Cervical cerclage during pregnancy is an effective treatment for cervical insufficiency with a success rate of approximately 81%-87% when performed vaginally or transabdominally. laparoscopic cervical cerclage was attempted by Lesser et al. in 1998, and to date, 49 successful full-term deliveries with 52 live infants (3 twins) have been reported worldwide with laparoscopic cervical cerclage. This procedure used to be performed with a thick 10-gauge silk or nylon suture, but since the introduction of polypropylene ligatures, the use of ligatures for cervical cerclage has gradually increased. In December 2008, the first laparoscopic cervical ligation with a polypropylene band was successfully performed in a woman with a history of five late miscarriages in a nonpregnant period. The results are reported later. Discussion I. Etiology and risks of cervical insufficiency Cervical insufficiency can arise from congenital anatomical abnormalities of the cervix and after acquired cervical ultra-high-frequency electrosurgical excision procedure (LEEP) or cold conization, as well as from laceration trauma during pregnancy and delivery and gynecological transcervical surgery. The prevalence of cervical insufficiency is about 1%, its preterm birth rate is 3.3 times higher, and it is the cause of 25% of midterm pregnancy miscarriages. According to statistics, nearly 10% of pregnancies are born prematurely, 85% of disabled children and 75% of neonatal deaths are related to preterm birth, which seriously affects the quality of the population and is a problem worth studying. The diagnostic criteria of cervical insufficiency can be summarized as follows: (1) a clear history of multiple spontaneous abortions in midterm pregnancies; (2) no aura symptoms at the time of abortion, no previous painful uterine contractions and disappearance of the cervical canal and protruding amniotic sac; (3) during non-pregnancy, a No. 8 cervical dilator can be placed into the cervix up to the uterine cavity without resistance; (4) during non-pregnancy, hysterosalpingography (HSG) confirms a tubular enlargement of the isthmus; (5) during non- The diagnosis was confirmed by the presence of the first of the above diagnostic criteria and any one of the other four criteria. In this paper, case 1 had two failed transvaginal cerclage due to cervical insufficiency, and the diagnosis was clearly established. Case 2 had a history of five midtrimester spontaneous abortions, which fulfilled the first of the above diagnostic criteria, and the cervical canal was 1.3 cm wide and met the fifth of the other four criteria. Therefore, the diagnosis could be confirmed and the operation was performed. History of cervical isthmus ligation The purpose of cervical isthmus ligation is to strengthen the cervical canal as much as possible, prevent the lower uterine segment from extending the cervical isthmus ligation and dilate the cervical opening, and assist the endocervical opening to bear the gravity of the fetus and fetal appendages in the second trimester; at the same time, postoperative fetal preservation treatment can reduce the uterine fiber tension and lower uterine segment load to maintain the pregnancy. Transvaginal cerclage was introduced by Shirodkar in 1955 and modified by MacDonald in 1957. The procedure is performed at 12-16 weeks of gestation with transvaginal suturing and tying of the endocervix. In practice, the endocervical suture from the vagina often does not reach the height of the endocervix, but is sutured in the middle and upper part of the cervix, therefore, there is a certain failure rate. In order to improve the efficacy of cervical cerclage and reduce complications, in 1965 Benson first reported transabdominal cervicouterine cerclage (TCIC), which is performed over the main ligament and the uterosacral ligament, ensuring that the cervical band is located at the level of the endocervix, and is suitable for patients who have undergone transvaginal cervical cerclage In 1982, Novy reported experience with TCIC using a 0.5-cm wide Mersilene band, which was indicated for patients with cervical laceration, congenital or surgical shortening of the cervix, and for patients with failed transvaginal cerclage. failed vaginal cerclage and progressive cervical loss with intact fetal membranes. The ratio of TCIC to transvaginal cerclage was 1:6 from 1966 to 1980. placed between the avascular zone at the level of the anatomical internal os of the cervix and the uterine artery. Preoperatively, 16 patients had 55 pregnancies (excluding early pregnancy miscarriages) and 42 fetal losses (24% infant gain rate). after TCIC, 16 patients had 22 pregnancies, 19 full-term deliveries, 2 preterm deliveries with good prognosis, and 1 fetal loss (95% infant gain rate) p<0.001. all infants were delivered by cesarean section. Postoperative morbidity and preterm delivery or early water breakage were few. In 1991 Novy re-evaluated TCIC application for 25 years and stated that transabdominal loops were beneficial in patients with extreme shortening of the cervix, congenital anomalies, deep lacerations, and significant scarring that resulted in failure of previous transvaginal loops. 2005 Kjollesdal, Norway, reported laparoscopic application of polypropylene cervical ring ligature ring (Mersilene band) placed in the avascular zone above the junction of the cervix and isthmus, without separation or tunneling through the broad ligament. The steps are simplified, bleeding is minimal, and the live birth rate is 80-95 percent. IV. Advantages and problems of LTCC With the rapid development of laparoscopic techniques in recent years, the surgical operation has become increasingly mature and widely used with good results, and laparoscopic surgical techniques are now increasingly replacing traditional open gynecological surgery. Laparoscopic transabdominal cervicoisthmic cerclage (LTCC) was the first case reported by Scibetta in the United States in 1998. In the same year, Lesser et al. attempted laparoscopic cervical cerclage with success, and since then, successful laparoscopic cerclage during pregnancy has been reported, even during pregnancy. To date, 49 full-term deliveries with 52 live babies (3 twins) and 3 failed cases have been reported worldwide with a success rate of 94%. Laparoscopic cerclage has a very precise anatomical placement of the band at the endocervix, avoiding vaginal foreign bodies compared to transvaginal cerclage and overcoming the technical problems of difficult suturing over scarred and shortened cervix. It is less invasive than open cerclage and has the same results as open cerclage. carter et al. compared 12 cases of laparoscopic cerclage with 7 cases of open cerclage. Patients had at least one history of miscarriage due to cervical insufficiency and at least one failed midterm pregnancy with transvaginal insertion. Live infants were obtained in 75% (12/19) of the laparoscopic annuloplasty and 71% (5/7) of the open group. The success rate of the procedure during pregnancy was 80% (4/5) in the laparoscopic group and 60% (3/5) in the open group, p=1.0 compared to the two groups. therefore, it is evident that laparoscopic loop is a safe and effective alternative to open loop. This method not only prolongs fetal gestation, but is also safe and effective for pregnant women.2 Robot-assisted laparoscopic loop ligation was reported in the United States in 2008, adding a new option to the laparoscopic cervical loop ligation procedure. The robot overcomes the limitations of conventional laparoscopic two-dimensional depth of view and manual manipulation, making the procedure more minimally invasive and equally effective, as well as providing an alternative to traditional open abdomen and rapid recovery during pregnancy with assisted transabdominal loops. However, there are reports of successful laparoscopic removal of the loop tie at 16 and 19 weeks of gestation due to premature water breakage and intrauterine death, and most patients still have a high-risk pregnancy. There is also a tendency for low birth weight babies. It is clear that preconception LTCC can be an effective alternative treatment for patients with cervical insufficiency who have a history of midtrimester miscarriage and failed transvaginal cerclage.