the majority of patients diagnosed with incompetent cervix can be treated successfully with a transvaginal cerclage .
a select group of patients who have failed the vaginal approach , or have extremely short cervices , anatomically deformed cervix , deeply lacerated cervices , or severely scarred from previous failed vaginal cerclages may benefit from the transabdominal approach .
the patient is a 36-year - old african - american woman ( gravida 2 , para 2 , aborta 0 , last menstrual period 4/1/03 ) referred from our maternal fetal medicine division for consideration for laparoscopic cerclage .
the patient had a previous laparoscopy at age 20 with normal findings . on physical examination , the cervix was normal in appearance , the vagina was normal , and on bimanual examination the uterus was midposition and normal size , shape and contour with some uterine descensus .
the patient was taken to the operating room after extensive counseling as to possible laparotomy and bleeding and underwent laparoscopic placement of an abdominal cerclage using a 5-mm mersilene band as is the usual suture used by our maternal fetal medicine ( mfm ) division .
this included placing the 5-mm mersilene band around the internal os of the cervix , tying the knots anteriorly , and suturing 2 0 silk suture to the cut mersilene to prevent any unraveling ( figure 1 ) .
( a ) placing suture ; ( b ) tying the suture ; ( c ) completed suture : mersilene and silk ; ( d ) showing posterior placement ; ( e ) end of case after irrigation .
she had some first trimester bleeding at 8 weeks in which the vaginal ultrasound confirmed cardiac activity .
the patient 's prenatal course was significant for chronic hypertension , an abnormal glucose tolerance test that was diet controlled with fastings less than 100 and 2-hour postprandials consistently less than 120 .
she began kick counting at 28 weeks and non stress tests were begun at 33 weeks .
an elevated creatinine level was noted at 33 weeks and decreasing creatinine clearance was noted , for a diagnosis of preeclampsia .
the patient was brought to the medical university of south carolina for bedrest and evaluation at 34 weeks .
she underwent a low transverse cesarean delivery after lung maturity was confirmed , that day delivering a 5 pound 12 ounce female infant , apgar 8/9 .
the patient tolerated the surgery well , and the infant and mother went home on postoperative day 3 , doing well .
certainly , the usual treatment for women at risk for cervical incompetence is a cerclage placed transvaginally . when this approach has failed , or when this approach is not possible because of anatomic deformities , a transabdominal cerclage is a viable option . data clearly show an improved fetal survival rate compared with fetal survival in untreated pregnancies .
the advantage of the abdominal approach is placement of the suture at the internal os with decreased movement .
the obvious disadvantage is the need for 2 or even 3 laparotomies ( although some skillful nonlaparoscopic surgeons have managed to remove these sutures through a colpotomy , most can not ) should the fetus succumb in the second trimester .
one must always keep the patient and fetus ' health first , and if unable to succeed laparoscopically , must be prepared to perform the abdominal cerclage via laparotomy to complete the procedure .
 abdominal cerclages are necessary when the standard transvaginal cerclages fail or anatomical abnormalities preclude the vaginal placement . 
 the disadvantage of the transabdominal approach is that it requires at least 2 laparotomies with significant morbidity and hospital stays . 
 we discuss a case of abdominal cerclage performed laparoscopically . 
 we feel it offers less morbidity and in the proper hands eliminates or significantly shortens hospital stays . 