Tag Archives: arthur haney

TAC Variations

When you think of a procedure like the TAC (transabdominal cerclage), you may think that it is a standardized operation. In fact, each surgeon has his or her own techniques, informed by their teachers and developed over their years of experience. So while there are some basics that are common to all TACs, the procedure itself can actually vary quite a bit.

So what are the defining characteristics of a TAC? What makes a TAC a TAC? Technically, there’s only one:

A TAC must be placed via an abdominal incision. If a surgeon tells you a TAC can be placed vaginally, he/she is either misleading you or very much mistaken. Either way, steer clear. A TAC is a transABDOMINAL cerclage, and can only be placed through an abdominal incision.

For the record, when I say “TAC” throughout this blog, I mean a cerclage that is placed via an abdominal incision and tied as a band around the internal os of the cervix at the cervicoisthmic junction. This has been proven to be the most effective form of TAC so far, although any cerclage that is placed through an abdominal incision is technically a TAC.

There are several areas where TACs differ:

Incision

Remember, this incision is NOT on your uterus, only on the outside. We’ve established that all TACs must be placed abdominally. Traditionally, this has meant through an open incision in the abdomen (laparotomy). Most of the time the incision is a low transverse incision — a horizontal line at about the level of your pubic hairline. Sometimes, however, there might be a reason for a vertical incision. If a surgeon does all of his placements vertically by default, I personally might consider seeing somebody else, as that type of incision makes recovery more difficult (in addition to creating a nasty scar). Sometimes a Pfannenstiel type incision has been used, but that is not as popular these days. Alternately, many surgeons now place TACs laparoscopically, or via several tiny incisions in the abdomen. This can be done with or without the DaVinci robot, but the incisions should be about the same regardless.

Here are a few examples of incisions:

Jill Donald Davis in-preg traditional almost 3 yrs

This is my scar, on my soft, stretch-marked 3 pregnancy belly. Dr. Davis in-pregnancy traditional TAC, September 2012. This scar has been used for TAC placement and 2 c-sections. 3 years post-TAC, 2.5 years post c-section #1, and 6 months post c-section #2.

Haney pre preg almost 2 months

This is a Dr. Haney traditional pre-pregnancy TAC at about 2 months post-op.

Haney 4 weeks

This is a traditional Dr. Haney TAC at 4 weeks post-op. Dr. Haney is able to make a very small incision for pre-pregnancy TACs and TACs on smaller women, but keep in mind that your OB will very likely use the same incision for your c-section, so it will be bigger anyway.

Davis pre preg traditional 1 month

This is a traditional Dr. Davis TAC at 1 month post-op.

Paraiso RoboTAC 3 months

This is a Dr. Paraiso RoboTAC, 3 months post-op. She has older scars as well; the arrows point to the TAC scars.

Scibetta in-preg lap TAC 3 yrs

Dr. Scibetta lap TAC, 3 years post-op. After 3 years and 2 c-sections, she says this scar on her right side is the only incision you can still see.

Material

There are three possibilities here:

    • 5 mm mersilene tape. This is probably the most common option. Mersilene is a nonabsorbable braided polyester suture. It is sterile, inert, and nonreactive, so it should be able to stay in your body indefinitely without causing any problems. It’s incredibly strong, and could essentially support the weight of a grown man jumping on it.
Mersilene Tape In Situ

5 mm mersilene tape in situ. From http://www.kjkhospital.com/CaseStudyDetails.aspx?nid=24

    • Neonatal/IV tubing. I only know of this being used in Australia. Tubing — either neonatal tubing or IV tubing — is used the same way as mersilene tape. As far as I know, success rates are similar.
Dr. Alexander Neonatal Tubing TAC

A TAC placed by Dr. Alexander in Brisbane using neonatal tubing.

  • Nylon suture material. This is not recommended. It is strong, but much more likely to erode into the tissue of your cervix.

Suture Type/ Knot Placement

Some surgeons use curved needles to thread the band behind the cervix, but some prefer to use a more blunt instrument like clamps. Most surgeons placing a TAC traditionally tie the knot posteriorly (behind the cervix), I believe, to avoid problems with bladder adhesions and irritation. (One paper I read said tying the knot posteriorly allows the TAC to be removed, theoretically, through the vagina in a procedure called a culdotomy, in which the vaginal wall is cut in order to access the knot via the rectouterine pouch. I have never heard of this being done.) However, the knot is sometimes anterior (in front of the cervix) when placed laparoscopically without the DaVinci robot. The knot is usually a square knot, but surgeons may have their own variations.

Most variations here are minor and don’t make a lot of difference. There are a couple, though, that potentially make a big difference.

