**5. Cervical cerclage suture placement techniques**

Cervical cerclage is defined as the placement of a suture in the cervix to maintain the pregnancy, which can be done through a transvaginal or transabdominal surgical approach. The two transvaginal techniques for ligation are the modified McDonald and the Shirodkar but without finding superiority of one over the other technique. Also, no superiority of one type of non-absorbable suture over another has been found, so the type of suture is freely chosen by the clinician. In the McDonald surgical technique, a simple non-absorbable suture is placed circularly in the cervix at the level of the cervical junction. Retrospective studies have found no benefit in placing a second suture to reinforce or reconstruct the cervical mucosa.

The Shirodkar technique involves the preparation and detachment of the cervical mucosa from the cyst in order to place the suture as close as possible to the height of the internal cervical os. To achieve this, the bladder and rectum are prepared and detached from the cervix, a non-absorbable suture is placed as close as possible to the internal cervical os, and the knot is then covered with mucosa [36–42].

Transabdominal suture placement at the level of the cervical isthmus is preferred in women in whom there is an indication for suture placement but the transvaginal approach is not possible due to anatomical problems (such as after cervical ectomy) or failure of transvaginal suture placement Transabdominal suture placement can be performed either open or laparoscopically depending on the surgeon's clinical experience.

Usually transabdominal banding is done at the end of the first trimester or at the beginning of the second trimester (between 10 weeks and 14 weeks of pregnancy) or before pregnancy and can remain between pregnancies in cases where the delivery is completed by cesarean section [36–42].
