Lifesaving Treatments for the Tiniest Patients—A Narrative Description of Old and New Minimally Invasive Approaches in the Arena of Fetal Surgery

Abstract

Fetal surgery has become a lifesaving reality for hundreds of fetuses each year. The development of a formidable spectrum of safe and effective minimally invasive techniques for fetal interventions since the early 1990s until today has led to an increasing acceptance of novel procedures by both patients and health care providers. From his vast personal experience of more than 20 years as one of the pioneers at the forefront of clinical minimally invasive fetal surgery, the author describes and comments on old and new minimally invasive approaches, highlighting their lifesaving or quality-of-life-improving potential. He provides easy-to-use practical information on how to perform partial amniotic carbon dioxide insufflation (PACI), how to assess lung function in fetuses with pulmonary hypoplasia, how to deal with giant CPAMS, how to insert shunts into fetuses with LUTO and hydrothorax when conventional devices are not available, and how to resuscitate a fetus during fetal cardiac intervention. Furthermore, the author proposes a curriculum for future fetal surgeons, solicits for the centralization of patients, for adequate maternal counseling, for adequate pain management and adequate hygienic conditions during interventions, and last but not least for starting the process of academic recognition of the matured field as an independent specialty. These steps will allow more affected expectant women and their unborn children to gain access to modern minimally invasive fetal surgery and therapy. The opportunity to treat more patients at dedicated centers will also result in more opportunities for the research of rare diseases and conditions, promising even better pre- and postnatal care in the future.

Case Report: Fetoscopic Laparoschisis (FETO-LAP)—A New Therapeutic Route to Explore for Fetuses with Severe Diaphragmatic Hernias

“…In our experience, particularly fetuses with left diaphragmatic hernia, presenting with large volumes of herniated liver and bowel within their chest, accompanied by a far posteriorly displaced and distended stomach and preferential streaming of ductus venosus and inferior caval venous blood to the right heart, pose a particularly unfortunate combination of small, poorly perfused lungs, impaired cardiac filling and hypoplasia of left heart structures [3]. This combination may not benefit much from FETO, as the high intrathoracic pressure and the lack of available intrathoracic space do not allow for sufficient lung distension by this approach which may further impair cardiac filling.…”

“…Via the working channel of the fetoscope, the fetal trachea was occluded with a commercially available latex balloon (Figure 2). Guided by maternal transabdominal ultrasound imaging, three additional 11-F-sheaths were inserted into the amniotic cavity and percutaneous partial amniotic carbon dioxide insufflation (PACI) was carried out as previously described [3,7] (Figure 2).…”

Spina bifida aperta

“…Selbst unter Fetalchirurgen wurde lange darüber gestritten, ob man Feten mit SBA überhaupt vorgeburtlich operieren sollegalt diese Fehlbildung doch, trotz ihrer gravierenden, die Lebensqualität zum Teil erheblich einschränkenden Folgen, als grundsätzlich gut überlebbar. So lag der Fokus der Fetalchirurgie ab Anfang der 1980er Jahre bis Mitte der 1990er Jahre aufgrund der zu dieser Zeit größeren Risiken und häufigeren Komplikationen fetalchirurgischer Eingriffe für Schwangere und Kind vor allem auf der vorgeburtlichen Behandlung lebensbedrohlicher fetaler Organerkrankungen oder Kreislaufstörungen [37] Da die mütterliche Sicherheit an 1. Stelle steht, werden Schwangere mit schweren chronischen Erkrankungen des Herz-Kreislauf-Systems, mit Schwangerschaftsvergiftung, schweren Lungen-, Magen-, Darm-oder Nierenerkrankungen, Gerinnungsstörungen, HIV oder bestimmten anderen Infektions-oder Stoffwechselerkrankungen, bzw.…”

“…Hierzu wird nach Zugang in die Fruchthöhle das Fruchtwasser weitgehend abgesaugt und simultan über die Trokare mit Kohlendioxid ausgetauscht (PACI = Partial Amniotic Carbon Dioxide Insufflation) [37]. Die PACI ist die wichtigste Voraussetzung zur Durchführung dieses technisch aufwändigsten minimal-invasiven vorgeburtlichen Eingriffs [77], da nur durch das Operieren in einem gasförmigen Medium ausreichend gute Sichtbedingungen geschaffen werden können.…”

Unidirectional barbed sutures vs. interrupted intracorporeal knots in thoracoscopic repair of congenital diaphragmatic hernia in pediatrics

“…In newborns and children, minimally invasive surgery (MIS) was adopted years ago, following its introduction in adults. This method has evolved from less invasive diagnostic procedures to more sophisticated treatment interventions ( 2 ).…”