  • I have heard of surgeons tying the band lateral to the uterine arteries, instead of medial to them, but that is a mistake (as opposed to a preference), and can lead to erosion into the arteries and bleeding.
  • Some surgeons don’t tie a band around the cervix at all, but instead stitch through the cervix. One example is a surgeon who makes an abdominal incision and places a modified Shirodkar stitch at the internal os. This, in my opinion, should not be done, as it is more susceptible to problems with erosion and more likely to cause damage to the cervix, and ultimately, more likely to fail. If you’re going to undergo major surgery, you might as well have the best, safest solution, which is a band tied around the internal os of your cervix.

Method

This encompasses all the other variations that might exist between surgeons. Some prefer only in-pregnancy, while some only do pre-pregnancy. Some have a strong preference for traditional, laparoscopic, or robotic laparoscopic. There are a lot of different approaches to anesthesia and pain management. Some doctors prefer spinal anesthesia in pregnancy, some always place the TAC under general anesthesia. Some prescribe ibuprofen for pain management, while others tell you never to take ibuprofen in pregnancy. There isn’t a clearly right way to do most of these things, and very experienced, very successful doctors have different opinions. Do your own research and decide who you want to trust based on that.

A Note About TAC Surgeons

When you start looking into a TAC, you will quickly realize that there are a few surgeons who are much more frequently mentioned than others. In the US, those are Dr. Haney, Dr. Davis, and Dr. Sumners (see The Big Three for contact info). When I got my TAC in 2012, all three were equally popular. Since then, Dr. Davis has semi-retired, and more women are seeing Dr. Haney, so the commentary is very much skewed toward Dr. Haney at the moment. While these three doctors have some differing opinions, they are all essentially equally experienced, and all have the same very high success rates. As far as the Big Three go, you’re in good hands all around, but I’ve been hearing some disturbing comments to the effect that Dr. Davis (or Dr. Sumners, or any other doctor) does it “wrong,” and therefore their TACs fail more often. That’s pure nonsense, so if you hear such a thing, don’t let it worry you.

My real point here is that there is no “right” or “best” surgeon, only the best one for you. If you have time, shop around. See who your insurance covers, and figure out if you can or want to travel. There are a lot of things to consider when you choose your surgeon. Here are a few:

  • How far are you willing to travel?
  • Does he or she accept your insurance?
  • How much experience does he or she have?
  • Does he or she prefer laparoscopic, traditional, or robotic assisted laparoscopic? (If you have a preference.)
  • What type of material does he or she prefer to use?
  • What are his or her stats? Success rate?
  • How comfortable are you with him or her?
  • Will he or she be available to answer questions after surgery/during pregnancy? Will he or she consult with your OB/MFM/perinatologist?
  • Does he or she offer an out-of-pocket rate? (if your insurance will not cover the procedure, you may save money by traveling cross country or even out of country to a doctor who offers an at-cost option)

These are all questions you’ll need to ask yourself and your doctor. As far as experience goes, you’ll have to remember that not all doctors can have 20+ years of experience placing TACs. Some of them will be less experienced, and that’s okay. With several of our beloved TAC doctors nearing retirement, more and more women will have to see these less experienced surgeons, which, of course, is how they gain experience. Also, no two doctors do any procedure the exact same way. They each put their own spin on it, and are constantly trying to improve their own performance. Some use mersilene, some use neonatal tubing. Some place one band, some place more. There are a hundred variations, and no “right” version. We all want the very best doctor when our baby’s lives are at risk, but placing a TAC is actually a relatively simple procedure. If you find yourself in a situation where it makes sense to you to see a surgeon with less experience, there might be some additional things to think about. Personally, if I were going to have my TAC placed by a newer surgeon, I would want 1) a traditional open placement, and 2) an in-pregnancy placement. Here’s my reasoning: 1) a traditional placement allows an inexperienced surgeon a more open field and better visualization. He or she can feel the tension of the band and the knot. 2) This one seems counter-intuitive, but according to at least one study, it’s more difficult to get the correct tension on the band when placing it on a non-pregnant cervix. Since the cervix swells during pregnancy, placing it in-pregnancy means that you already know what size it will be. Placing it before than can lead to the band being too loose or too tight, both of which can cause the TAC to fail. These are probably more cautious than necessary, and if your convenient local doctor only does pre-pregnancy lap-TACs, you will do just fine. Going with the method your doctor feels most comfortable performing is probably more important than any specific type of placement. If you have any questions, please feel free to email me (Jill) at tac.questions@gmail.com.

The Big Three

Here’s the most basic contact information for the big three TAC doctors in the US. I’ll keep updating this post as I get new information. If you are specifically looking for a doctor in California, I keep a list of all of the doctors I know of who do TAC/TVCIC in the state, and everything I know about them. Email me at tac.questions@gmail.com for more information.

