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Fetal Surgery Draft.pptx
- 1. Fetal Surgery Lt Col VK Singh Paediatric Surgeon
- 3. Introduction • Till few yrs back, little could be done for babies in utero with congenital anomalies • Damage to the organ couldn’t be arrested or minimized before birth • Now- Improved imaging including 3D / 4D USG and ultra fast MRI including functional imaging
- 5. Fetal Surgery • Type of surgery that is performed on a developing fetus while it is still in the womb. • Reserved for cases in which the condition is severe and may cause significant disability or death if left untreated • The decision to perform fetal surgery is made on a case-by-case basis, and careful consideration is given to the risks and benefits for both the mother and the fetus • 1982 – first open fetal surgery for obstructive uropathy
- 6. Contraindication • Severe affliction • Other associated life threatening abnormalities • Chromosomal & genetic conditions
- 7. Fetal Surgery Disorder Natural History Benefits Recommended ꝶ CDH Lung Hypoplasia Normal anatomy→Reverse Open /FETO LUTO VUR→HN→Oligohydra→Lung Hypoplasia Removal of Uropathy→Avoids irreversible changes Vesicostomy/VAS/Valve ablation CPAM Lung Hypoplasia→Hydrops Resection Open/Fetoscopic/Aspirate/Las er ablation SCT Vascular insufficiency→Hydrops Resection Open/Laser / Fetoscopy Placenta Circulation anomalies Blood steal Disrupt abnormal anastomosis Laser/RFA CHAOS Lung inflation→Cardiac insufficiency→Hydrops Normal airway Fetoscopic tracheostomy /Valveplasty/EXIT MMC Spinal cord lesion, Hydroceph, ACM, Myeloplegia Prevent destructive effects of amniotic fluid on nerves Open/Fetoscopic repair ABS Amputation/ cord constriction Amniotic band dissection Fetoscopic band release
- 8. Types of FS • Open Surgery • FETENDO (Fetal Endoscopic surgery) • FIGS- IT (Fetal image guided surgery for Intervention or Therapy) • EXIT (Ex Utero Intrapartum Treatment)
- 9. Open Fetal Surgery • Indications • Spina bifida • LUTO • CPAM • Sacrococcygeal teratoma • Other masses • Pros • Good Visualisation • Less Injury • Cons • Maternal Morbidity • Preterm Labour • PPROM • Infection
- 10. Open Fetal Surgery • Mother – GA ↓ Lower Abdominal Incision ↓ Pre-Op / Intraop USG ↓ Placenta Visualised ↓ Uterus Opened using staplers ↓ Infusion with warmed RL ↓ Surgery At the end of surgery – Mother is still Pregnant and Child will be Reborn after few months
- 11. Fetoscopic Surgery-FETENDO • Indications • Amniotic band sequence • CDH - FETO • Spina bifida repair • Lower urinary tract obstruction (PUV) • Pros • Less Invasive • Less Morbidity • Cons • Skill • Cost • Risk
- 12. FIGS - IT Indications: • Disorders of Monochorionic placentation • TTTS (Twin to twin transfusion syndrome) • TAPS (Twin Anemia Polycythemia Sequence) • sIUGR (Selective IUGR) • TRAP (Twin Reverse Arterial Perfusion) • Catheter/ shunts→ Bladder/Abdomen/Chest • Fetal cardiac defects • Pros • Least Invasive • Less Morbidity • Day Care • Cons • Skill • Risk • Not for major anomalies
- 13. FIGS - IT Indications: • Disorders of Monochorionic placentation • TTTS (Twin to twin transfusion syndrome) • TAPS (Twin Anemia Polycythemia Sequence) • sIUGR (Selective IUGR) • TRAP (Twin Reverse Arterial Perfusion) • Catheter/ shunts→ Bladder/Abdomen/Chest • Fetal cardiac defects
- 14. EXIT • Controlled method of C- section • Near term fetal intervention to secure airway • Preservation of placental blood flow until other means of gas exchange is established
- 15. EXIT - Indications • A- Airway • CHAOS – Congenital high airway obstruction syndrome • Removal of balloon in CDH • B – Resection of thoracic / pulmonary masses • C – ECMO – CHD & CDH • D – Separation of conjoint twins
- 16. MOMS Trial • Prospective and randomized • Prenatal Vs postnatal repair • NEJM 2011 • Less need for VP shunt in first year (44% vs 84%) • Improved mental/motor composite score at 30 months • Less need for CIC 938% vs 51%) • Durable
- 17. Laser for TTTS • Prospective and randomized • Laser vs amnioreduction • Stopped early due to significant benefit in laser group • NEJM 2004 • Better survival of at least one twin at 28 days (76% vs 56%) • More likely to be free of neurologic complications (52% vs 31%)
- 20. CDH • The key to successful management is to have a fetus with competent lungs after birth • Presence of liver in thorax • LHR – less than 1.0 • These fetuses need intrapartum intervention for postpartum surgery to succeed • FETENDO with temporary tracheal occlusion • EXIT procedure to remove the balloon before birth
- 21. CDH • Why open intra partum surgery fails? • Reduction of the liver into abdomen kinks the Ductus Venosus
- 22. FETO
- 30. Maternal and fetal risks • Maternal • Surgery • Anaesthesia • Fetal • Prematurity • Intrauterine infection • Fetal vascular embolic events • Intestinal atresia • Renal agenesis • Premature closure of ductus arteriosus • CNS injuries – Maternal hypoxia / fetal circulatory disturbance
- 31. Future Possibilities • Deliver stem cells or DNA to treat sickle cell anemia or other genetic conditions • Haemoglobinopathies • Immunodeficiency diseases • MPS • Fanconi anemia