**4. Milestones in development of fetal surgery**

Criteria for fetal surgery are summarized in **Table 2**.

#### **4.1 Ethical considerations**

The ethical issues in the field of fetal surgery are complex because the medical intervention is always invasive, often experimental, involves at least two patients the mother and fetus, and the success rate is difficult to measure. On the

**5**

*Principles of Fetal Surgery*

(**Table 2**) [7–10].

*4.2.1 Surgical team*

essential [13, 14].

*4.2.2 Surgical approach*

**4.2 Surgical techniques and procedures**

*DOI: http://dx.doi.org/10.5772/intechopen.85883*

III. No curative postnatal treatment.

pathology.

*Successful fetal surgery criteria.*

**Table 2.**

I. Prompt diagnosis of the pathology and associated anomalies.

II. Pathophysiology of the disease is documented, and overall prognosis is promising

other hand, strong evidence on the benefits of fetal surgery are not present, with many centers considered fetal surgery as an experimental technique to correct fetal anomalies. Controlled randomized studies to evaluate the effects of fetal surgeries on both mother and fetus are still needed. More often, doctors attempt fetal surgery in clinical settings without reporting post-operative outcomes in medical journals. The overall goal of fetal interventions is clear: to improve the health of fetus by intervening before birth to correct or treat prenatally diagnosed abnormalities. Mother and fetus that undergo these interventions must have the same protection afforded to other study participants, with detailed explanation of both short and long-term risks and benefits of these interventions on both the mother and the fetus. Therefore, diagnostic or therapeutic fetal intervention, cannot be performed without mother explicit informed consent

IV. Animal models prove feasibility of the in utero technique, preventing serious effects of the

V. Fetal therapy performed in specialized multi-disciplinary fetal care centers within clear procedure with local ethics committee approval and signed informed maternal or parent consent.

In fetal surgery, there are complex diseases and two patients, so careful planning and open communication before, during, and after surgery between the members of the multidisciplinary care team are essential. The team must include pediatric surgery, obstetrics, pediatric anesthesia, obstetric anesthesia, cardiology, radiology, otolaryngology, neonatology, neonatal nursing, and operative room nursing [11, 12]. During any fetal procedures, the use of ultrasound will guide the pediatric surgeon and/or obstetrician and allow for monitor the fetus during surgery. The surgeon should actively communicate with the anesthesia team, as well as nursing and scrub staff, throughout the procedure. Also, the presence of knowledgeable technical support staff familial with the specialized equipment and instrument is

Currently, fetal surgery can be classified into three broader areas; open fetal surgery, minimally invasive fetal surgery and EXIT procedures. Each procedure is subdivided into several subdivisions, in an attempt to treat a wide number of severe pathologies that would compromise the fetus. During minimally invasive fetal surgeries a small skin incision on the mother's abdomen was done. The location of the placenta, as well as the intrauterine pathology will guide the site of the planned incision. 1–2 mm instruments were used to access the fetus are to minimize maternal morbidity. Also, curved instruments may be used to avoid injury to anteriorly placed placenta. During fetal access, any present fluid (ascites, pleural effusions,


### **Table 2.**

*Pediatric Surgery, Flowcharts and Clinical Algorithms*

**3. History and general principles of fetal surgery**

cavity which was left with some amount of amniotic fluid [3–6].

First fetal intervention 1963 Direct visualization of the fetus 1970 Start of open fetal surgery 1982 Thoraco-amniotic fetal shunt placement 1987 Treatment of twin–twin transfusion syndrome by laser ablation 1990 Closure of fetal myelomeningocele using fetoscopy 1997 Treatment of fetal congenital diaphragmatic hernia by tracheal clipping (Fetendo technique) 1997 Excision of fetal amniotic band using fetoscopy 1997

2001

Treatment of fetal congenital diaphragmatic hernia by fetoscopic balloon tracheal occlusion

**4. Milestones in development of fetal surgery**

**4.1 Ethical considerations**

*Time scales for important fetal surgeries.*

technique

**Table 1.**

Criteria for fetal surgery are summarized in **Table 2**.

The ethical issues in the field of fetal surgery are complex because the medical intervention is always invasive, often experimental, involves at least two patients the mother and fetus, and the success rate is difficult to measure. On the

• Multidisciplinary fetal teams, including a fetal surgeon, ultrasonographer, perinatologist, and anesthesiologist, are critical to the delivery of optimum care.

In 1963 first fetal intervention was performed (**Table 1**), the first fetal transfusion

was reported by Liley. He used Tuohy needle (size 16-G) into the fetal peritoneal space. He injected a contrast material into the amniotic cavity to localize the fetal abdomen and the swallowed contrast opacify the fetal bowel. In the 1970s, endoscopy was used for direct visualization of the fetus, and the first fetal blood sampling or biopsy tissue was reported, however because of the limited technical skill, the therapeutic uses were not applicable [1, 2]. After that, with more use of ultrasound as non-invasive diagnostic tool, the use of diagnostic fetoscopy was replaced with percutaneous needle-based techniques under ultrasound guidance. In the 1980s open fetal surgery was started (direct exposure of the fetus by maternal laparotomy and hysterostomy), then open fetal surgery was replaced with a less invasive fetoscopy, where video camera was inserted inside the uterus under ultrasound guides. At first, fetoscopy was performed in amniotic fluid medium, using a single port to enter the uterine cavity and with a side way working channel. However, amniotic fluid medium poses many limitations for many fetal surgeries especially that require dissection and suture. Low quality images in the fluid medium, and any bleeding will prevent an adequate imaging, and it can end the procedure. Moreover, the "fluctuation" of the fetus during the intervention prevent maintenance of the ideal accessible position. In 2010 Kohl et al. use low insufflation pressure carbon dioxide of amniotic

**4**

*Successful fetal surgery criteria.*

other hand, strong evidence on the benefits of fetal surgery are not present, with many centers considered fetal surgery as an experimental technique to correct fetal anomalies. Controlled randomized studies to evaluate the effects of fetal surgeries on both mother and fetus are still needed. More often, doctors attempt fetal surgery in clinical settings without reporting post-operative outcomes in medical journals. The overall goal of fetal interventions is clear: to improve the health of fetus by intervening before birth to correct or treat prenatally diagnosed abnormalities. Mother and fetus that undergo these interventions must have the same protection afforded to other study participants, with detailed explanation of both short and long-term risks and benefits of these interventions on both the mother and the fetus. Therefore, diagnostic or therapeutic fetal intervention, cannot be performed without mother explicit informed consent (**Table 2**) [7–10].
