Page 4 - World Journal of Laparoscopic Surgery

HL Chauke

The critical point determining success for fetal surgery and number of cases where an original research was
is a multidisciplinary approach. This itself has led to the undertaken. Older articles were considered where the author
current advances in management as each discipline felt that they carried information that was indispensable for
constantly strive to excel in their field with audit as the key the completion of this review.
factors in reaching new frontiers. The International Fetal
Medicine and Surgery Society, has endorsed a consensus RESULTS
statement aimed at guiding the practice of fetal surgery
(Table 1). 7 The findings of the literature search are discussed under
different subheadings below.
With the practice of open surgery considerable fetal and
maternal morbidity were encountered. This has been the
driving force behind the birth of minimal access techniques Ethical Consideration
as clinicians tried to balance the benefit and side effect of Intrauterine surgical procedures are fraught with ethical
intervention. Major drawback of open access was has been dilemmas. The experimental nature of the procedures and
preterm labor, preterm rupture of membrane and the maternal-fetal conflicts are issues that need consideration.
chorioamnionitis, although there has been notable success. Surgery in the fetus is effectively surgery on the mother
Minimal access surgery is a well-established surgical who is always an innocent bystander with no direct benefit
approach, often regarded as the preferred method if not as far as her well-being is concerned. Risks of anesthesia
gold standard for some form of surgical treatment such as and surgery to both mother and fetus should be addressed
in some general surgical conditions and the elderly. 8,9 and the woman counselled appropriately to obtain informed
Advantages of this technique have been described elsewhere consent. The concept of the fetal patient and the boundaries
8,9
for different kinds of surgical setting. The question arises that define this status is often blurred. However, once the
as to the status of minimal access surgery in the current
woman confer patient status to her unborn baby, the
management of fetal conditions given its established role in
beneficence-based obligations of the clinician to the fetal
other forms of surgery. The above question has prompted
patient should be weighed against autonomy considerations
this literature review. 10
for the pregnant mother. Possible outcomes and effect
AIM on pregnancy, alternative form of treatment and effect of
the proposed intervention on her future should be discussed
The aim of this article was to review the role of minimal
and recommendation from the International Society of Fetal
access surgery in the management of fetal conditions as
Medicine and Surgery (Table 1), adhered to.
published in the literature.
A multidisciplinary team of experts came together at the
MATERIALS AND METHODS National Institutes of Health (NHI) in the year 2000 with
11
Literature search was performed using Highwire, further recommendations. The principle of redistribution
Medscape, Medline and google scholar. Keywords used for of resources is another ethical issue that need a review on
the search were as follows: its own when it comes to fetal surgery. Some may argue
Fetal surgery, Fetoscopy, Minimal access surgery. against the use of limited resources in a world burdened
Articles were considered in terms of the year of publi- with vast and potentially preventable conditions, for
cation, relevance to the topic, publishing/research institution procedures that are best regarded as experimental with
questionable long-term effects to the recipients (fetuses).
Long-term data is needed to assess the effect that these
Table 1: Prerequisites for fetal surgery
procedures will have during adulthood to the index patient.
1. There should be accurate diagnosis, exclusion of associated
anomalies and proper staging of the condition.
2. The natural history and prognosis for the given condition Technical Aspects
should have been established.
3. Absence of effective postnatal treatment. Instruments used in fetal endoscopic surgery are purpose-
4. Animal studies performed in utero have demonstrated designed. This has come as a result of cooperation between
feasibility and effectiveness of the proposed therapy. companies and clinicians. Entry into amniotic cavity is by
5. The intervention should take place in specialized setting, with diamond-cut needle within sheath. This has been designed
multidisciplinary involvement. These centers should have strict
protocols and institutional ethics committee approval with to minimize rupture of membrane and is expandable.
informed consent for the affected parents. Troncars are miniaturised and endoscopes are usually 18
5
7
Adapted from Deprest et al , 2006 cm in length, 1.2 to 3.5 mm in size. Thirty telescopes offer
2
JAYPEE