**4.4 EXIT procedures**

EXIT procedures principles is to perform controlled delivery to allow for fetal intervention and establishment of airway prior to cord clamping/cutting. Indications of EXIT procedures includes severe airway obstruction or likelihood of cardiopulmonary insufficiency at birth. Cervical masses, congenital lung malformations (CLM), congenital high airway obstruction (CHAOS), pulmonary agenesis, transition to ECMO. It performed under general anesthesia (fetal anesthesia, uterine relaxation), with maintenance of placental circulation and dorsal supine leftward tilt. Steps includes; Pfannenstiel incision, then customized hysterotomy based on placental location, partial delivery of fetus, and placement of

**7**

*Principles of Fetal Surgery*

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

cesarean section (**Figure 2**) [30, 31].

*Successful oro-tracheal intubation during the EXIT procedure.*

**5. Drawbacks of fetal surgery**

*4.4.1 Anesthetic care*

**Figure 2.**

monitors, fetal airway establishment during surgical intervention then delivery was completed with, transition of the baby to postnatal care, and finally completion of

Before anesthesia, all physiological changes associated with pregnancy must be considered. The effects of pregnancy on mother pulmonary and cardiovascular function must be considered. Adequate precautions should be taken to prevent hypoxemia and aspiration. The magnesium sulfate used in tocolysis may decreases capillary oncotic pressure and increases capillary permeability with increased risk of pulmonary edema. Aorto-caval compression must be prevented by using left uterine displacement. The doses of anesthetic drugs must be adjusted. Maternal local anesthesia can be effectively used for most needle-based and single port fetoscopic procedures. When multiple ports or caesarian section could be necessary, regional anesthesia; epidural or combined spinal epidural can be added. On the other hand, fetal anesthesia is indicated only for endoscopic procedures performed directly on the fetus. All fetal anesthetic drugs are typically administered through intramuscular route and consists of opiates and non-depolarizing muscle relaxants. Atropine is usually given to avoid fetal bradycardia. For placental or cord procedures with no direct fetal contact, the risk–benefit of fetal anesthesia should be weighed [32–35].

The drawbacks of fetal surgery, includes bleeding, amniotic fluid leak, chorioamnionic separation, chorioamnionitis, premature rupture of membranes, preterm labor, preterm birth, and fetal loss. Premature rupture of membranes, preterm labor is the most common complication of minimally invasive fetal surgery, with high morbidity, including oligohydramnios, chorioamnionitis, and preterm delivery. However, accurate analysis of the frequency of these complications are difficult

**Figure 1.** *Fetoscopic laser ablation of abnormal chorionic vessels for TTTS.*

*Pediatric Surgery, Flowcharts and Clinical Algorithms*

**4.3 Fetoscopic procedures**

**4.4 EXIT procedures**

cystic structures, or the bladder) are aspirated or shunted into the amniotic space. During fetal cardiac valvuloplasty and radiofrequency ablation for treatment of

Usually all patients submitted for a fetoscopic procedure are often pre-medicated with a tocolytic agent. Local or regional anesthesia are usually used. The surgery can be performed in the surgical theater, labor or delivery unit, or in the ultrasound department (depends on gestational age of the fetus). The used instruments, particularly, endoscopes have undergone numerous evolution, based on prototypes developed in animal models. Fetoscopes diameters are between 1.0 and 2.0 mm. Sharp trocars have been developed to accommodate the wide range of diameters used for different operations. Operative fetoscopy is a sonoendoscopic enterprise that has evolved so that the surgical team can see the ultrasound and fetoscopic images simultaneously. Basically, the ultrasound is used to identify an appropriate entry point to direct the trocar into the amniotic cavity, avoiding the placenta and the fetus as well as maternal organs, such as the bowel and bladder. However, some operators have documented the safety, in their hands, of a transplacental approach. Despite this experience, most operators still attempt to avoid the placenta. Nowadays, fetoscopic technique is indicated when direct visualization of the fetus (more than ultrasonography) is needed, as in treatment of cases of twin to twin transfusion syndrome, posterior urethral valves, constricting amniotic bands, and tracheal balloon occlusion for treatment of congenital diaphragmatic hernia. Fetoscopic procedures are performed using 1.2- to 3.0-mm endoscopes. Pictured is a 3 mm 0° endoscope,

complicated twin gestation, needle-based access is very helpful [15–20].

adjustable length, with a 1-mm working channel (**Figure 1**) [21–29].

EXIT procedures principles is to perform controlled delivery to allow for fetal intervention and establishment of airway prior to cord clamping/cutting. Indications of EXIT procedures includes severe airway obstruction or likelihood of cardiopulmonary insufficiency at birth. Cervical masses, congenital lung malformations (CLM), congenital high airway obstruction (CHAOS), pulmonary agenesis, transition to ECMO. It performed under general anesthesia (fetal anesthesia, uterine relaxation), with maintenance of placental circulation and dorsal supine leftward tilt. Steps includes; Pfannenstiel incision, then customized hysterotomy based on placental location, partial delivery of fetus, and placement of

**6**

**Figure 1.**

*Fetoscopic laser ablation of abnormal chorionic vessels for TTTS.*

**Figure 2.** *Successful oro-tracheal intubation during the EXIT procedure.*

monitors, fetal airway establishment during surgical intervention then delivery was completed with, transition of the baby to postnatal care, and finally completion of cesarean section (**Figure 2**) [30, 31].
