Journal of Obstetrics and Gynaecology

ISSN: 0144-3615 (Print) 1364-6893 (Online) Journal homepage: http://www.tandfonline.com/loi/ijog20

Robotic-assisted prophylactic transabdominal cervical cerclage in singleton pregnancies T. L. Foster, R. N. Addleman, E. S. Moore & J. E. Sumners To cite this article: T. L. Foster, R. N. Addleman, E. S. Moore & J. E. Sumners (2013) Roboticassisted prophylactic transabdominal cervical cerclage in singleton pregnancies, Journal of Obstetrics and Gynaecology, 33:8, 821-822 To link to this article: http://dx.doi.org/10.3109/01443615.2013.812068

Published online: 12 Nov 2013.

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Date: 07 November 2015, At: 10:40

Journal of Obstetrics and Gynaecology, November 2013; 33: 821–822 © 2013 Informa UK, Ltd. ISSN 0144-3615 print/ISSN 1364-6893 online DOI: 10.3109/01443615.2013.812068

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Robotic-assisted prophylactic transabdominal cervical cerclage in singleton pregnancies T. L. Foster1,2, R. N. Addleman3, E. S. Moore3 & J. E. Sumners2

Downloaded by [Washington University in St Louis] at 10:40 07 November 2015

1St Vincent Women’s Hospital, 2Center for Prenatal Diagnosis and 3St Vincent Hospital, Indianapolis, Indiana, USA

Introduction Advances with surgical robots have reduced some limitations associated with conventional laparoscopy. Research into the use of robotics in gynaecological procedures has found that, with experience, most surgeons report better patient outcomes (Mais et al. 1996) or have outcomes that at least equal those of conventional laparoscopy in terms of conversions, complications, operative time and length of stay (Payne and Pitter 2011). The advent of robotic-assisted surgery and its successful introduction into gynaecological surgery presents an opportunity to increase the efficacy and safety of transabdominal cervical cerclage (Visco and Advincula 2008; Schreuder and Verheijen 2009). Our work has explored the use of transabdominal cervical cerclage in delaying pre-term delivery among select women with cervical insufficiency. Transabdominal cerclage has reported success rates of 85–95% and was associated with significantly increased neonatal survival rates (Hole et al. 2003; Lotgering et al. 2006; Simcox and Shennan 2007; Fox and Chervenak 2008; Umstad et al. 2010; Foster et al. 2011). Transabdominal cerclage has also been associated with lower incidence of pre-term delivery and pre-term rupture of membranes, when compared to the transvaginal route (Davis et al. 2000). Although the transabdominal cerclage approach may be beneficial, it is more invasive than transvaginal cerclage. We have incorporated the use of Robotic-Assisted TransAbdominal Cerclage (RoboTAC) in non-pregnant patients. Our previously reported experience in non-pregnant women suggests that RoboTAC is a safe alternative to the traditional laparotomy, with quicker recovery time (Moore et al. 2012). The improved visualisation and articulated dissection with robotics, along with

the potential for reduced venous bleeding with positive intraperitoneal pressure has led us to investigate RoboTAC in pregnancy. Others have reported case studies of the robotically-assisted procedure with pregnant patients (Wolfe et al. 2008; Fechner et al. 2008). We initiated an institutional review board-approved pilot study to assess the feasibility and safety of RoboTAC utilisation during pregnancy. Here, we briefly discuss the safety trial design, the issues encountered, and our decision to discontinue this study.

Case series A prospective, non-randomised trial was initiated in 2010. RoboTAC was offered to women with a singleton pregnancy for whom transabdominal cerclage was clinically appropriate, i.e. if the patient had one of the following clinical indications: short, congenitally deformed, deeply lacerated or markedly scarred cervix preventing adequate application of vaginal cerclage; or a failed prophylactic vaginal cerclage in a previous pregnancy. After discussion of the transabdominal cerclage procedure and its risks, patients were offered RoboTAC as part of this clinical trial, as an alternative to the laparotomy approach. Any patient who had premature rupture of the membranes, irregular uterine activity, a maternal temperature above 38° Celsius, or fetal anomaly seen on ultrasound, was excluded from the study. RoboTAC was done between 11 and 15 weeks’ gestation using the da Vinci® Surgical System. Preoperative examination and fetal assessment by the principal investigator was a standard part of care. Blood loss was estimated by the anaesthetist, while the operating room staff recorded the procedure time.

Table I. Singleton-patient procedure outcomes. Patient

BMI

Gestational age at TAC (weeks ⫹ days)

Gestational age at delivery (weeks ⫹ days)

EBL (ml)

Anaesthesia time (hours:minutes)

Procedure time (hours:minutes)

Length of stay (hours:minutes)

1 2 3 4 5 6∗ 7∗

22.5 26.1 26.9 26.7 42.4 25.2 29.7

15 ⫹ 1 12 ⫹ 3 13 ⫹ 5 11 ⫹ 5 13 ⫹ 3 13 12

33 ⫹ 5 37 ⫹ 2 33 ⫹ 4 36 ⫹ 4 39 ⫹ 2 34 ⫹ 3 N/A

180 150 200 50 150 100 500∗∗

5:01 3:31 3:08 2:45 3:37 2:52 5:47

4:16 2:55 2:19 1:52 2:37 2:15 5:07

25:23 24:22 25:02 28:52 20:29 54:44 31:31

∗Patient requiring conversion to laparotomy. ∗∗Estimate of blood loss by the anaesthesiologist was 500 ml, but low haemoglobin postoperatively, prompted a two-unit transfusion.

