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Published:January 12, 2020DOI:https://doi.org/10.1016/j.ajog.2020.01.005
      The Multicentre Randomised Controlled Trial of Transabdominal Versus Transvaginal Cervical Cerclage (MAVRIC) trial allowed clinicians to perform open or laparoscopic procedures. It is interesting that none of the investigators in this UK national trial chose a laparoscopic approach.
      We disagree that there is a better cosmetic result because women will require a cesarean delivery (performed through the same scar), and therefore, a laparoscopic approach would end up resulting in more skin scarring. Laparoscopic surgery generally takes longer, and a limiting factor for many of our investigators is theater time. Most of our women only stay 1 night and return to normal activities quickly; therefore, the stated recovery advantages of laparoscopy may be modest in this group of relatively young fit individuals.
      A more important issue would be efficacy and safety. The National Institute for Health and Care Excellence UK reported in January 2019 an interventional procedure guidance (IPG639, generally used when a new procedure has uncertain risks and benefits) on this laparoscopic approach.

      Laparoscopic cerclage for cervical incompetence to prevent late miscarriage or preterm birth. Interventional procedures guidance. Jan. 30, 2019. Avaiklable at: www.nice.org.uk/guidance/ipg639. Accessed January 2020.

      When reviewing all available evidence, they found success (live birth/neonatal survival) to be equivalent between laparotomy and laparoscopic cases (89%). The evidence base of benefit now sits with the laparotomy route as used in the MAVRIC trial, and a direct comparison to laparoscopy would be valuable, given the unreliability of nonrandomized comparisons made previously.
      The National Institute for Health and Care Excellence UK reported cases of uterine perforation, bowel and bladder trauma, and vascular injury with the laparoscopic approach, although in only 1% of cases. We agree a laparoscopic approach is reasonable but more direct evidence is required to state it is preferred and equally efficacious and safe; it may not be.

      Reference

      1. Laparoscopic cerclage for cervical incompetence to prevent late miscarriage or preterm birth. Interventional procedures guidance. Jan. 30, 2019. Avaiklable at: www.nice.org.uk/guidance/ipg639. Accessed January 2020.

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