Transabdominal cervicoisthmic cerclage: a reappraisal 25 years after its introduction.

Most cerclage operations for cervical insufficiency are performed transvaginally. The transabdominal route is beneficial in treating patients with cervices that are either extremely short, congenitally deformed, deeply lacerated, or markedly scarred because of previously failed transvaginal cerclage procedures. The average gestational age at surgery was 11.5 weeks and the operation was performed after early ultrasonographic verification of fetal viability. Patients with advanced cervical effacement or dilatation in the second trimester were excluded. A 5 mm wide Mersilene band was applied in an avascular space above the junction of the cervix and the uterine isthmus without dissection or tunneling among broad ligament vessels. This simplified surgical approach resulted in little operative blood loss (mean, 75 ml; range, 50 to 200 ml). After transabdominal cervicoisthmic cerclage, 21 pregnancies in 20 patients resulted in 18 term births, one premature birth with favorable outcome, and two early fetal deaths (90% salvage rate). A review of the world literature indicated 130 pregnancies with transabdominal cervicoisthmic cerclage during pregnancy and a cumulative success rate of 89%. Preconceptional transabdominal cervicoisthmic cerclage was reported in 30 pregnancies with an overall fetal survival rate of 81%. A survey of specialists in maternal-fetal medicine indicated an increasing interest and familiarity with transabdominal cervicoisthmic cerclage since its introduction more than two decades ago although this procedure is still not widely applied in obstetric practice.