title: Needleless Robotic-Assisted Abdominal Cerclage in Pregnant and Nonpregnant Patients.
abstract: OBJECTIVE
  To demonstrate the step-by-step surgical technique of "needle-free" robotic-assisted transabdominal cerclage placement.
  
  
  METHODS
  Through surgical video footage, presentation of a step-by-step demonstration of robotic-assisted laparoscopic placement of abdominal cerclage (Canadian Task Force classification III).
  
  
  METHODS
  The procedure was undertaken at Banner University Medical Center in Phoenix, Arizona. The local Institutional Review Board does not consider case reports research, and thus its approval was not required.
  
  
  METHODS
  The patients had a history of cervical insufficiency. The first patient (case 1) was a nongravid 32-year-old woman with 2 late second trimester pregnancies delivered by cesarean section owing to cervical insufficiency. The second patient (case 2) was a 26-year-old woman in her sixth pregnancy with 4 previous second trimester losses due to cervical insufficiency, including a failed McDonald cerclage.
  
  
  METHODS
  Robotic-assisted abdominal cerclage placement was performed in both patients. The procedure used an 8-mm, 0° scope; an 8-mm, 30° scope; monopolar scissors; and Maryland bipolar graspers. Following a complete survey of the pelvis and abdomen, the cervicouterine isthmus was identified bilaterally. The anterior leaflet of the right broad ligament was entered sharply, and the dissection was carried out in small increments to ensure safety and hemostasis. The right uterine artery was identified and skeletonized. The left broad ligament was entered in a similar fashion. Once a bladder flap was developed, a gentle wiping technique allowed for mobilization of the bladder from the vesicouterine junction with excellent hemostasis. In case 1, a uterine manipulator was used to flex the uterus. In case 2, a laparoscopic paddle device was introduced gently to allow for mobilization of the gravid uterus. An avascular tunnel was created on both sides of the cervicouterine isthmus, thereby eliminating the need for the Mersilene tape needle. Thus, a needleless Mersilene tape was introduced into the tunnel formed previously. In our opinion, the ideal knot placement is in the posterior cul-de-sac, as shown in the nongravid uterus. However, in the gravid uterus, owing to the difficulty of access, the knot was placed anteriorly, and reperitonization was performed. Four square knots were sufficient, with the snug (but not too tight) Mersilene tape at the cervicouterine isthmus. In both cases, there was minimal blood loss with no complications. In addition to these 2 operations, robotic-assisted transabdominal cerclage was successfully performed in another 21 patients.
  
  
  CONCLUSIONS
  A needle-less robotic-assisted laparoscopic technique can be performed safely and effectively in both gravid and nongravid patients.
authors.affiliation: Banner University Medical Center, University of Arizona College of Medicine, Phoenix, Arizona. Electronic address: swwcjm@mac.com.
authors.forename: Jamal
authors.initials: J
authors.lastname: Mourad
authors.affiliation: Banner University Medical Center, University of Arizona College of Medicine, Phoenix, Arizona.
authors.forename: Yechiel Zeev
authors.initials: YZ
authors.lastname: Burke
mesh_terms: D000005:Abdomen / Q000601:surgery*; D000328:Adult; D001956:Broad Ligament; D023802:Cerclage, Cervical / Q000379:methods; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000379:methods; D017410:Practice Guidelines as Topic; D011247:Pregnancy; D011262:Pregnancy Trimester, Second; D065287:Robotic Surgical Procedures; D016896:Treatment Outcome; D055988:Uterine Artery / Q000503:physiopathology / Q000601:surgery*; D002581:Uterine Cervical Incompetence / Q000503:physiopathology / Q000601:surgery*
keywords: Abdominal cerclage; Cervical incompetence; Cervical insufficiency; Gravid; Nongravid; Pregnancy loss; Robotic-assisted cerclage