Role of Maternal Laparoscopy in Fetal Surgery

Abstract

Introduction:

Fetal surgery is an evolving field that includes fetoscopic entry into the uterus for conditions such as twin-to-twin transfusion syndrome, severe congenital diaphragmatic hernia, and fetal lower urinary tract obstruction. ^1,2 Fetoscopic entry may be complicated by placental location and the location of maternal organs. Laparoscopic assistance enhances direct observation of the uterus for assistant trocar insertions, repositioning of maternal organs, monitoring of internal bleeding, monitoring of uterine leakage, and desired uterine access in challenging cases of fetal surgery. The approach also promotes collaboration between medical specialties. Twin-to-twin transfusion syndrome results in imbalanced blood flow between twins as a result of arteriovenous malformations. Fetoscopic laser ablation of placental anastomoses is indicated for Quintero stages II to IV between 16 and 26 weeks gestation. ^3,4 Laparoscopic assistance during fetoscopic laser ablation for twin-to-twin transfusion syndrome with an anterior placenta has been documented previously to improve neonatal survival and avert the risk of preterm premature rupture of membranes. ^{5 –8} This video demonstrates the role of laparoscopy in fetoscopy for two cases of twin-to-twin transfusion syndrome in the setting of an anterior placenta.

Methods:

An open Hasson entry was performed in both cases. Additional laparoscopic trocars were placed under direct vision after retracting maternal viscera. The uterus was entered and the placenta was avoided in both cases. Fetoscopy and laser photocoagulation of placental anastomoses was performed during both cases.

Results:

Both cases resulted in minimal blood loss, no uterine leakage, safe repositioning of maternal organs, and optimal fetoscopic entry for laser photocoagulation of placental anastomosis. The mothers tolerated the operation well. Two of the four fetuses experienced fetal bradycardia during the surgery, which resolved after general anesthesia was removed. One recipient twin suffered fetal demise one day after laser ablation.

Conclusion:

Laparoscopy-assisted fetoscopic surgery is an effective tool to facilitate optimal uterine entry in challenging cases of fetal surgery.

No competing financial interests exist.

Runtime of video: 7 mins 36 secs

Parts of this video were presented at the Society of Gynecologic Surgeons annual meeting in July 2020.