Fetal Surgery

Abstract

Fetal surgery has emerged from the realm of medical curiosity into an exciting, multidisciplinary specialty now capable of improving patient outcomes for a wide variety of diseases. Recent advances allow prenatal providers to both accurately diagnose and treat many fetal anomalies while maintaining maternal safety. As the initial postnatal health care providers to the majority of these newborns, neonatologists need to be familiar with some of the more recent state-of-the-art procedures currently being used. In this review, the authors discuss the prenatal evaluation process and various operative approaches (ie, open hysterotomy, fetoscopy, and percutaneous) to conduct fetal surgery. They then analyze the effectiveness of some of the more established and experimental prenatal therapies that are being performed for a number of fetal anomalies, including twin-twin transfusion syndrome, thoracic malformations, airway obstruction, congenital diaphragmatic hernia, myelomeningocele, and aortic valve stenosis.

A Large Animal Model of the Fetal Tracheal Stenosis/Atresia Spectrum

“…Additionally, since pregnancy may be allowed to continue after a given procedure, the absence of endotracheal intubation combined with the unique healing properties of the fetal environment enhance the remodeling and epithelialization of the repaired area. Because certain forms of tracheal anomalies are incompatible with postnatal life, different forms of fetal intervention for the treatment of these diseases are often justified [33].…”

Current Status of Fetal Cardiac Intervention

“…2 Recently, however, interest in FCI has accelerated. 3–18 As with other fetal interventions, 19,20 FCI can only become a highly useful clinical tool if it is applied to conditions in which a feasible mode of therapy is available and either the fetus is at risk for demise as a result of the condition or intervention may alter the evolution of the condition such that the severity of the postnatal disease is substantially reduced (Table 1). For conditions in which the fetus is at high risk for prenatal or neonatal death, the rationale for FCI is obvious, to improve survival.…”

Fetal surgery for neural tube defects

“…Minimising the incision size associated with open fetal surgery may reduce uterine irritability, preterm labour and the need for tocolytics, while improving the safety of vaginal delivery 23. Animal models also suggest that the compromised uterine blood flow and uteroplacental oxygen delivery associated with open fetal surgery would be avoided with a fetoscopic approach 24.…”

“…The fetal deaths in both series were considered complications of the procedure, rather than disease progression; consequently, in the USA, the fetoscopic approach was abandoned in favour of open repair 18. Nonetheless, future advances in fetoscopy and robotic surgery, as well as improved prevention of preterm labour will hopefully reduce the risks associated with fetal MMC repair 23. As this remains the only current fetal surgery for a non-lethal condition, it has generated vigorous debate about the overall risk-benefit ratio to the mother and infant.…”