Page 6 - World Journal of Laparoscopic Surgery

HL Chauke

Twin Reversed Arterial Perfusion (TRAP) Obstructive Uropathy
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This is a rare condition (1:35000 livebirth) characterized Urinary tract abnormalities constitute 50% of prenatal
by perfusion imbalance as a results of vascular connection diagnosed fetal anomalies. 34 The major problem is
between an acardiac achephalic twin and a normal fetus. 29 obstruction leading to renal damage and lung hypoplasia
Blood is pumped by the normal fetus to the ‘monster’. secondary to oligohdramnios. Percutaneous vesicoamniotic
Mortality, if untreated is between 50 and 75%. 5,29 Several shunts have been used with complication rate of 25% due
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to shunt displacement. Other tried procedures include
therapeutic strategies including use of potassium chloride,
in utero percutaneous cystoscopy and ablation of posterior
amnioreduction, extracorporeal knot ligation of the cord, 35
urethral valve. Long-term results will clarify the value of
laser, monopolar and bipolar coagulation as well as ultrasonic these procedures.
transaction has been tried. 5,29-31 Although the numbers are
not big and difficult to make comparison, laser, bipolar and Other Procedures
ultrasonic transaction seems to be promising. Minimal access surgery has been used for the release of
amniotic band syndrome with the use of fetoscope. These
Fetal Tumors bands are associated with limb constrictions and amputations
Two common tumors that has been studied are the as well as postural deformities. Other area that has received
attention is the repair of cleft palate endoscopically with
Sacroccocygeal teratoma (SCT) and congenital cystic
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adenomatoid of the lung (CCAM). The problems with these minimal or no scarring. Attempt to repair myelomeningocoele
endoscopically has been described using carbon dioxide
tumors is that they may cause compression or lead to high-
(amniotic fluid removed) and maternal skin craft as the patch
output cardia failure resulting in fetal death. Open surgery 36
material. The results of open surgery for this procedure
has been used to successfully excise the tumors but limited is yet to be challenged. There is work reported in animals
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by complications. Percutaneous approach using radio- on fetoscopic management of aortic and pulmonary stenosis.
frequency ablation (RFA) for treatment of SCT has been
reported but was associated with uncontrolled burns to OVERALL COMPLICATIONS
adjacent tissues. 32,33 Open approach seem to offer better While major complications of open surgery have been
results for thoracic lesions and SCT when both are reduced by minimal invasive approach, preterm labor and
complicated by hydrops. 29 PPROM remain challenge (Table 2).

Table 2: Maternal morbidity and mortality for 178 interventions at University of California, San Francisco with
postoperative continuing pregnancy, divided into operative subgroups
Open hysterotomy Endoscopy Percutaneous All interventions
FETENDO/Laparatomy FIGS/Laparatomy
and FETENDO and FIGS
Patients with postoperative 79 68 31 178
continuing pregnancy
Gestational age at 25.1 24.5 21.1 24.2
surgery (wks)
Range (wks) 17.6-30.4 17.9-32.1 17.0-26.6 17.0-32.1
delivery (wks)
Gestational age at 30.1 30.4 32.7 30.7
delivery (wks)
Range (wks) 21.6-36.7 19.6-39.3 21.7-40.4 19.6-40.4
Interval surgery to 4.9 6.0 11.6 6.5
delivery (wks)
Range (wks) 0-16 0-19 0.3-21.4 0-21.4
Pulmonary edema 22/79 (27.8%) 17/68 (25.0%) 0/31 (0.0%) 39/178 (21.9%)
Bleeding requiring 11/87 (12.6%) 2/69 (2.9%) 0/31 (0.0%) 13/187 (7.0%)
blood transfusion
PTL leading to delivery 26/79 (32.9%) 18/68 (26.5%) 4/31 (12.9%) 48/178 (27.0%)
PPROM 41/79 (51.9%) 30/68 (44.1%) 8/31 (25.8%) 79/178 (44.4%)
Chorioamnionitis 7/79 (8.9%) 1/68 (1.5%) 0/31 (0.0%) 8/178 (4.5%)
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Table from Wu and Ball, 2009.
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JAYPEE