Endoscopic Fetal Tracheal Occlusion: Evolution of Techniques

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Abstract
Extensive experimental and clinical work has supported a rapid evolution of endoscopic equipment and minimally invasive techniques to successfully perform a variety of fetal surgical interventions. The purpose of this study is to report the technical lessons learned by our first ten attempts at endoscopic human fetal tracheal occlusion for the treatment of congenital diaphragmatic hernia. The uterus is exposed through a low transverse incision. Intraoperative ultrasonography is used to outline the placenta, guide compression trocar insertion, place a fetal fixation stitch, identify the midline of the fetal neck, and place a T-fastener in the fetal trachea. Fetoscopic tracheal dissection and occlusion is made possible by continuous high-flow irrigation of the operative field and amniotic cavity with warm lactated Ringer's solution. In six cases the fetal dissection was performed entirely endoscopically. Early in our experience, technical considerations (e.g., vision impaired by blood in the amniotic fluid, fetal position) forced conversion to open surgery in four patients. Development of a high-flow irrigation system that allowed exact matching of inflow and outflow was critical for visualization. Fetoscopic surgery is a complex technical task. Innovative multidisciplinary imaging and the development of new techniques to improve visualization and fetal position have allowed successful fetal endoscopic tracheal occlusion.