A model for fetal surgery through intrauterine endoscopy

doi:10.1016/0022-3468(94)90268-2

Journal of Pediatric Surgery

Volume 29, Issue 8, August 1994, Pages 1007-1009

https://doi.org/10.1016/0022-3468(94)90268-2 Get rights and content

Abstract

Video-endoscopic technology may offer new hope for the future of fetal surgery. Ten time-dated pregnant ewes (95 to 105 days; term, 145 days) were used to develop a model of fetal surgery through intrauterine endoscopy. Special 5-mm ports were designed with short, flexible, balloon-tipped shafts. The cannulas were inserted through purse-stringed hysterostomies. Amnioinfusion of warmed physiological fluid (Hartmann) was used as the work medium. Fetal heart rate and oxygen saturation (pulse oximetry), temperature, and amniotic pressure were monitored continuously through endoscopically placed sensors. Surgical procedures included subcutaneous dissection of the abdominal wall and ligation of the urethra in the male fetus (n = 7), ligation of the urachus within the umbilical cord (n = 8), and endoscopy of the fetal esophagus and trachea (n = 6). Bloodless surgery was achieved with a novel coagulation device that allows bipolar cutting and coagulation in an electrolyte-rich fluid medium. The mean fetal operative time was 147 minutes (range, 130 to 195). The intraamniotic temperature was maintained between 38.0 ± 0.9°C and 41.7 ± 1.7°C throughout the procedure. Oxygen saturation ranged from 51 ± 20% to 72 ± 14%, and fetal heart rate from 120 to 140 beats per minute. In conclusion, intrauterine endoscopy in a fluid medium allows fully monitored surgical procedures, lasting more than 2 hours, to be performed on the fetal lamb.

References (18)

JM Sackier
Laparoscopy in pediatric surgery
J Pediatr Surg
(1991)
JM Estes et al.
Fetoscopic surgery for the treatment of congenital anomalies
J Pediatr Surg
(1992)
MR Harrison et al.
Fetal surgery in the primate I
Anesthetic, surgical and tocolytic management to maximize fetal-maternal survival
J Pediatr Surg
(1982)
NM Fisk et al.
Amnioinfusion increases amniotic pressure in pregnant sheep but does not alter fetal acid-base status
Am J Obstet Gynecol
(1991)
RW Jennings et al.
New techniques in fetal surgery
J Pediatr Surg
(1992)
MR Harrison et al.
Correction of congenital hydronephrosis in utero: I. The model: Fetal urethral obstruction produces hydronephrosis and pulmonary hypoplasia in fetal lambs
J Pediatr Surg
(1983)
SS Miller
Laparoscopic operations in paediatric surgery
Br J Surg
(1992)
JL Alain et al.
Extramucosal pylorotomy by laparoscopy
J Pediatr Surg
(1991)
JA O'Neill
The fetus as a patient
Ann Surg
(1991)

There are more references available in the full text version of this article.

Cited by (46)

