Trans‐broad‐ligament abdominal cerclage versus blind needle‐piercing abdominal cerclage during pregnancy: A comparison of surgical outcomes

Abdominal cerclage can be performed using conventional laparoscopy or robotic assistance, either preconceptionally or during pregnancy, with favorable outcomes.1-3 Blind needle-piercing abdominal cerclage (BNPAC) during pregnancy carries significant risks, including excessive bleeding and inadvertent amniotomy, potentially resulting in pregnancy loss and cerclage failure.3-5 To enhance surgical safety, we developed the trans-broad-ligament abdominal cerclage (TBLAC) technique, which enables clear identification and exclusion of the bilateral uterine vessels. This study compares the surgical outcomes of TBLAC versus BNPAC during pregnancy. A retrospective chart review was performed to compare the surgical outcomes of pregnant patients who underwent TBLAC or BNPAC from July 2012 to October 2024. All surgical procedures were carried out by minimally invasive surgery by five gynecologic surgeons (XG, JN, LC, JBN, or CG) at Baylor College of Medicine affiliated hospitals. Institutional Review Board (IRB) approval was obtained from the Baylor College of Medicine. Patient consent was waived due to the retrospective nature of the study. For TBLAC, following transperitoneal entry and robotic docking, the bladder is dissected caudally to expose the cervix and uterine vessels. A window is created lateral to the uterine vessels through the broad ligament on each side. The vessels are skeletonized, and a tunnel is developed between the cervical stroma and medial aspect of the uterine vessels. A Mersilene tape, prepared with 0-polyglactin or 0-polypropylene sutures, is guided through the windows and tunnels bilaterally, encircling the cervix medial to the vessels (Figure S1). The tape is secured anteriorly at the internal os and reinforced with silk suture (Figure S2). Hemostasis is confirmed. For BNPAC, following abdominal entry, the vesicouterine peritoneum is incised and the bladder is dissected caudally to expose the cervix and uterine vessels. A straightened Mersilene tape needle is inserted and advanced posterior to anterior between the lateral cervix and uterine vessels at the level of the internal os. Once visualized anteriorly, the tape is pulled through. The procedure is repeated on the contralateral side (Figure S3). The tape is laid flat posteriorly and tied anteriorly at 12 o'clock with six demi-clé knots. The tails are secured with silk suture. The pelvis is irrigated, and hemostasis is confirmed. All statistical analysis was carried out using SPSS version 25 (IBM, Armonk, NY, USA) and statistical significance was set at a P valueless than 0.05. The study included 13 patients in the TBLAC group, and 12 patients in the BNPAC group, all with previous second/third-trimester loss or delivery between 20 and 34 weeks; and 21 (84%) patients had failed previous cerclage. Three patients had previous cervical surgery. One underwent trachelectomy because of cervical cancer. Two underwent a loop electrosurgical excision procedure. Baseline characteristics were comparable. Mean operative time was significantly shorter in the TBLAC group (124.2 min vs. 161.2 min, P = 0.007). No significant differences were observed in blood loss (50 mL versus 30 mL), hospitalization (1 day vs. 1 day), delivery outcomes, or neonatal survival. Complications included uterine cramping and spotting in the TBLAC group, and urinary tract infection, wound infection, and ruptured membranes in the BNPAC group (Table 1). Detailed neonatal outcomes for the two groups are presented in Table S1. This study introduces TBLAC as a novel and potentially safer approach for cerclage placement during pregnancy. A key and unanticipated finding was the significantly shorter operative time in the TBLAC group compared with the BNPAC group (124.2 min vs. 161.2 min). This advantage is likely due to the enhanced visualization and anatomical dissection afforded by TBLAC, allowing for precise placement of the cerclage medial to the uterine vessels and avoidance of blind needle passes, thereby reducing the risk of vascular or ureteral injury. The shorter operative time may confer benefits in minimizing maternal and fetal exposure to anesthesia, reducing operative cost, and limiting uterine manipulation—an important consideration in reducing uterine irritability and risk of membrane rupture. Furthermore, TBLAC eliminates the risk of inadvertent amniotomy associated with BNPAC, as demonstrated by one fetal loss due to ruptured membranes in the BNPAC group. Notably, neonatal survival was 100% in both groups, and the outcomes of TBLAC compared favorably with previously published data on laparoscopic abdominal cerclage during pregnancy, further supporting the safety of the TBLAC approach.6 However, several limitations should be acknowledged. The retrospective nature of the study introduces selection bias and limits data completeness, particularly for neonatal outcomes. The small sample size reflects the rarity of indicated abdominal cerclage during pregnancy, reported at 0.05%–0.4%,7, 8 and limits the statistical power to detect differences in secondary outcomes. Lastly, long-term follow up was limited because patients sought continued care at outside institutions. In summary, TBLAC may represent a feasible and efficient approach to abdominal cerclage in pregnancy, offering clear visualization and reduced operative time. Further prospective, multicenter studies with larger cohorts are warranted to validate these findings and better define the role of TBLAC in clinical practice. QY contributed to data curation, formal analysis, visualization, writing—original draft, writing—review and editing, and validation; DYL contributed to writing—original draft, and writing – review and editing; JN, LC, and JBN contributed to writing—review and editing, and surgery; NFBAL and ZG collected the data; XG contributed to data curation, conceptualization, methodology, supervision, project administration, surgery, writing—review and editing, and validation. All authors have read and agreed to the published version of the manuscript. The authors would like to thank Dr. Carl Giesler and the Division of Minimally Invasive Gynecologic Surgery, Baylor College of Medicine, Houston, TX, USA, for surgery assistance. The authors have no conflicts of interest. Data sharing is not applicable to this article as no new data were created or analyzed in this study. FIGURE S1. Trans-broad ligament technology. Figure S2. Tape was tied anteriorly at the 12 oclock position in an appropriate tension. Figure S3. Blind needle-piercing from posterior to anterior. Table S1. Detailed outcomes of newborn in two groups. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.