**4.3 Fetoscopic procedures**

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