Unusual pleuroamniotic shunt complication managed using a two-port in-CO2 fetoscopic technique: technical and ethical considerations

Fetal interventional procedures and surgeries: a practical approach

The identification of congenital birth defects and fetal malformations continues to increase during the antenatal period with improved imaging techniques. Understanding of how to treat specific fetal conditions continues to improve outcomes from these treatment modalities. In an effort to further improvement in this field, we provide a review that begins with a brief background of fetal surgery including the history of fetal surgery, ethics surrounding fetal surgery, and considerations of how to treat the fetus during intervention. A synopsis of the most commonly encountered disease processes treated by fetal intervention/surgery including definitions, treatment modalities, and outcomes following fetal intervention/surgery is then provided. Within the sections describing each disease process, methodology is described that has helped with efficiency and success of procedures performed at our institution.

Low-Fidelity Simulator for the Standardized Training of Fetoscopic Meningomyelocele Repair

BACKGROUND

Fetoscopic meningomyelocele repair in a gas-filled uterus is a new technique performed in very few centers. There are few opportunities as well as ethical prohibitions on the initial development and subsequent refinement of innovative fetal surgery techniques in humans, and using an animal model is both very expensive and logistically difficult.

METHOD

We developed a low-fidelity endoscopic fetal surgery simulation using a plastic doll and pieces of chicken breast to simulate a fetal meningomyelocele, and a polyurethane ball to simulate a gas-filled uterus, along with a standard endoscopy system and instruments.

EXPERIENCE

A unique two-port technique with significant differences from the standard laparoscopic surgery procedure was developed and refined through an iterative phase into a standardized methodology, and the simulator was then used to train three other teams to perform standardized fetoscopic meningomyelocele repair.

CONCLUSION

A low-fidelity fetoscopic surgery simulator is a useful tool for developing new fetoscopic operations and for training multidisciplinary fetal surgery teams without the need for extensive use of an animal model. This simulator may be used to further explore the human uterus as a new surgical space for additional fetal surgeries.

Ethical issues in fetal therapy

The introduction of routine fetal ultrasound and the technical improvements in ultrasound equipment have greatly increased our ability to diagnose fetal anomalies. As a consequence, congenital anomalies are diagnosed today earlier and in a greater number of patients than ever before. The development of fetal intervention and fetal surgery techniques, improved anesthesia methodology, and sophisticated perinatal care at the limits of viability, have now made prenatal management of some birth defects or fetal malformations a reality. The increasing number of indications for fetal therapy and the apparent desire of parents to seek out these procedures have raised concern regarding the ethical issues related to the therapy. While fetal therapy may have a huge impact on the prenatal management of some congenital birth defects and/or fetal malformations, because of the invasive nature of these procedures, the lack of sufficient data regarding long-term outcomes, and the medical/ethical uncertainties associated with some of these interventions there is cause for concern. This chapter aims to highlight some of the most important ethical considerations pertaining to fetal therapy, and to provide a conceptual ethical framework for a decision-making process to help in the choice of management options.