S'abonner

Isthmic retroperitoneal cerclage via vNOTES as a potential alternative to an abdominal cerclage: First technique description. - 25/01/23

Doi : 10.1016/j.jogoh.2022.102518 
J Baekelandt a, b,
a The Department of Obstetrics and Gynecology, Imelda Hospital, Bonheiden, Belgium 
b KU Leuven-University of Leuven, Department of Development and Regeneration, Faculty of Medicine, Group Biomedical Sciences, UZ Herestraat 49 - box 902, 3000 Leuven, Belgium 

Corresponding author.

Abstract

Objective

To describe a new technique for performing an isthmic retroperitoneal cerclage via vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES).

Design

Stepwise explanation of the surgical technique using original video footage. This study was exempted from requiring hospital IRB.

Setting

Department of Obstetrics and Gynaecology, Imelda Hospital, Belgium.

Intervention

A circumferential vaginal incision is made around the cervix after infiltration of the tissue with local anaesthetic and adrenaline. The bladder is deflected from the cervix up to the level of the isthmus but the peritoneum is not opened. The rectum is deflected from the cervix up to the level of the isthmus but the peritoneum is not opened. A Gelpoint vPath (9.5 cm) (Applied Medical, Rancho Santa Margarita) is used as a vNOTES port. The inner ring of the Alexis is inserted into the retroperitoneal dissection space around the cervix, covering the bladder anteriorly and the rectum posteriorly. An insufflation stabilization bag (ISB) is connected to the Gelseal cap to minimize pressure fluctuations within the confines of the retroperitoneal operative space. The paracervical space is opened just inferior to the uterine artery. A paracervical tunnel is made from the anterior to the posterior retroperitoneal space just lateral to the cervix and just inferior to the uterine artery. This procedure is performed bilaterally. A vessel loop is inserted from anterior to posterior through the paracervical tunnel on each side of the cervix. The Gelseal cap is removed and an Ethibond-2 suture is tied to the vessel loop. The Gelseal cap is placed again. By pulling on the vessel loop, it is replaced by the Ethibond suture. The Ethibond suture is now tied endoscopically to complete the cerclage; alternatively the suture could be tied vaginally without endoscopic instruments to the surgeon's preference. The vNOTES port is removed and the vaginal mucosa is sutured to the cervix again using a resorbable suture.

Discussion

Abdominal cerclage is the preferred approach to treat patients with refractory cervical insufficiency [1]. Over the last 20 years this technique increasingly gets performed laparoscopically with similar success rates [2]. The new transvaginal approach demonstrated in this video article may help reduce the invasivess even more by avoiding abdominal incisions and opening the peritoneum, while still benefiting from the vNOTES endoscopic visualization and minimally invasive instruments [3]. The cerclage is placed permanently at the level of the isthmus, similar to an abdominal cerclage. It is placed more cranially than a McDonald or Shirodkar cerclage and leaves no non-resorbable sutures in the vagina [4]. It can be an alternative to a conventional transvaginal cervicoisthmic cerclage [5, 6] in patients with a narrow vagina and without uterine descensus. Following the guidelines of the IDEAL collaboration we present this technique to be peer reviewed in its early developmental phase before starting further studies [7].

Conclusion

This is a first feasibility and technique description report on performing a retroperitoneal isthmic cervical via vNOTES. This technique should be considered new, not to be performed on pregnant patients or outside of clinical trials, and only in carefully counselled patients.

Le texte complet de cet article est disponible en PDF.

Keywords : vNOTES, Cerclage, Cervical insufficiency, Preterm birth, McDonald, Shirodkar



© 2022  Publié par Elsevier Masson SAS.
Ajouter à ma bibliothèque Retirer de ma bibliothèque Imprimer
Export

    Export citations

  • Fichier

  • Contenu

Vol 52 - N° 2

Article 102518- février 2023 Retour au numéro
Article précédent Article précédent
  • Impact of Enhanced Recovery After Surgery (ERAS) program in gynecologic oncology and patient satisfaction.
  • Sara Fernandez, Béatrice Trombert-Paviot, Tiphaine Raia-Barjat, Céline Chauleur

Bienvenue sur EM-consulte, la référence des professionnels de santé.
L’accès au texte intégral de cet article nécessite un abonnement.

Déjà abonné à cette revue ?

Mon compte


Plateformes Elsevier Masson

Déclaration CNIL

EM-CONSULTE.COM est déclaré à la CNIL, déclaration n° 1286925.

En application de la loi nº78-17 du 6 janvier 1978 relative à l'informatique, aux fichiers et aux libertés, vous disposez des droits d'opposition (art.26 de la loi), d'accès (art.34 à 38 de la loi), et de rectification (art.36 de la loi) des données vous concernant. Ainsi, vous pouvez exiger que soient rectifiées, complétées, clarifiées, mises à jour ou effacées les informations vous concernant qui sont inexactes, incomplètes, équivoques, périmées ou dont la collecte ou l'utilisation ou la conservation est interdite.
Les informations personnelles concernant les visiteurs de notre site, y compris leur identité, sont confidentielles.
Le responsable du site s'engage sur l'honneur à respecter les conditions légales de confidentialité applicables en France et à ne pas divulguer ces informations à des tiers.