Fetal endoscopic myelomeningocele repair

Percutaneous minimal‐access fetoscopic surgery for myelomeningocele – not so minimal!

“…describing 19 patients on whom his fetal surgical team in Bonn operated. That report documented high rates of fetal death, iatrogenic hemorrhage, premature rupture of membranes, persistent hindbrain herniation and complications of prematurity, and was accompanied by an editorial by Dr David Shurtleff stating that ‘the extremely high complication rates for mother and infant in this study and the principle of primum non nocere indicate that at this time it is unethical to pursue intrauterine endoscopic myelomeningocele repair in humans until the procedure has been perfected in animals.’ Undaunted, Professor Kohl completed his pilot study of 30 patients in Bonn, and now reports a retrospective series of a subsequent 51 patients operated between July 2010 and June 2013 in Giessen using an approach which has been shaped by his experience. Thus, it would seem that, by this point, the procedure should be optimized and standardized, and its results should be clear.…”

Intrauterine Treatment of Spina Bifida

“…Heavy problems, such as fetal demise, strong trocar site bleeding that required termination of an uncompleted operation, incomplete or even failed patch coverage, oligohydramnios due to port site leaks, premature rupture of membranes, chorioamnionitis, and prematurity as low as 28 weeks have been encountered by groups using the percutaneous approach. [67][68][69] On the contrary, the technique where the uterus is exposed by a laparotomy allows port site control, a noninvasive positioning and fixation of the fetus, and a safe access also in patients with anterior placenta. 63 While in open fetal OSB surgery, the repair is done as postnatally with a three-layer closure (see earlier), the fetoscopic approach adopts simply patches or a direct skin closure.…”

Anesthesia for In Utero Repair of Myelomeningocele

“…77 " Ethical considerations regarding the principal concept of primum non nocere argues that until a procedure is appropriately tested in animals it is unethical to pursue in human trials. 78,79 As the prominence of fetal surgery increases, legal questions will arise. 80 For example, a pregnant patient can currently consent to fetal surgery, but if its efficacy becomes more clear, will she legally be allowed to decline intervention?…”