FOR IMMEDIATE RELEASE
MESA, Ariz. – November 1, 2026
The Marchand Institute for Minimally Invasive Surgery is proud to announce the publication of the largest analysis ever assembled on transabdominal cervical cerclage in the American Journal of Obstetrics & Gynecology (AJOG). Known across the specialty as the Gray Journal, AJOG has been published continuously since 1920 and is the most widely read journal in obstetrics and gynecology. The Institute regards this paper as the most significant publication in its history.
The paper, “Surgical and Obstetric Complications of Transabdominal Cervical Cerclage by Laparoscopic, Open, and Robotic Approaches: A Systematic Review and Meta-Analysis,” appeared online as an Article in Press on November 1, 2026 (DOI 10.1016/j.ajog.2026.10.040).
Read the Study
Official journal page: ajog.org, Articles in Press
DOI: 10.1016/j.ajog.2026.10.040
PubMed: PMID 42967520. The protocol was prospectively registered with PROSPERO (CRD420261422920) and the review was reported to PRISMA 2020 standards.
Authors: Greg J. Marchand, MD; Daniela Gonzalez Herrera, MD; McKenna Robinson, BS; Brooklynn O’Connell, BS; Dakota Anderson; Sarah Mera, BS; Adriana Palma, BS (Marchand Institute for Minimally Invasive Surgery, Mesa, Arizona); Fatima Ibrahim, MD (Fayoum University, Egypt); and Ali Azadi, MD (University of Arizona College of Medicine Phoenix and Creighton University School of Medicine Phoenix).
Why Abdominal Cerclage Matters
Cervical insufficiency is the painless opening of the cervix in the middle of pregnancy. It affects an estimated one in every 100 to 200 pregnancies and is responsible for a disproportionate share of second-trimester losses and extremely premature births. The standard treatment is a cerclage, a strong stitch placed around the cervix to hold it closed. Most cerclages are placed through the vagina. When that approach has already failed, or when the cervix is too short, scarred or surgically absent to hold a stitch, the suture must be placed higher, at the junction of the cervix and the uterus, from inside the abdomen. That operation is a transabdominal cerclage.
For most of its history the transabdominal cerclage required open surgery, a laparotomy, often twice in one pregnancy once the cesarean delivery is counted. Over the last two decades laparoscopic placement, through incisions a few millimeters wide, and more recently robotic placement have spread widely. The randomized MAVRIC trial settled that abdominal placement beats a repeat low vaginal cerclage in these women. What it did not settle is the question every one of these patients and their surgeons now face: by which route?
A Question the Institute Has Been Asking for Sixteen Years
Dr. Marchand’s involvement with this operation predates the Institute. In 2010 he and the late Dr. Richard Demir presented a laparoscopic cervical cerclage performed in an 18-week pregnant uterus at the Society of Laparoendoscopic Surgeons and the British International Congress of Obstetrics and Gynaecology, and published the technique as a training video. In 2023 Rutgers New Jersey Medical School incorporated that technique into its OB/GYN core competencies curriculum, a recognition the Surgical Review Corporation highlighted at the time.
The Institute has also published on the evidence behind the operation twice before: a 2021 meta-analysis of complications in the Journal of Minimally Invasive Gynecology (PMID 33249271) and a 2022 meta-analysis of efficacy in the European Journal of Obstetrics & Gynecology and Reproductive Biology (PMID 35042177). Like every other synthesis in the field, those reviews compared the laparoscopic literature with the open literature as two separately pooled bodies of evidence. The new AJOG paper was built to ask a narrower question: does the difference between those two pools hold up when the routes are compared inside the same studies? It does not. The separately pooled method cannot establish an advantage for either route, and the within-study evidence does not show one.
Study Design and Methodology
The team searched PubMed, Cochrane CENTRAL, Web of Science and Embase from August 1, 2020 to June 12, 2026, carried forward every eligible study from the previous review, and screened citation lists. Eligible studies were observational studies and trials reporting complications of abdominal cerclage by laparoscopy, laparotomy or robotic assistance with five or more patients per arm. Screening was duplicate and blinded, complication counts were taken from the source full texts against a written schema, risk of bias was assessed with instruments matched to each study design, and certainty was graded separately for the comparative and the absolute questions.
The search returned 822 database records, 440 once duplicates were removed, and 67 reports were included. After four overlapping reports were withdrawn, 63 studies with 70 study arms (38 laparoscopic, 28 open, 2 robotic and 2 mixed) and 5,094 unique women were analyzed, with 66 arms contributing to at least one pool. The primary analysis was restricted to the six studies that reported both abdominal routes within the same study population, 317 pregnancies in all, because only those studies can answer whether one route is safer than another. All six were non-randomized and all six were judged at serious risk of bias with ROBINS-I.
Key Findings
- No detectable difference between routes. Across the six comparative studies and 317 pregnancies, total fetal loss gave a risk ratio of 0.83 (95% CI 0.19 to 3.64) and a risk difference of -1.5 percentage points (-6.5 to +3.6) for laparoscopic versus open placement. Second-trimester loss gave a risk ratio of 0.97 (0.21 to 4.46). The intervals are wide enough to include clinically important differences in either direction, so this is not evidence of equivalence. Certainty for every comparative estimate was very low.
