Laparoscopic cervico-isthmic cerclage with Berci fascial closure needle

The laparoscopic abdominal cerclage is an established approach in the management of selected cases of cervical insufficiency. The main challenge is to safely insert the cerclage at the level of cervico-isthmic junction, medial to the uterine vessels. This narrated video demonstrated the step-by-step laparoscopic cervico-isthmic cerclage technique using a handheld Berci fascial closure needle to accurately place the suture, medial to the uterine vasculature.

Cervico-isthmic or abdominal cerclage was first introduced in 1965 and since then has demonstrated high success rate with low complications.1 The laparoscopic approach was first described in 1998 and the key aspect of the technique is the suture placement, medial to the uterine vessels at the level of cervico-isthmic junction, although a modified approach placing the suture lateral to the vessels had been described.2 Most authors use a straightened needle to thread the suture through a posterior or anterior approach.3 Here, we present a technique using a Berci (fascial closure) needle to apply a polyester tape from posterior to anterior, medial to the uterine vessels (video 1).

The patient was a 30-year-old female who had two previous midtrimester miscarriages. She underwent an ultrasound indicated cervical cerclage at 23 weeks of gestation in the third pregnancy and delivered vaginally at 34 weeks. This, however, was complicated by a circular cervical laceration leaving a very short cervix, precluding a repeat cervical cerclage. She was counselled and planned for an interval laparoscopic abdominal cerclage.

The key steps in the surgical technique are:

1. The uterovesical peritoneum was opened and the dissection extended laterally to identify the uterine vessels.

2. A Berci needle was introduced through a small incision just above the symphysis pubis and used to puncture the uterus anteriorly, medial to the uterine vessels, exiting at a point about 1.5 cm above the uterosacral ligament.

3. The needle was then used to grasp a 4 mm polyester tape (Cervix set, SMI AG, Belgium) with the needles removed, pulling it anteriorly (figure 1).

4. The procedure was later repeated on the other side.

5. Finally, the tape was tied anteriorly, flattened onto the cervix and the uterovesical reflection reapproximated.

The patient had an uncomplicated pregnancy a few months after the cerclage and delivered via a planned lower segment caesarean section at 37 weeks of gestation .

Compared with the traditional technique of using a straightened cerclage needle, handholding a Berci fascial closure needle allows easier and direct needle manipulation, ensuring a precise suture placement medial to the uterine vessels at the cervico-isthmic junction.