical footage surrounding a case report is used to describe a four-step technique for robot-assisted abdominal cerclage placement in women with recurrent pregnancy loss or other anatomic variants before pregnancy. This video article was reviewed by the Investigational Review Board and further investigation was waived because the study was "not considered human subject research."

SETTING

Tertiary medical center.

PATIENT(S)

A 38-year-old G4P0220 (Gestations: 4, Term deliveries: 0, Preterm deliveries: 2, Abortions: 2, Living children: 0) with a history of two second trimester losses who had failed a prior history-indicated transvaginal cerclage (Fig. 1).

INTERVENTION(S)

The patient underwent an uncomplicated robot-assisted abdominal cerclage using a four-step strategy: Step 1, create the bladder flap; Step 2, identify pertinent anatomy; Step 3, place the cerclage; and Step 4, hysteroscopy.

MAIN OUTCOME MEASURE(S)

Intraoperative technique presenting a four-step method to ensure successful robot-assisted abdominal cerclage placement.

RESULT(S)

Robot-assisted abdominal cerclage is a safe, viable alternative to traditional abdominal cerclage placed via laparotomy. This video outlines four critical steps to facilitate placement and decrease patient morbidity. This patient did well operatively without increased blood loss or operative time and was discharged home on postoperative day 1. She went on to have a successful future pregnancy and currently is scheduled for an elective cesarean section at term.

CONCLUSION(S)

Abdominal cerclages significantly improve pregnancy and neonatal outcomes in women who previously have failed transvaginal cerclage. Robot-assisted abdominal cerclage placement allows a minimally invasive approach with enhanced dexterity and better visualization for the surgeon compared with conventional laparoscopy or laparotomy, as well as decreased pain and shorter recovery time for patients. This video demonstrates placement of a robot-assisted abdominal cerclage in a patient with recurrent pregnancy loss using a simple four-step strategy to ensure successful, correct, and easy placement. To our knowledge, this is the first video demonstrating a stepwise approach to robot-assisted abdominal cerclage placement.

Robotic assisted laparoscopic cerclage: A systematic review

INTRODUCTION

The gold standard in the management of cervical incompetence is cerclage via vaginal approach. Minimally invasive techniques, such as robotic, have been also described.

MATERIALS AND METHODS

A systematic search was performed in PubMed and Scopus, searching evidence on robotic assisted laparoscopic cerclage in both pregnant and non pregnant women.

RESULTS

Sixty-four patients were included in this study. Cervical insufficiency, failure of transvaginal cerclage, and short cervix were the most frequent indications for robotic assisted cerclage. Mean operative time was 107.3 minutes. Mean estimated blood loss was 62.8 mL. Four patients converted to laparotomy. No postoperative complications were reported. Pregnancy after robotic cerclage was reported in 59 patients with mean gestational age at delivery of 36.4 weeks. The majority of pregnant women who underwent robotic assisted cerclage gave birth to live neonates.

CONCLUSION

Till now, evidence does not show a clear advantage of robotic over laparoscopic approach, under the evaluation of the current literature. However, further comparative studies might be essential to clarify the possible role of da Vinci robot in this field; this might be quite difficult even in the near future based on the fact that only five cases per year are described in the current literature.

Robotic surgery in gynecology

Robotic surgery is the most dynamic development in the sector of minimally invasive operations currently. It should not be viewed as an alternative to laparoscopy, but as the next step in a process of technological evolution. The advancement of robotic surgery, in terms of the introduction of the Da Vinci Xi, permits the variable use of optical devices in all four trocars. Due to the new geometry of the "patient cart," an operation can be performed in all spatial directions without re-docking. Longer instruments and the markedly narrower mechanical elements of the "patient cart" provide greater flexibility as well as access similar to those of traditional laparoscopy. Currently, robotic surgery is used for a variety of indications in the treatment of benign gynecological diseases as well as malignant ones. Interdisciplinary cooperation and cooperation over large geographical distances have been rendered possible by telemedicine, and will ensure comprehensive patient care in the future by highly specialized surgery teams. In addition, the second operation console and the operation simulator constitute a new dimension in advanced surgical training. The disadvantages of robotic surgery remain the high costs of acquisition and maintenance as well as the laborious training of medical personnel before they are confident with using the technology.

First Trimester Laparoscopic Cerclage

STUDY OBJECTIVE

To review the indications, rationale, and technique for abdominal cerclage, specifically focusing on a laparoscopic approach to this procedure during the first trimester of pregnancy.

DESIGN

This is an educational video directed toward gynecologic surgeons. Patient consent was obtained for use of surgical video footage, and Institutional Review Board exemption was granted. A patient case is discussed and a step-by-step description of the technique used to perform laparoscopic cerclage in the first trimester of pregnancy is demonstrated using surgical footage.

SETTING

The estimated incidence of cervical insufficiency affecting pregnancy is as high as 1%. Cervical cerclage placement is the treatment for this condition. Although most cerclages are placed transvaginally via the Shirodkar or McDonald technique, abdominal cerclage is necessary in women with a previous failed transvaginal cerclage or in those with minimal cervical tissue accessible vaginally [1,2]. Both laparoscopic and robotic approaches to this procedure have been developed, allowing patients to enjoy a more rapid recovery as well as to avoid an unnecessary laparotomy[3-6]. The observational studies reporting outcomes for laparoscopic-assisted abdominal cerclage quote fetal survival rates of >85%, which is comparable to the rates for abdominal cerclage[7-18]. Complication rates are low, also congruent with the laparotomic approach[12-18].

INTERVENTION

The patient, a 35-year-old gravida 3, para 1, 0, 1, 1, at 11 weeks gestation, had a history of a full-term vaginal delivery followed by an excisional procedure for cervical dysplasia, and then an early second trimester pregnancy loss. She was referred for laparoscopic-assisted abdominal cerclage after a severely shortened cervix was noted on examination. Laparoscopic cerclage placement was uncomplicated, with minimal blood loss encountered. The patient did well in the immediate postoperative period and was discharged home on postoperative day 1. The remainder of the pregnancy was uneventful, and she delivered via scheduled cesarean section at term.

CONCLUSION

With proper patient selection and operative planning, the technique of laparoscopic cerclage is both safe and advantageous in terms of faster recovery. Obstetric outcomes are equivalent, if not superior, to an open abdominal approach to this procedure.

Two Live Births following Robotic-Assisted Abdominal Cerclage in Nonpregnant Women

Introduction. To report the robotic-assisted abdominal cerclage performed in two nonpregnant women and the success of live birth outcomes. Presentation of Cases. A 36-year-old woman with a complaint of recurrent second trimester pregnancy losses and a 35-year-old patient with a complaint of preterm deliveries and cervical insufficiency underwent robotic assisted abdominal cervicoisthmic cerclage placement in nonpregnant period. The two patients had spontaneous pregnancy after the robotic-assisted abdominal cerclage and delivered healthy infants. Discussion. The limitations of traditional laparoscopic abdominal cerclage have been accomplished with robotic surgery advantages especially intuitive movements and increased range of motion. There are only a few studies in the literature including robotic assisted abdominal cerclage in nonpregnant women, and only five successful live birth outcomes were reported. In this paper, we reported the sixth and seventh cases of achieved live pregnancy after robotic assisted abdominal cerclage in the literature. Conclusion. Robotic assisted abdominal cerclage is a good alternative surgical method with successful pregnancy outcomes.