TMC PULSE

t m c » p u l s e | j u n e 2 0 1 5 31 cerebrospinal fluid shunt and improves leg function when compared to a stan- dard after-birth repair of the condition. Texas Children's Fetal Center adopted the technique as a treatment option and began open fetal surgery to treat spina bifida in 2011. "At the same time, with an open fetal surgery, prematurity is a major risk to the fetus, and in the worst cases, fetal death is a possibility," said Whitehead, an associate professor of neurosurgery at Baylor College of Medicine. "Our technique may lower the rate of prematurity—by implement- ing the two-port procedure, the babies may have a longer gestational age before they're born, which would be an extraordinary benefit." The current open fetal surgery technique involves a uterine incision to accommodate the repair, which has the potential to cause significant maternal complications. The risks of preterm delivery, the necessity of a cesarean section in that pregnancy and all subsequent pregnancies, and the risks of uterine rupture all loom large. In an effort to build upon the success of the MOMS trial, with a focus on reducing the risks to the mother, the team at Texas Children's Hospital sought an alternative path. Their journey would entail years of preparation and training, both domestically and internationally. Across the Atlantic, Jose Luis Peiro, M.D., and Elena Carreras, M.D., of Vall D'Hebron Hospital in Barcelona, Spain, had been working on a technique to repair spina bifida in fetal sheep, an initiative that Texas Children's Hospital supported from the begin- ning. Working together, the teams at Texas Children's Fetal Center and Vall D'Hebron Hospital ultimately devel- oped a new way to perform this feto- scopic surgery. A small telescope that can be combined with tiny instruments to allow surgery inside the uterus, a fetoscope would eliminate the need for the 5-6 centimeter opening required for an open procedure. Designed to counter the risks asso- ciated with an open procedure, such as preterm delivery and poor healing of the uterine scar, the new, experimental technique may permit the fetus to be born vaginally, rather than with the cesarean section required for all other babies with spina bifida. "Our methodology is different," explained Belfort. "We open the maternal abdomen and exteriorize the uterus—the mother still gets a scar on her belly, but we don't make the 5-6 cm opening that is required in her uterus for an open procedure. What we're trying to do is convert a reasonably morbid open procedure into one where the mother's life is less at risk and her fertility and future pregnancy history are less impacted." Refining their technique, the two surgeons performed more than 30 sim- ulated procedures, including two full simulations, gowned and gloved, under actual operating room conditions with a full support team. "Myelomeningocele repair is a rou- tine part of a pediatric neurosurgeon's practice," said Whitehead, "but I'm not used to taking care of fetal patients— we definitely need each other." "Incorporating a coordinated approach is absolutely critical when you only have two ports to work through," added Belfort. "A lot of these other groups have had one person try- ing to do everything by themselves, but in this technique we work together— I hold the scope and a grasper and Dr. Whitehead performs the suturing and repair procedure. Our instruments have to work together and not impede each other, and given that it involves two people doing one task, it's not something that's inherently intuitive. This is an area where nobody has specific expertise, and we're teaching and training each other while simulta- neously developing a new field." Belfort affirmed that while the results of their initial cases have been very encouraging, this procedure is still an experimental operation. "We only offer this less-invasive option to patients who have already made the decision to have open fetal surgery because we can always opt for that if needed," he clarified. "The Texas Children's Fetal Center is one of the few centers in the United States that performs the open procedure, and the only one to offer both open and feto- scopic approaches. "We'd love to prove that this tech- nique is the way to go and ultimately end up refining the process further," concluded Belfort. "If this works, it would be a huge win for women and their babies. With ever advancing tech- nology and imaging capabilities, as well as the work of dedicated surgeons, I am excited to see what the future holds when it comes to repairing anomalies fetoscopically." Thankfully, they can already add one win to the charts—Grayson is progressing well after a successful birth on September 21, 2014. "He has not developed hydrocephalus and has full movement of his legs," said Canezaro. "We are grateful to Dr. Belfort and his team for helping our son achieve this milestone, which would not have been possible without the exceptional care we received at Texas Children's Hospital and Baylor College of Medicine." With ever advancing technology and imaging capabilities, as well as the work of dedicated surgeons, I am excited to see what the future holds when it comes to repairing anomalies fetoscopically. — MICHAEL BELFORT, M.D., PH.D. Obstetrician and Gynecologist-in-Chief at Texas Children's Hospital LEFT: At 25 weeks gestation, utilizing an approach developed by Belfort and Whitehead, the team successfully closed the opening in Canezaro's unborn baby's spine. RIGHT: The procedure was performed by a team of specialists from Texas Children's Fetal Center and Baylor College of Medicine. (Credit: William Stewart Productions)

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