Tag Archives: george davis

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: Tanesha’s Story

Tanesha’s story is so sadly familiar. After losing three beautiful babies, she’s got her TAC and is ready to try again. Thanks for sharing your experience, Tanesha.

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

I’m about 2 days post-op from my Dr. Davis pre-pregnancy TAC and decided to share my journey up to this point. I have not given up hope and I hope that you will not either. I’m 35 years old and I have 2 children from a prior marriage – a 16 year old daughter and 12 year old son. My husband and I married in January 2010. We conceived twin boys January 2013 on our 3 year wedding trip to NYC and were on top of the moon.

Vacation

Tanesha and her husband on vacation, when the twins were conceived.

At my 20 week anatomy scan it was discovered that my cervix was open and I had to be rushed to L&D. Long story short, I had an emergent cerclage, and since my membranes were already bulging, they then ruptured. After Pprom (preterm premature rupture of membranes) of baby A’s waters and 3.5 weeks on hospital bed rest, I had to deliver them due to infection and they were born too soon. After meeting with specialists and all, it was decided that due to my history, my issue was more related to the fact that I had twins and not my cervix. No one thought that I’d need a preventative cerclage and that it was more risky since it could cause infection. I would only have p17 (progesterone) shots and weekly cervical length checks.

Angels Tyler and Taylor

Tanesha’s beautiful boys, Tyler and Taylor. Photo by NowILayMeDownToSleep photographers.

Taylor and Tyler feet

Taylor’s and Tyler’s perfect tiny feet. Photo by NowILayMeDownToSleep photographers.

It didn’t take me long to get pregnant and I did so 4 months after my loss in October 2013, the same month my twin boys were due. I was so excited and thankful for another chance. I stayed positive. Had affirmations that I posted daily. I started a journal. I tried to drown out my fears with faith and hope. February 17th, I went and did a little shopping. When I got home I noticed some brown spotting. I was 17 weeks and had just had my first p17 injection about 5 days prior and my cervical length at that time was 5 cm. I decided to go to L&D as a precaution even though I felt that I was overreacting. Of course, as soon as I was checked out, the sonographer told me that my cervix was open and she could already see my baby girl’s hand. Heartbreak all over again! I had my baby girl within 24 hours and started the process of grief and disbelief all over again.

I started researching and found Dr. Davis and Dr. Haney. Since Dr. D was less than 2 hours away from me and I had such a good feeling about him I called, did a phone consult, and scheduled my appointment for a little more than 6 weeks from my loss. My husband had this week off already because my stepson is attending Duke this fall and on Monday we had to go down for Duke Blue Devil days in NC. Thankfully Dr. D had the same week open for my TAC. We went down on Thursday for pre-op. It took less than 2 hours and we checked into our hotel, the Hampton Inn on Blackhorse Road, before heading to his office since we were so early. The hospital rate for our stay was $99 and it was nice, clean, and in a good busy area with lots of restaurants. The hospital was about 5 minutes away and easy to find. Dr. D didn’t think we would get GPS coverage in our area, but we did and found it quickly. We used free valet parking and headed up to the 3rd floor for our appointment. We waited about 20 minutes and filled out some paperwork and Dr. D came and got us. We chatted, admired his collection of sodas, and I cracked up at his dry humor and multitasking skills. He asked me what I was going to have for my “last meal.” SMH. That didn’t help my nerves but it still cracked me up. He then walked us down to show us where to come in for surgery the next day. No food or drink after midnight. He gave us some restaurant suggestions and then we were free to go.

Fast forward to Friday. We checked in in the general same day surgery area around 11 am. Be prepared to wait an hour or 2 to actually go back for this part. I paid $100 copay and finally went back. The nurses were awesome in prepping me. They were really sweet and talked to me a lot. They were sweet even though my veins gave them problems (they give everyone problems). They went and got my husband and explained how everything would work, and then I finally went back around 2:30 or so for the surgery. I did not see Dr. D beforehand and I was knocked out almost immediately from general anesthesia. When I woke up, they wheeled me to recovery and I felt pretty good. I was not really loopy after getting to my room. I was a little hungry but not starving and I was on a liquid diet for 24 hours. My husband said that Dr. D came up to him and told him, “Piece of cake” and shook his hand. That was his post-surgery report in true Dr. D fashion. Lol. The next day after having the catheter removed I did some walking around, had a post-surgical ultrasound, and Dr. D gave me a summary of his reports and helped me with aftercare instructions. We then hit the road and came back home.

Post op selfie

Tanesha’s post-op selfie.

I am feeling a lot better than I thought I would. Besides having D&Cs after each loss, I had never had major surgery so I was pretty freaked out and worried. I felt in good hands and I am glad about my decision. I still have worries about conceiving after the TAC, etc., but I feel like this was necessary to move on. I’m 35 now and I would like to have to my rainbow as soon as possible. Dr. D gave us no restrictions. We can start TTC (trying to conceive) as soon as we feel up to it. I was actually ovulating when he did my ultrasound the day before the surgery (which I already knew) so hopefully things will stay intact and I will bounce back to my normal schedule soon. Sorry that this post was so long but I wanted to share my experience. Wish us luck on our new journey of TTC with the TAC and remember to stay strong and never give up on your dreams!

Thank you to Dr. D

Tanesha saying thank-you to Dr. Davis post-op.

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: 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.