A Transabdominal Cerclage (TAC) is a specialized surgical procedure used to treat severe cervical insufficiency, a condition where the cervix is too weak to remain closed during pregnancy. This weakness can lead to second-trimester pregnancy loss or very preterm birth. The procedure involves placing a strong, non-absorbable synthetic band high around the opening of the cervix where it meets the uterus. This band physically reinforces the upper portion of the cervix to support the growing weight of the pregnancy. The TAC is reserved for the most challenging cases, offering a high probability of successful full-term delivery.
Why the Transabdominal Approach is Necessary
The Transabdominal Cerclage is typically not the first line of treatment for cervical insufficiency. It becomes necessary when a standard transvaginal cerclage (TVC) is unlikely to succeed or is anatomically impossible. The most common indication for the abdominal route is a history of a failed TVC, defined as spontaneous delivery before 28 weeks despite the vaginal stitch being in place. This failure suggests the lower placement of the TVC was insufficient to counteract the pressure of the pregnancy.
Anatomical issues often prevent the effective placement of a TVC, making the abdominal approach the only viable option. These structural problems can result from previous cervical surgeries, such as a loop electrosurgical excision procedure (LEEP) or cone biopsy, which remove significant amounts of cervical tissue. A history of radical trachelectomy, where most of the cervix is removed for cancer treatment, also necessitates a TAC.
The TAC allows the suture to be placed much higher on the cervix, specifically at the cervico-isthmic junction. This junction is the internal opening of the uterus. This superior placement offers a more secure and mechanically effective closure, providing better structural support for the entire length of the cervix. This placement is physically inaccessible through the vagina, justifying the increased invasiveness of the abdominal operation.
Preparing for and Undergoing the Procedure
The timing of the Transabdominal Cerclage is flexible, but it is often performed electively before a patient becomes pregnant, known as an interval placement. Performing the surgery in the non-pregnant state is advantageous because the uterus is smaller and less vascular, which simplifies the surgical field and minimizes potential risks like bleeding. If performed during pregnancy, the optimal window is in the late first or early second trimester, around 10 to 14 weeks of gestation.
The procedure is performed in an inpatient hospital setting under general or regional anesthesia. Traditionally, the TAC was placed via a laparotomy, requiring a small abdominal incision similar to a Cesarean section scar. Modern surgical techniques frequently utilize a minimally invasive approach, such as laparoscopy or robot-assisted surgery. These techniques involve several small incisions, allowing for a faster recovery with less post-operative pain.
During surgery, the surgeon accesses the uterus and identifies the cervico-isthmic junction. A durable, non-absorbable tape, such as Mersilene, is threaded through an avascular space between the uterine vessels and the lower uterine segment. The stitch is pulled taut and tied to create a tight band around the cervix, effectively closing the internal os and providing maximum support. This high placement distinguishes the TAC from a TVC, which is placed lower and can occasionally slip or fail.
Post-Surgical Management and Delivery
Following the placement of a Transabdominal Cerclage, patients undergo a period of recovery that varies depending on the surgical technique used. With minimally invasive methods, the hospital stay is short, sometimes allowing for discharge within 24 hours, and recovery time for returning to regular activities is about two weeks. The long-term management of a pregnancy with a TAC is less restrictive than with a TVC, and patients do not require strict bed rest or significant activity modification.
The presence of the TAC band necessitates a Cesarean section for delivery because the stitch is placed too high on the cervix to be safely removed through the vagina. Attempting a vaginal delivery or trying to cut the stitch from below risks tearing the cervix and causing severe hemorrhage. Therefore, a planned Cesarean delivery is scheduled between 37 and 39 weeks of gestation, once the baby has reached full term.
The synthetic band is left in place after delivery. Since the stitch is not removed, it remains functional for any future pregnancies, eliminating the need for repeat cerclage procedures. This permanence simplifies reproductive planning and offers a reliable, high-success-rate solution for women with a confirmed history of severe cervical insufficiency.