Master Class

Laparoscopic approach to abdominal cerclage


Preterm birth remains a significant cause of infant morbidity and mortality. A well-established cause of preterm birth is cervical insufficiency, which occurs in approximately 1% of pregnancies and up to 8% of recurrent miscarriages and midtrimester pregnancy loss. A cerclage, a purse-string suture around the cervix, is placed to treat cervical insufficiency and, thus, prevent second-trimester loss and preterm birth. While, traditionally, placement of the cerclage was performed via a vaginal route, over the past 50 years, abdominal cerclage has been utilized in cases in which a vaginal cerclage has failed or the cervix is extremely short. The advantage of the abdominal approach is the ability to place the suture at the level of the internal os. Moreover, there is no potential risk of ascending infection and resultant preterm labor or premature rupture of membranes secondary to a foreign body in the vagina, as in the case of vaginal cerclage. There has been a reluctance to perform abdominal cerclage as a first-time treatment secondary to the need for cesarean section, risk of hemorrhage at the uterine vessels, and in the past, the need for a laparotomy.

Dr. Charles E. Miller, a minimally invasive gynecologic surgeon in Naperville, Ill., and a past president of the AAGL.

Dr. Charles E. Miller

With the introduction of a laparoscopic or robot-assisted approach to abdominal cerclage in preterm birth prevention, there has been an upsurge in the popularity of abdominal cerclage as the first-line surgical procedure, especially after a failed vaginal cerclage. In 2018, Moawad et al., in a systematic review of laparoscopic abdominal cerclage, noted slight improvement in neonatal outcomes with laparoscopy vs. laparotomy.

For this edition of the Master Class in gynecologic surgery, I have enlisted the assistance of Jon I. Einarsson, MD, PhD, MPH, who is chief of the division of minimally invasive gynecology at Brigham and Women’s Hospital and professor of obstetrics/gynecology at Harvard Medical School, Boston. Dr. Einarsson is a past president of the American Association of Gynecologic Laparoscopists. He is a very well-known, published clinical researcher and surgical innovator. Dr. Einarsson is the founder of Freyja Healthcare, a privately held medical device company advancing women’s health through innovation.

It is a pleasure and honor to welcome my friend and colleague, Dr. Jon I. Einarsson, to this edition of the Master Class in gynecologic surgery.

Dr. Miller is professor of obstetrics and gynecology in the department of clinical sciences, Rosalind Franklin University, North Chicago, and director of minimally invasive gynecologic surgery at Advocate Lutheran General Hospital, Park Ridge, Ill. Dr. Miller reported that he has no disclosures relevant to this Master Class. Email him at

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