title: Robotic-assisted Abdominal Cerclage Placement During Pregnancy and Its Challenges.
abstract: OBJECTIVE
  To demonstrate a surgical video of 2 cases, in which the steps of robotic-assisted abdominal cerclage placement were delineated in one and a uterine vessel injury was repaired in the other.
  
  
  METHODS
  Step-by-step explanation of the technique using a surgical video (Canadian Task Force classification III).
  
  
  METHODS
  The procedures were performed at a teaching hospital. The first patient was a 25-year-old gravida 4 para 0, with a history of cervical incompetence, who was 13 weeks pregnant at the time of surgery. She had failed McDonald cerclage and was referred for abdominal cerclage placement. The second patient was a 32-year-old gravida 6 para 0 who was 15 weeks pregnant. She had a history of 3 second-trimester miscarriages with painless cervical dilation and had failed McDonald cerclage during her previous pregnancy. Both patients were taken to the operating room for robotic-assisted abdominal cerclage placement early in the second trimester.
  
  
  METHODS
  Robotic-assisted abdominal cerclage placement was performed with ultrasound guidance. The procedure was begun with formation of the bladder flap [1]. An avascular space between the ascending and descending branches of uterine artery, at the level of the cervicoisthmic junction, was subsequently developed. The Mersilene tape was passed through this space in a posterior-to-anterior direction and pulled taut until it was laid flat along the posterior uterine wall. Six knots were then placed with the Mersilene tape on the anterior aspect of the uterus. The free ends of the tape were trimmed and approximated with a nonabsorbable suture to prevent knot slippage. The vesicouterine reflection was then reapproximated, and correct cerclage placement was confirmed with transvaginal ultrasound. In the second case, an incidental uterine vessel injury occurred during development of the avascular space. Hemostasis was attained immediately by clamping the vessel with the fenestrated graspers. Permanent hemostasis required application of the vascular clips, proximally and distally on the lacerated arterial site.
  
  
  CONCLUSIONS
  A robotic approach was chosen for our patients requiring transabdominal cerclage placement during pregnancy, in an attempt to decrease the surgical morbidity associated with laparotomy [2,3]. Despite the challenges introduced by the enlarged gravid uterus, both procedures were successfully completed, and the patients delivered at term via cesarean section.
authors.affiliation: Yale New Haven Health/Bridgeport Hospital, Bridgeport, Connecticut. Electronic address: guldenmenderes@gmail.com.
authors.forename: Gulden
authors.initials: G
authors.lastname: Menderes
authors.affiliation: Yale New Haven Health/Bridgeport Hospital, Bridgeport, Connecticut.
authors.forename: Mitchell
authors.initials: M
authors.lastname: Clark
authors.affiliation: Yale New Haven Health/Bridgeport Hospital, Bridgeport, Connecticut.
authors.forename: Lindsay
authors.initials: L
authors.lastname: Clark-Donat
authors.affiliation: Yale New Haven Health/Bridgeport Hospital, Bridgeport, Connecticut.
authors.forename: Masoud
authors.initials: M
authors.lastname: Azodi
mesh_terms: D000005:Abdomen / Q000601:surgery; D000022:Abortion, Spontaneous; D023802:Cerclage, Cervical / Q000379:methods*; D005260:Female; D006801:Humans; D010298:Parity; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D011262:Pregnancy Trimester, Second; D012371:Robotics; D055988:Uterine Artery / Q000473:pathology*; D002581:Uterine Cervical Incompetence / Q000601:surgery*
keywords: Abdominal cerclage; Robotics; Uterine vessel injury