Laparotomy-Assisted 2-Port Fetoscopic Repair of Spina Bifida Aperta: Report of a Single-Center Experience in Paris, France

Abstract

Background: Given the maternal morbidity of open fetal surgery, the development of prenatal fetoscopic repair for spina bifida aperta (SBA) is encouraged. Objective: We hereby report the early results from our center, using a laparotomy-assisted CO2-fetoscopic approach. Methods: This study was conducted in patients with an SBA<T1 and >S1, <26 weeks’ of gestation, with Chiari II. Fetoscopic repair was performed using 2 operating trocars in the uterus exteriorized through a transverse laparotomy. Endoscopy was performed under humidified and heated CO2 insufflation. Following dissection of the lesion, a 1-layer approach was performed with a muscle/skin flap sutured over a patch of Duragen. Main outcomes were watertight repair at birth and the need for postnatal neurosurgical surgery including shunting within 6 months. Results: Of 87 women assessed for prenatal therapy, 7 were included. Surgery was performed at 24 (23-26) weeks’ gestation. There was no fetal demise. Conversion to hysterotomy was not performed, although surgery could not be performed in one case because of fetal position. Severe preeclampsia developed postoperatively in one case. In the other 6 cases, follow-up was uneventful except for premature rupture membranes which occurred in 3/6 cases at 30, 34 and 36+5-weeks’ gestation. Gestational age at delivery was 32+5 (31-36+5) weeks’ gestation. Repair was watertight at birth except in two cases which required complementary postnatal surgical repair. Reverse hindbrain herniation during pregnancy was observed in 4/6 cases. In 3/6 cases, shunting was necessary within six months after birth. At 12 months, a functional gain >= 2 metameric levels, was observed in 3 cases of the 6 survivors Conclusion: Laparotomy-assisted fetoscopic repair is a reasonable option for women who choose and are eligible for antenatal surgery, both in terms of maternal and perinatal morbidity.

Implementation and Assessment of a Laparotomy-Assisted Three-Port Fetoscopic Spina Bifida Repair Program

“…To report on our experience and then based on the IDEAL recommendations confirm the replication of the safety of this hybrid fetoscopic method, as already reported by other centers [22,23]. Other studies report the outcome of small groups of patients (seven cases, one case) but do not describe the implementation of the surgical approach or the establishment of a multidisciplinary team [24,25]. As part of our training, we were supervised directly by experts from the fetal team of TCH; in addition, essential requirements had to be met prior to the start of the surgery to join the consortium [20].…”

Development of a double‐layer electrospun patch as a potential prenatal treatment for myelomeningocele

“…[5][6][7] The latest advance in prenatal surgical repair is to close the defect by fetoscopy, a minimally invasive technique that reduces maternal and foetal morbidity of in utero open surgical repair. 4,[8][9][10] Although foetal surgical repair has been shown to reduce the risk of hydrocephalus and possibly improve lower limb motor function, it can only be performed after skin keratinization (i.e., after 20 weeks). However, given the progression of neuronal loss beginning early in foetal life, 11 a procedure performed earlier in pregnancy would significantly improve the outcomes of prenatal repair.…”

“…Several studies have shown that prenatal coverage of the defect improves neurological function and reduces morbidity from hydrocephalus and Arnold–Chiari II malformation by reversal of hindbrain herniation 5–7 . The latest advance in prenatal surgical repair is to close the defect by fetoscopy, a minimally invasive technique that reduces maternal and foetal morbidity of in utero open surgical repair 4,8–10 . Although foetal surgical repair has been shown to reduce the risk of hydrocephalus and possibly improve lower limb motor function, it can only be performed after skin keratinization (i.e., after 20 weeks).…”