Cervical insufficiency has an incidence of 0.1-1.0% during pregnancy and is one of the causes of miscarriage and preterm delivery in mid- to late-term pregnancies. Cervical cerclage is the main effective treatment for cervical insufficiency, which can prolong the pregnancy and reduce the occurrence of miscarriage and preterm delivery. However, in a small number of patients, after the diagnosis of cervical insufficiency, active management during pregnancy and transvaginal cervical cerclage in the middle of pregnancy, inevitable miscarriage still occurs. What are the options for this group of patients for their next pregnancy? Doctors have another option to solve the worries of similar patients – transabdominal cervical isthmus ligation. Cervical insufficiency arises from congenital anatomical abnormalities of the cervix or after acquired cervical loop electrosurgery (LEEP), cold knife conization (CKC), and cervical lacerations due to pregnancy and delivery, transcervical surgery. Studies have shown that 25% of miscarriages in mid-term pregnancies and 10% of preterm births are associated with cervical insufficiency, mainly in the form of “recurrent mid-term spontaneous abortions without other causes, opening of the uterus without significant uterine contractions, and miscarriage due to bulging amniotic sac”. The principle of cervical cerclage is to strengthen the cervical canal, prevent the extension of the lower uterine segment and dilatation of the cervical opening, and assist the endocervical opening to bear the gravity of the fetus and fetal appendages in late pregnancy. Transvaginal cervical cerclage is usually performed between 12 and 16 weeks of gestation, with the endocervical opening sutured and tied tightly via the vagina. However, the position of the ring is low (often not reaching the height of the endocervix) and the sutures left in the endocervix after the ring are a foreign body in the body, increasing the risk of vaginal infection and chorioamnionitis. Transvaginal cervical cerclage is more difficult if the patient has a short cervix, a cervical laceration, or scar formation. In contrast, transabdominal cervical cerclage is performed by placing the band through the abdomen at the level of the isthmus of the cervix, closer to the level of the internal cervical opening (see figure attached), with a success rate of 85-90%. Therefore, patients with “difficulty in transvaginal cervical cerclage” and “history of failed transvaginal cervical cerclage during pregnancy” can consider transabdominal cervical isthmus cerclage, which has a higher live birth rate due to the placement of the suture closer to the endocervix, and reduces exposure of foreign bodies in the vagina and infection. The latter has a higher live birth rate and reduces exposure of foreign bodies in the vagina, reduces infection, and also leaves the loop in place for the next pregnancy. However, there are risks associated with transabdominal cervical isthmus ligation. Firstly, the band needs to be placed transabdominally, and secondly, the delivery method needs to be a cesarean section. Currently, laparoscopic surgery has become popular, and transabdominal cervical isthmus ligation through laparoscopic surgery is less invasive, has a faster postoperative recovery, and is as effective as open surgery. 2008 saw the introduction of robot-assisted laparoscopic isthmus ligation in the United States, which overcomes the limitations of conventional laparoscopic two-dimensional depth observation and manual manipulation, making the procedure more minimally invasive and equally effective. The greatest complication of the procedure is damage to the adjacent vessels and increased bleeding, which is related to the surgical skill and proficiency of the surgeon. Transabdominal cervical isthmus ligation can be performed before pregnancy or in the early stages of pregnancy (11-14 weeks of gestation). If the gestational week is greater, transabdominal IUD is not appropriate because the uterus is enlarged, making it difficult to operate and increasing complications. In comparison, pre-pregnancy cervical cerclage bleeds less and avoids pregnancy-related complications (e.g., premature rupture of membranes, miscarriage). After transabdominal cervical cerclage, if embryonic abortion occurs during early pregnancy, a curettage can be performed with the cervical cerclage wire intact. If inevitable miscarriage occurs in mid-trimester, the cervical cerclage is removed (transabdominal or transvaginal removal of the cerclage wire in the posterior vaginal fornix) followed by vaginal delivery. In late pregnancy, after the fetus has matured, the removal of the cervical cerclage can be performed at the same time as the cesarean section. If there are plans for another pregnancy, the cerclage can also be left in place, although there is a risk of infection and erosion of the cerclage if the cerclage is left in the body for too long. With all of the above, I believe that you have a preliminary understanding of transabdominal cervical isthmus ligation. In general, transabdominal IUI is more “invasive” than transvaginal IUI, so it is recommended that patients with cervical insufficiency should first consider transvaginal IUI during pregnancy, while patients who have failed transvaginal IUI can choose transabdominal IUI, or choose transabdominal IUI in patients who cannot undergo transvaginal IUI due to short cervix, scarring, or laceration.