Robotic Cerclage in Advanced-stage Endometriosis

Study objectiveTo show a stepwise surgical technique of robotic-assisted transabdominal cerclage placement in a patient with deeply infiltrative endometriosis.DesignA step-by-step surgical tutorial using narrated video.SettingThe George Washington University Hospital. Local institutional review board approval is not required for case reports (Canadian Task Force Classification III).PatientsA 38-year-old woman with cervical incompetence and a history of infertility with 5 pregnancies accomplished by in vitro fertilization. Pregnancies were as follows: 3 first trimester losses, 1 second trimester loss, and another second trimester loss despite McDonald cerclage placement.InterventionsIndications for transabdominal cerclage placement include a congenital short or amputated cervix, cervical scarring that would prevent a transvaginal approach, and failed prior vaginal cerclage [1]. Robotic-assisted abdominal cerclage placement was performed in a case of advanced rectovaginal endometriosis. Normal anatomy was restored; however, no excision of endometriosis was performed because the patient was asymptomatic and already undergoing in vitro fertilization for infertility. The procedure used a 12-mm camera port through the umbilicus, 2 ancillary 8-mm robotic ports, and a 5-mm assistant port; ¼-inch-width Mersilene tape (Ethicon, Somerville, NJ) was preloaded in the abdomen through the 12-mm port before docking. Survey of the pelvis revealed the presence of advanced rectovaginal endometriosis hindering visualization of the cervicouterine isthmi on the posterior side of the uterus. The preloaded needle was parked on the right parietal peritoneum. Before cerclage placement, retroperitoneal spaces dissection bilaterally was necessary to lateralize the ureters and mobilize the rectum away from the cervicovaginal junction where the cerclage would be placed. Anteriorly, the vesicouterine peritoneum was dissected transversely, and the bladder was dissected off the lower uterine segment. A window was created in the posterior leaf of the right broad ligament lateral to the cervicouterine junction and medial to the ureter. The uterine vessels were then skeletonized, and the needle was placed through the lateral cervical isthmus medial to the vascular bundle going posterior to anterior. The procedure was repeated on the contralateral side with the needle going in the anteroposterior direction. The tape was pulled tightly against the anterior cervical isthmus. The tape ends were tied together posteriorly. There was minimal blood loss with no complications.ConclusionA robotic-assisted abdominal cerclage can be performed safely and effectively in patients with advanced-stage endometriosis.