What - and why - the pediatric surgeon should know about twin-to-twin transfusion syndrome
2005, Journal of Pediatric Surgery
Endoscopic laser ablation of placental vessels is the most commonly performed fetal operation today. Herein, we review the pathophysiology of twin-to-twin transfusion syndrome and the challenges of its treatment. Pediatric surgeons, with their knowledge of fetal and congenital pathology, and their technical expertise with minimally invasive surgery, can be of great benefit to the patient and the medical team.
Foetal surgery and cleft lip and palate: Current status and new perspectives
2005, British Journal of Plastic Surgery
Citation Excerpt :
The procedure has been later applied in a variety of feto-endoscopic surgical interventions: to create lower urinary tract obstruction,21 to place a transabdominal vesico-amniotic shunt into the foetal bladder in order to rescue renal function threatened by urinary tract obstruction,11 in foetal tracheoscopy-guided transfection or temporary obstruction of the trachea to induce pulmonary hyperplasia17,22–24 and finally, in the covering of myelomeningocele.25–28 Several other reports show widespread acceptance and application of the technique, employed in animal models as well as in the treatment of life threatening malformations in humans.8,10,11,19,29–38 Current research focuses on the feto-endoscopic treatment of congenital diaphragmatic hernia.
Now-a-days, high-resolution ultrasound allows an accurate and relatively early diagnosis of congenital malformations. In a limited number of such conditions foetal surgery may be lifesaving. However, premature labour has been the major drawback for open foetal surgery. Recently, improvement of video-endoscopic technology has boosted the development of operative techniques for feto-endoscopic surgery, which has been demonstrated to be less invasive than the open approach. Main clinical application of fetoscopic procedures today is the treatment of feto-foetal transfusion syndrome.
Although still in development, feto-endoscopic surgery seems to offer new hope for surgical foetal therapy not only in cases of life threatening conditions. Experimental intrauterine correction of cleft lip and palate (CLP) has been lately performed using the feto-endoscopic approach. This procedure offers two major advantages: first, scarless foetal wound healing and bone healing without callus formation, which would also allow a better/normal maxillary growth, and second, significant decrease of foetal and maternal morbidity.
Herein, we report the current status of experimental and clinical foetal surgery and propose possible directions for continuing research to make intrauterine procedures safer. Furthermore, we discuss current knowledge and new perspectives of experimental foetal cleft lip and palate repair, which in the future may lead to such excellent results in the operative treatment of clefts, that less or no secondary corrections and therapies, such as orthodontic, dental, logopedic, etc. would be needed. Only if these conditions can be fulfilled, will we be able to improve substantially our therapy for the human foetus with a cleft lip and palate. In spite of all efforts, however, it must be considered that it may not ever be possible to find the optimal treatment method for this or other craniofacial malformations.
Prenatal management of gastroschisis: The place of the amnioexchange procedure
2003, Clinics in Perinatology
Requirements for fetal surgery: The diaphragmatic hernia model
2000, European Journal of Obstetrics and Gynecology and Reproductive Biology
Fetal surgery for congenital diaphragmatic hernia and other fetal conditions can only be considered if (1) the morbidity of antenatal intervention is acceptable, (2) the diagnosis of the condition can be made accurately, (3) the condition can be differentiated from other, non-surgical anomalies. In addition, (4) the natural evolution of the disease, if left untreated, should be predictable, and the condition should be lethal or severely debilitating, (5) there should not exist adequate postnatal treatment, and (6) the proposed in utero operation should be technically feasible. Open fetal surgery has proven too invasive to be justified for the treatment of diaphragmatic hernia, and progress in postnatal therapy (including ECMO) has dramatically improved the neonatal outcome in all but a severe subgroup of patients. Recently, advances in endoscopic fetal surgery (which appears to be less stressful for the fetus and the gravid uterus) and a new approach to accelerate fetal lung growth and maturation have renewed the feasibility of in utero intervention for diaphragmatic hernia.
Endoscopic fetal surgery: Perspectives
1999, Archives de Pediatrie
L'introduction de nouvelles techniques chirurgicales entraîne volontiers des réactions opposées, d'enthousiasme et de méfiance. Cela a été le cas pour la cœliochirurgie. Ce l'est aussi, de manière sans doute plus aiguë vu la difficulté de la tâche et la rareté des indications, pour la chirurgie fœtale. En effet, si la chirurgie ≪ ouverte ≫ compte quelques succès, le contrôle du stress opératoire et de la tocolyse restent des obstacles majeurs. Pour éviter ces deux écueils, l'abord ≪ mini-invasif ≫ à utérus fermé représente une solution technique élégante. Son efficacité est encore à prouver mais les ≪ cas cliniques ≫ se multiplient. Il restera à déterminer au mieux les critères d'intervention anténatale. Dans beaucoup de cas, ce sera probablement le plus difficile.
“Open” fetal surgery has had little success in the management of fetal malformations, and is limited by two important unresolved difficulties: control of the operating stress on the fetus and maternal tocolysis. The “mini-invasive” approach by endoscopic surgery circumvents these difficulties and appears promising. Decision making with the dilemma between prenatal or postnatal surgery remains critical.
Tracheoscopic endoluminal plugging using an inflatable device in the fetal lamb model
1998, European Journal of Obstetrics and Gynecology and Reproductive Biology
Objective. Intra-uterine tracheal occlusion has been proposed to reverse pulmonary hypoplasia, an important prognostic factor in congenital diaphragmatic hernia. We aimed to evaluate the feasibility and pulmonary effects of tracheoscopic tracheal obstruction with a detachable balloon.
Study design. Fourteen mid-trimester fetuses out of 24 in 13 ewes underwent tracheoscopic balloon obstruction. Ten non-operated fetuses served as controls. Plugging was performed under fiber-tracheoscopy using a detachable balloon. Outcome measures consisted of: total operating time, tracheoscopy time, fetal survival, efficiency of plugging, and pulmonary effects. The Mann–Whitney test and linear regression were used for statistical analysis.
Results. Mean operating time and tracheoscopy time were 65±12 and 6.6±3.9 min, respectively. One intra-operative death occurred in each group. The post-operative mortality was 2/13 for cases and 2/9 for controls. In all 14 fetuses, the trachea was successfully obstructed. In the 11 treated animals born alive, the lung-to-body-weight ratio was 0.060±0.01, while in controls it was 0.031±0.01 (P=0.0001). In a subset of six fetuses obstructed for 14–18 days, mean-terminal-bronchial density was 0.95±0.59, compared to 2.06±0.80 for controls (P=0.046).
Conclusions. Using fetal tracheoscopy, the trachea can successfully be obstructed with an inflatable balloon. Pulmonary hyperplasia is achieved when the obstruction lasts 2 weeks.

View all citing articles on Scopus

^☆: Presented at the 1993 Annual Meeting of the Section on Surgery of the American Academy of Pediatrics, Washington, DC, October 29–31, 1993.

View full text

A model for fetal surgery through intrauterine endoscopy☆

Abstract

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

Am J Obstet Gynecol

J Pediatr Surg

J Pediatr Surg

Laparoscopic operations in paediatric surgery

Br J Surg

Extramucosal pylorotomy by laparoscopy

J Pediatr Surg

The fetus as a patient

Ann Surg