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Re: Advanced dilitation and previable tripletsFrom: DoctorJoe@aol.comTue Apr 30 11:18:28 1996
<<Joe Can you elucidate on the modified shirodkar technique? Rick>> The way we do it is to advance a bladder flap, similar to but not as extensive as with a vaginal hyst (this is where the detractors of the procedure say it's too bloody - if you have okay hands, it's NO BIG DEAL) and place a 5 mm Mersilene strip around the cervix about as high as you can. I usually make a little 'poke hole' in the vag epithelium posterior to the cervix, about at the level of where you can feel the uterosacrals come in - I use this for a target. Then I use a suture doubly armed with large BLUNT needles, and slide the needles first on one side and then the other, from the bladder flap area UNDER the "bladder pillars", around the cervix (under the epithelium but not into much of the body of the cervix, avoiding the possibility of ROM), coming out through the little poke hole posteriorly. Tie the suture down snuggly (test the cervical os with your finger to make sure it's closed enough) and cut off the needles. Use a 2-0 or 3-0 poly suture to reapproximate the bladder flap over the suture anteriorly. Leave the knot exposed posteriorly, so it can be cut near term and the suture pulled. I believe this is described in Plauche's book, Operative Obstetrics, by Saunders. I do it this way to avoid repeated sticks into the cervix, avoid the chance of poking the membranes, avoid a lot of exposed suture, and avoid round suture (as opposed to the 5 mm tape) cutting through soft tissue. If you get this nice and high, you get EXCELLENT 'reformation' of a long cervix. Joe P
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