Document Type : Case Report
1 The Minimally Invasive Gynecological Surgery Unit, Department of Gynecology, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
2 Department of Obstetrics and Gynecology, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
Worldwide, cervical cancer is the third diagnosed
cancer and fourth leading cause of cancer deaths in
We present a case of a pregnant obese patient who previously underwent a fertility-sparing surgery.
A 29-year-old obese woman with body mass index (BMI) of 30.4, para 0, and large for gestational
age (LGA) came to our clinic (S. Orsola-Malpighi
Hospital, Bologna, Italy), in January 2012 for a short
cervical length evaluation. She had a history of oncological surgery for squamocellular cervical cancer
two years earlier (stage I (T1N0M0)). She underwent
a vaginal trachelectomy and laparoscopic pelvic node
dissection in our hospital (S. Orsola-Malpighi Hospital, Bologna, Italy). The follow-up examination was uneventful, and subsequently, she had a spontaneous
conception. Transvaginal ultrasound scanning confirmed a single intrauterine pregnancy at 10 weeks of
gestation. The size was consistent with dates and the
result of nuchal translucency screening, performed
at 11 weeks’ gestation, was normal. Her cervical
length was <1 cm. Because of a virtually nonexistent cervix, we proposed a laparoscopic transabdominal cervical cerclage (LTCC) that was performed at
12 weeks' gestation. Under general anaesthesia, the
patient was placed in dorsal lithotomy position and a
Foley catheter was inserted. No vaginal instrumentation was used. The intervention was done with minimal uterine manipulation and minimal dissection. The
vesico-uterine peritoneum was open and the bladder
was dissected off the lower uterine segment bluntly. It
was pierced the broad ligament medial to the uterine
vessels with a laparoscopic suturing device without
dissecting the uterine vessels. Mersilene band was
placed at uterus at the level of cervical isthmus, and it
was then knotted against the posterior cervical isthmus (
Laparoscopic view of the placement of the suture at posterior cervical isthmus.
Cervical length with cerclage in situ by transvaginal ultrasound.
Uterine suture during caesarean section.
Current management of early stage cervical cancer in most young women consists of
radical hysterectomy or radiotherapy, both of
which will inevitably compromise fertility (
Traditionally, it is performed vaginally, but
there are cases that require an abdominal approach (
In our case, both lymphoadenectomy and cerclage were performed by laparoscopy, even in obese patients. In the past, obesity was considered a relative contraindication to operative laparoscopy. Many currently available studies have demonstrated that laparoscopy is not only safe and practicable, but it achieves the same results as open technique. Moreover, as compared with the open procedure, the laparoscopic approach results in fewer operative complications, faster recovery and less need for pain medication. The decreased risk of adhesion formation is another major advantage of minimally invasive approach which may guarantee the achievement of a spontaneous future pregnancy.
Therefore, it should be particularly appropriate for obese women (
The main complications of laparoscopic cerclage are miscarriage and preterm labour. Other
ones described are preterm premature ruptures
of membrane, chorioamnionitis, and uterine
rupture. Burger et al. (
Trachelectomy is a safe treatment to preserve fertility in selected women with early stage cervical cancer. Conception rate is high, but premature delivery caused by cervical insufficiency is common. Traditional treatment consists of placing a vaginal cerclage around cervix through an abdominal approach. Laparoscopic cerclage is a valid alternative to laparotomic procedure. It offers the benefits of reduced post-operative pain, faster recovery and fewer adhesions. It can be left in situ for women who desire a future pregnancy, while it is safe and feasible even in obese women.