- Major hemorrhage and uterine perforation were uncommon after laparoscopic placement. No major hemorrhage was reported in 1,889 laparoscopic procedures across 22 arms, which places the upper limit of that risk at 0.20 percent. The open literature that reported hemorrhage at the prespecified threshold pooled at 2.0 percent correction-free and 5.3 percent with a continuity correction (10 events in 300 procedures). The paper draws no comparison from those descriptive pools: within the studies that compared the routes directly, major hemorrhage and uterine perforation had no event in either arm, so no risk ratio could be estimated.
- Pregnancy loss is not uncommon. In the descriptive single-route series, total fetal loss was 7.46 percent (5.43 to 9.88) after laparoscopic placement and 8.90 percent (6.33 to 12.28) after open placement in the correction-free model. A conventional continuity-corrected model gave estimates 0.5 to 3.3 points higher, and seven-fold higher for uterine perforation, which is why the paper reports both.
- The apparent advantages in earlier reviews do not reproduce. Differences in hemorrhage and second-trimester loss between the separately pooled laparoscopic and open literatures were not reproduced when routes were compared within cohorts. Four of the six comparative studies sit inside the largest previous synthesis in the field (83 studies, 3,398 women), which reported that no study compared the routes directly. The comparison was never absent; it was dissolved, because a study reporting both routes enters a separately pooled analysis as two single arms.
Clinical Takeaways
Women who need a transabdominal cerclage can be told that in nearly two thousand reported laparoscopic procedures not one major hemorrhage was recorded, and that uterine perforation was likewise uncommon after laparoscopic placement. They should also be told that roughly one pregnancy in twelve was still lost after an abdominal cerclage, by either route, and that no route has been proven to lower that risk. Route selection cannot be justified by comparative complication data, which do not exist in sufficient quantity. It should follow surgical expertise, individual anatomy and the timing of placement, weighed alongside the efficacy evidence and the patient’s own preference. The study also sets out what the field needs next: not more single-arm series, but reports from centers performing both operations, with arm-level numerators and denominators for each complication and the thresholds, definitions and timing stated.
“This is the largest body of evidence ever assembled on abdominal cerclage, and its message for women is reassuring and sobering at the same time,” said Greg J. Marchand, MD, FACS, FACOG, FICS, lead author and Director of the Marchand Institute for Minimally Invasive Surgery. “Not one major hemorrhage was reported in 1,889 laparoscopic procedures. Pregnancy loss is a different story: roughly one pregnancy in twelve was still lost, and no route has been shown to change that. Women deserve to hear both halves of that sentence.”
“For twenty years our field compared the laparoscopic literature with the open literature and declared a winner, and I include my own earlier reviews in that,” Dr. Marchand added. “When you count only the studies that compared both routes in the same patients, the advantage disappears into the uncertainty. That does not mean the routes are equal. It means nobody has proven the difference, and we should stop saying we have. I have spent most of my career placing these stitches through incisions the size of a fingernail, and I believe in the approach. What I believe more is that patients deserve to be told what the data actually show.”
On the question of how surgeons should choose, Dr. Marchand said: “Choose the route your surgeon does best, in the anatomy in front of you, at the point in pregnancy you are in, weighed with the efficacy evidence and what the patient wants. That should decide, not a comparison of two separate pools of literature.”
Acknowledgements
The Institute thanks Daniela Gonzalez Herrera, McKenna Robinson, Brooklynn O’Connell, Dakota Anderson, Sarah Mera and Adriana Palma of the Marchand Institute research team, and co-authors Fatima Ibrahim of Fayoum University and Ali Azadi of the University of Arizona College of Medicine Phoenix and Creighton University School of Medicine Phoenix. The Institute is also grateful to the editors and reviewers of AJOG, whose five rounds of rigorous review made this a considerably better paper. The study received no external funding, and the authors declare no conflicts of interest.
About the Marchand Institute
The Marchand Institute for Minimally Invasive Surgery is a 501(c)(3) tax-exempt non-profit research and educational institution based in Mesa, Arizona (EIN 42-2857240). The Institute produces peer-reviewed systematic reviews and meta-analyses in minimally invasive gynecologic surgery and women’s health, conducts FDA clinical trials, and trains surgeons through an SLS-accredited fellowship. All reviews are prospectively registered with PROSPERO and reported to PRISMA standards. The Institute accepts no pharmaceutical or medical device industry funding and declares no conflicts of interest. It is directed by Greg J. Marchand, MD, FACS, FACOG, FICS, a dual board-certified minimally invasive gynecologic surgeon, the first Master Surgeon in minimally invasive gynecology accredited by the Surgical Review Corporation in the United States, a member of the U.S. Department of State’s Fulbright Specialist Roster, and the holder of a Guinness World Record and two World Record Academy records for minimally invasive procedures.
For more information on our surgical fellowships or to view our library of research, please visit MarchandInstitute.org.
Media Contact
Maria A. Sainz, Director of Communications and Media Relations
Marchand Institute for Minimally Invasive Surgery
maria@marchandobgyn.com | (480) 999-0905
10238 E. Hampton Ave., Suite 212, Mesa, AZ 85209
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