Tag Archives: cervical cerclage

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.

Stories of Strength: Brittany’s Story

Brittany, whose cervical insufficiency was compounded by treatments for precancerous cells on her cervix, had her TAC placed as an emergency procedure late in her pregnancy. Unfortunately, the damage was already done. This is one way that a TAC can fail, and one option for how to proceed when it does. Thank you for sharing your story, Brittany. You’re a strong mama, and we wish you the very best.

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

My name is Brittany and this is my story. I was 19 when I found out I was pregnant and while I was happy to find out I was carrying twins, I also had found out I had pre-cancerous cells in my cervix. Due to a weak cervix, I had my twin boys at the gestational age of 24.5 weeks and they had to stay in the NICU for four months. I had to have two surgeries on my cervix and was only left with 9mm functional cervix and was told I am lucky to already have my kids.

Fast forward to 2013, my husband and I wanted to try for another baby because our kiddos are now 5. Remembering what the other doctors said about my cervix, I told my new doctor I would need a cerclage done. I was about 6-8 weeks pregnant when I started to have some bleeding on and off but my cervix was still shut. But I kept insisting bleeding is not normal and my cervix is barely there . . . Unfortunately, at 15 weeks I went into full on labor and that’s when the military doctors FINALLY believed me and my cervical issues. So they rushed me to a hospital in Savannah, GA. I stayed there over night and all contractions stopped. We were referred to Dr. Davis but had to drive up to NJ to be seen for the TAC (trans-abdominal cerclage). Two other doctors said I was too far along to have it done, but Dr. Davis had hope as long as we could get there.

We made it up there and had an amazing surgery. I got to see my baby, got the TAC, and Dr. Davis was amazed at how well it had gone. I went from 9mm to 3cm. He told me it looked great but we weren’t out of the woods yet. Mind you I had been bleeding and while Dr. Davis was doing my TAC, he couldn’t see why I was bleeding/clotting. Sadly, at 18 weeks my waters ruptured which is known as PPROM (preterm premature rupture of the membranes). The TAC did not fail – my cervix never opened – but since I was bleeding, the blood was like sandpaper and tore my membranes. I was told to abort our baby, but I had faith and had heard so many stories of fellow ladies going through the same thing, so I chose to be on strict bed rest. But, on week 19+6 I went into labor and had to go to the hospital. Since my daughter was not at a gestational age where she could survive, Dr. Davis told my doctor to just go in and cut the TAC instead of having a c-section since a c-section would further damage my uterus. I delivered the next day at 20 weeks. The nylon “string” he used is still around my cervix. I am currently trying to see Dr. Davis again to have it removed and get a pre-pregnancy TAC to eventually try again one day for our rainbow baby. It is not a guaranteed fix but I know it will hopefully help get me to a gestational age of a healthy baby. I hope my story can help in some way or give information on some questions you may have. Thank you for reading my story. Please keep your fingers crossed for us that everything goes well in the future and we get our rainbow we so desperately want.