Arthur Haney
Pre-pregnancy and in-pregnancy TAC, placed traditionally (laparatomy, no laparoscopy)

Currently practicing in Chicago.

ahaney@babies.bsd.uchicago.edu

Center for Reproductive Medicine and Fertility
333 S. Desplaines Street
Suite 201
Chicago, IL 60661
Office: (773) 702-6127
Appointments: (773) 702-5161

The University of Chicago Medicine
5841 S. Maryland Avenue, MC 2050
Chicago, IL 60637

George Davis
Pre-pregnancy and in-pregnancy TAC, placed traditionally and laparoscopically via DaVinci robot; In-pregnancy TVCIC

Dr. Davis has retired, sadly, and is no longer practicing in either New Jersey or Tennessee.

askdrdavis@aol.com

 

 

James Sumners
Pre-pregnancy and in-pregnancy TAC, placed traditionally and laparoscopically via DaVinci robot; In-pregnancy TVCIC

Currently practicing in Indianapolis.

james_sumners@yahoo.com
FB: https://www.facebook.com/DrJamesSumners

Center for Prenatal Diagnosis
8081 Township Line Rd, Indianapolis, IN 46260
(317) 415-8070

Keep in mind, there are other very good surgeons who place the TAC and TVCIC. These three have the most experience of them all, but that doesn’t mean you have to see one of them. Also, please remember that all three of these surgeons are incredibly busy. I have no idea how they do all the work that they do, let alone have a life. They save hundreds of babies every year, so don’t get too frustrated if they don’t get back to you immediately, or even if you don’t get a response. It’s not because they don’t care. They care so much and they help such a huge number of women that sometimes emails or phone calls slip through the cracks. I promise you, they’re doing their best. If it’s critical that you reach them as soon as possible, usually calling is a better option.

Stories of Strength: Colleen’s Story

My second Story of Strength is from Colleen. These are two posts from her blog, nvoutbackwoman.wordpress.com. Colleen is currently 16 weeks pregnant with her rainbow baby and doing well. Thanks for sharing, Colleen! I hope you have an uneventful pregnancy, and will look forward to an update when you have that baby!

If you’d like to share your story, please send it and any pictures to tac.questions@gmail.com.

Broken Hearts

Well, it’s been a while since I posted, and a lot has been going on in our lives since July. Shortly after my last post, and before we moved into the house, we found out we were pregnant. We were both so excited and a little bit nervous. Though my intuition told me earlier, at 18 weeks, we found out we were having a little girl. Besides a little nausea and some heartburn, my pregnancy was going well. We picked out the sweetest bedding at Pottery Barn, a neutral tan color with little owls, and planned a shower for February. I read about the best ways to prepare for a baby, and cut out anything remotely questionable out of my diet. I talked to her all the time, telling her how beautiful and smart she was and how much fun we would have together.

However, on December 8th when I was 23 weeks pregnant, I started not feeling well. I felt cramps, similar to menstrual pains, and saw a tiny bit of blood, so I decided to go to the hospital just to ease my fear. B was at work, so I drove myself. They told me everything looked good. The baby was kicking up a storm, and her heart rate was perfect. The nurse told me I was probably dehydrated, and they discharged me.

All that night the cramping continued, and started to become more painful. Around 6am I returned to the hospital, feeling like there was still so,etching wrong. The nurse finally checked my cervix, and ran out of the room. Another nurse came in and while she rapidly hooked me up to an IV, she told me I needed to call my husband and he needed to get there ASAP. With tears in my eyes I asked her if I was dilating. She told me I was completely dilated and was going to have the baby soon. I was not prepared for this.

After that, everything happened quite fast. B and a friend of mine arrived shortly after my OB, who gravely told me this was not good. He said he suspected that I had a condition called incompetent cervix, and would need a cerclage in future pregnancies. Basically my cervix could not handle the weight of a growing baby, and opened prematurely. He did an u/s to see how our baby was positioned. She was breech with the cord around her neck. The hospital called a special neonatal team to fly in from out of state, and they delayed her birth until after they arrived. Suddenly there were people everywhere, talking to me about viability, asking how much we wanted done. They said they would life flight her to Utah, but that I couldn’t go, though B could. I prayed that God would let me keep my baby.

He did not. After a few pushes, my beautiful baby girl was born. I remember the second they cut the cord and she was forever separated from me. B followed her to the room where they tried to get her to breathe. A few minutes later a solemn woman came in to talk to me. She didn’t have to say anything, but she told me they did all they could. My heart was ripped in two. I hated my body, my doctor, and the nurse that sent me home the night before.