Correspondence: T. L. Foster, 8081 Township Line Road, Indianapolis, Indiana 46260, USA. E-mail: [email protected]

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Seven patients were recruited. Six successfully completed their pregnancy and there was one fetal loss. Procedure outcomes can be observed in Table I. A consistent problem was encountered with access to the upper cervix beyond the extremely soft, enlarged uterus. The procedure was converted to laparotomy in two cases. In one of these, initial camera placement showed that the uterus rode high into the lower abdomen and access to the lower uterus was impossible with a laparoscopic approach. In the other, placement of the cerclage was completed with RoboTAC, but bleeding from a laceration of the posterior broad ligament was encountered and laparotomy was required for control. In this pregnancy, fetal heart rate was normal immediately postoperatively, but was not present the next day. Suction curettage evacuated the pregnancy 2 days later and the cerclage was intact on ultrasound examination 6 weeks later. No other maternal complications were encountered.

Discussion We have demonstrated that the complication rate with laparotomy transabdominal cerclage during pregnancy or RoboTAC in non-pregnant patients (Foster et al. 2011; Moore et al. 2012) is quite low. The current study, even with a small number, showed difficulties with access to the lower uterus and the possibility of laceration of the soft uterus and adnexal structures and that the complication rate with RoboTAC in pregnant patients may far exceed the risks established in our studies cited previously. One can speculate that performance of RoboTAC at a significantly earlier gestation might reduce the problem involving the size and softness of the uterus, but would obviously generate a higher apparent postoperative fetal loss rate because of the naturally occurring losses seen in the 1st trimester. Robotic-assisted transabdominal cervical cerclage (RoboTAC) is an advantageous procedure in the non-pregnant individual, but should be approached cautiously during pregnancy.

Prior presentation Presented at the CAOG Annual Meeting, 17–20 October, 2012, at The Drake Hotel in Chicago, Illinois.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

References Davis G, Berghella V, Talucci M et al. 2000. Patients with a prior failed transvaginal cerclage: a comparison of obstetric outcomes with either transabdominal or transvaginal cerclage. American Journal of Obstetrics and Gynecology 183:836–839. Fechner AJ, Alvarez M, Smith DH et al. 2008. Robotic-assisted laparoscopic cerclage in a pregnant patient. American Journal of Obstetrics and Gynecology 200:e10–e11. Foster TL, Moore ES, Sumners JE. 2011. Operative complications and fetal morbidity encountered in 300 prophylactic transabdominal cervical cerclage procedures by one obstetric surgeon. Journal of Obstetrics and Gynaecology 31:713–717. Fox NS, Chervenak FA. 2008. Cervical cerclage: a review of the evidence. Obstetrical and Gynecological Survey 63:58–65. Hole J, Tressler T, Martinex F. 2003. Elective and emergency transabdominal cervicoisthmic cerclage for cervical incompetence. Journal of Reproductive Medicine 48:596–600. Lotgering FK, Gaugler-Senden IP, Lotgering SF et al. 2006. Outcome after transabdominal cervicoisthmic cerclage. Obstetrics and Gynecology 107:779–784. Mais V, Ajossa S, Guerriero S et al. 1996. Laparoscopic versus abdominal myomectomy: a prospective, randomized trial to evaluate benefits in early outcome. American Journal of Obstetrics and Gynecology 174:654–658. Moore ES, Foster TL, McHugh K et al. 2012. Robotic-assisted transabdominal cerclage (RoboTAC) in the non-pregnant patient. Journal of Obstetrics and Gynaecology 32:643–647. Payne TN, Pitter MC. 2011. Robotic-assisted surgery for the community gynecologist: can it be adopted? Clinical Obstetrics and Gynecology 24:391–411. Schreuder HW, Verheijen RH. 2009. Robotic surgery. British Journal of Obstetrics and Gynaecology 22:510–516. Simcox R, Shennan A. 2007. Cervical cerclage in the prevention of preterm birth. Best Practice and Research in Clinical Obstetrics and Gynaecology 21: 831–842. Umstad MP, Quinn MA, Ades A. 2010. Transabdominal cervical cerclage. Australian and New Zealand Journal of Obstetrics and Gynaecology 50:460–464. Visco AG, Advincula AP. 2008. Robotic gynecologic surgery. Obstetrics and Gynecology 112:1369–1384. Wolfe L, DePasquale S, Adair CD et al. 2008. Robotic-assisted laparoscopic placement of transabdominal cerclage during pregnancy. American Journal of Perinatology 25:653–655.

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