Page 5 - World Journal of Laparoscopic Surgery

Current Status of Minimal Access Surgery (MAS) in the Field of Maternal-Fetal Medicine

maximum visibility in the amniotic cavity but zero degrees
are available. Flexible cannulas and telescopes using
fiberoptic technology are also available for placental
operations. 5
Carbon dioxide is the gas used for adults endoscopy as
it makes visualization easy, is well-absorbed and does not
support combustion. This has been shown to result in fetal
acidosis and placental insufficiency, when used in fetal
surgery. 12,13 Because ultrasound is needed to aid in troncar
insertion and fetal monitoring, sonographic images would
5
be compromised by use of carbon dioxide. A fluid exchange
medium is often used.
Clinical Application
Fig. 1: Laser treatment of twin-to-twin transfusion syndrome
There are number of fetal conditions that minimal access (From Lambretti, 20 2009)
surgery has been utilized successfully.
coagulation with laser, Banet et al, reported normal
Twin to Twin Transfusion Syndrome (TTTS)
development in 78% at 22 months, 11% minor neurological
This is a complex condition occurring in 10 to 20% of deficit (minor neurological abnormalities, e.g. mildly delayed
5,14
monochorionic pregnancy. The pathological basis for motor development) while 11% had major neurological sequel
this condition is often unpaired vascular anastomoses such cerebral palsy. 21 These findings were similar to the
between the twins. One twin, the donor, suffers from one reported in the eurofetus (major abnormalities in 13%). 22
intrauterine growth restriction due to chronic vascular In his study, no difference was noted between the
insufficiency and the other become fluid overloaded. There amnioreduction and laser-treated group. This underscores
are various staging systems that are used in the management the inherent effect of the underlying condition as well as
of TTTS, for example; Quintero, Cincinnati, Children’s gestational age in treatment outcome not necessarily the
Hospital of Philadelphia (CHOP) and the Cardiovascular form of treatment. 14 Laser, seem to be the best choice in
15
Profile Scoring system. Mortality has been reported to be the treatment of severe TTTS.
around 80% if untreated. 15
Treatment options available include, amnioreduction, Congenital Diaphragmatic Hernia (CDH)
23
microseptostomy, fetoscopic laser photocoagulation, This condition affects 1:2400 livebirths. The underlying
photoscopic cord coagulation. A randomized controlled trial problem is an anatomical defect in the diaphragm leading to
comparing laser versus serial amnioreduction concluded that herniation of abdominal organs into the thorax. This results
laser was superior to serial amnioreduction in the manage- in lung compression, lung hypoplasia, hydrops and fetal
ment of this condition before 26 weeks. 16 The study demise. The condition ranges from mild to severe. Initial
composed of 72 women for the laser group and 70 women open approach to correct the defect was faced with serious
for the amnioreduction group, reported higher likelihood of technical challenges. 24,25 Negative prognostic factors for
survival, lower incidence of periventricular leukomalcia and this condition that predict outcome is the presence/absence
more less neurological complications at 6 months of age in of liver herniation (liver up/liver down) and the lung-head
favor of laser treatment. Other studies have reported similar ratio (LHR). 25,26
findings. 17,18 The procedure is depicted in Figure 1. Due to the discouraging results of open surgery,
Another option is fetoscopic reduction through cord endoscopic fetal surgery evolved. Initial strategies using
occlusion/coagulation for the recipient twin with advanced trancheal clips gave some hope, but clips resulted in laryngeal
19
cardiomyopathy and no chance of survival. Advantages nerve damage and were difficult to remove. 27 The
of these procedures are that they can be done under local/ subsequent use of balloon and EXIT (Ex Utero Intrapartum
regional anesthesia or a combination thereof and the patient Treatment) procedure retained the success of the procedure
can be discharged the same day. and overcame the problems with the clips. 28 Further
23
Long-term outcome of laser treatment has been studied. research is ongoing. This form of treatment seem to hold
In a study of 189 children who underwent intrauterine photo- hope for the future.
World Journal of Laparoscopic Surgery, January-April 2010;3(1):1-6 3