They brought her in to us shortly after, I was not ready to see her and was crying hysterically. She was so perfect, I did not understand how this could be happening. Her skin was still so warm and she was bigger than I thought. She had long legs and fingers, downy hair, and her daddy’s ears. We named her Addison Grace.

The next several days were a blur. We learned how to make funeral arrangements, post an obituary, and how to tell people our daughter was dead.

She will always be our daughter, our firstborn child, and I will always think about the beautiful little girl, and then woman, she would have become. When we have more children, God willing, they will know about their sister.

Proud New Owner of a Bionic Cervix

We left for Chicago on April 12 and spent the weekend enjoying the city before my surgery Monday morning. We checked out the Bean, the Art Institute and had cocktails on the 96th floor of the Hancock Building after a cubs game.

Monday morning we took a cab to the hospital, driving by the incredible Museum of Science and Industry. We really need to go back, there’s so much to do there! The hospital itself was beautiful, brand new, and very modern. I checked-in at a huge white desk and the lady gave me a little buzzer…I joked we must have gone to the Cheesecake Factory by accident. They also had a large screen your loved ones could track your location with (like the airport arrivals board). Pretty cool, but a little impersonal too. We waited quite a while before my buzzer buzzed. Another lady’s had at the same time and as we walked back, she showed me pictured on her phone of her car, which had just been squished by a pile of bricks that randomly fell off of a building. “You never know when it’s your time,” she joked. Thanks….

Once they pulled me back, they made Brady wait in a smaller room while I was prepped. I had to change into the gown and stash all of my stuff into a garment bag. They took my vitals and placed my IV, then let Brady back in. The anesthesiologist came in and asked me a million questions and made me so much more nervous. I was terrified of going under general (thanks to an episode of Grey’s where Mandy Moore never wakes up) and we discussed a spinal instead. They explained the risks were comparable with both and I finally decided to go ahead with the general. The residents also came in and talked to me, and one, Dana, I think, was super sweet and helped me relax. The resident with the anesthesiologist was in ortho and I jokingly forbade him to touch my bones. He was kinda cute and I realized he (and everyone else) would see me naked and unconscious soon…. lovely. Dr. Haney came in there at some point and lightly chided the anesthesiologist (who was actually starting to grow on me) for making me nervous. He explained the whole procedure again and told Brady I wouldn’t remember much for a while after I woke up.

They then started to wheel me into the OR. Brady got to walk a little of the way before they shoo’d him away. Then they had me move to the table and “spread my arms like Jesus.” That part is a little hazy. Then the anesthesia resident put the mask over my face, but it was all weird, like crooked and over my eye. I was making faces so Dana was like, “No dummy, put it this way” and fixed it. Haha she didn’t say that exactly, but you could hear it in her voice. It was much more comfortable and I took a few deep breaths and next thing I know I’m waking up in recovery.

Everything was unbearably loud to me. The monitors beeping, other people talking, the enormous lady they wheeled by that kept hollering. The recovery nurse noticed I was wincing and apologized for how loud the lady was. She then started asking me how I was feeling and explained the PCA pump (push button pain meds). She told me to push it and let me know how it felt. It made me nauseous almost instantly so she unhooked it and called over the anesthesiologist. He was annoyed they gave me the drug they did (dilaudid) as I told them Vicodin makes me feel sick, and it usually reacts similarly. He also asked me if I’d heard about the Boston bombings (which happened while I was out). I was like “ummmmm no… I was unconscious?” It took forever to get a new PCA and then when it finally came, the nurse couldn’t get it to work. At this point poor Brady was wonder what the heck was happening to me. Dr. Haney had come and told him the procedure went well right after surgery, but no one told him why I was stuck in recovery for so long.

Finally they got me to my room. I was thrilled to be somewhere quiet, and Brady was finally called to come up with me. The room was quite large, and had a small room with a computer and a sink attached that made it even more private and insulated from the hallway. The view of the skyline was lovely. Nurses came in and out all evening and I slept most of the time while Brady watched movies. I was excited to eat as there was a Jamba Juice downstairs (we dont have one in our town), so he got me one and I drank a good deal of it. The next morning they said I should try and get up, and they removed my IV and catheter (super fun). The first time I sat up I thought I might throw up from the pain. It was intense

I was discharged that afternoon and we took a cab back to the hotel. There was a beautiful fruit arrangement waiting for me courtesy of my wonderful aunt. It tasted great to me, despite the crazy gas pains I started feeling. Apparently air builds up in your stomach when they open you up and it’s not so fun. We headed to bed early, as we had a flight early the next morning. I told the airport I needed assistance and popped a Percocet when we got there, so the airport is a bit of a blur.

I’ll post more regarding my recovery later, this is enough for now 🙂

Colleen

Colleen & Dr. Haney