Robot-Assisted Transabdominal Cervical Cerclage With the Hugo RAS System: Surgical Technique and Perioperative Outcomes in a High-Risk Obstetric Case.

OBJECTIVE: Cervical insufficiency, the inability of uterine cervix to retain pregnancy in absence of labor, is a major cause of preterm births and stillbirths. Therapeutic options include expectant management, progesterone, pessaries, or surgical cerclage [1]. Minimally invasive approaches provide several advantages over laparotomy, including decreased blood loss, lower post-operative pain, shorter hospital stay and faster recovery while achieving comparable or improved obstetric outcomes [2,3]. Robotassisted transabdominal cerclage (RA-TAC) is gaining popularity due to the enhanced three-dimensional visualization, improved dexterity and precision in performing fine dissection and knot-tying [4]. This video article demonstrates our RA-TAC technique and setup in a complex patient using the Hugo™ RAS system (Medtronic, Minneapolis, MN, USA) [5].

DESIGN: Step-by-step explanation of surgical technique of RA-TAC in a 40-year-old, BMI 36 kg/m2 patient, with unfavorable obstetric history and desire for further pregnancy.

SETTING: Academic Hospital, IRCCS Policlinico di S. Orsola Bologna, Italy.

INTERVENTION: All possible therapeutic strategies and related complications have been discussed with the patient. Considering her strong desire for pregnancy, her surgical and obstetric history- including prior preterm deliveries despite vaginal cerclage (2020-2021)- and her BMI, a preconceptional RA-TAC was planned. A "straight" port placement in a "compact" docking configuration was installed. Surgery was performed under general anesthesia in 49 minutes. There were no intraoperative or postoperative complications. After 15 months, the patient successfully delivered a healthy 2896g male infant via elective cesarean section at 36+6 weeks, with no need for perinatal care; the cerclage was removed and bilateral salpingectomy was performed.

CONCLUSIONS: Robotic-assisted surgery represents a feasible option for transabdominal cerclage, particularly in patients with obesity or intra-abdominal adhesions. Surgeon ergonomics, three-dimensional visualization, unrestricted range of motion, improved tremor control are key-advantages in procedures demanding maximal precision. While current literature lacks strong evidence demonstrating superiority of robotic-assisted over laparoscopic cerclage, this video illustrates technique, feasibility and potential benefits of RA-TAC.