On The Horizon for Fetal Myelomeningocele Repair

Fetoscopic surgery

• Minimize patient morbidity: The impetus for fetoscopic repair derives from the observation that open fetal repair is associated with significant risk to the mother. Preliminary data suggests lower rates of premature rupture of membranes, less uterine dehiscence, significantly later gestational age at delivery, and a higher possibility of future vaginal deliveries.
• Fetoscopic maturation: The optimal closure method is under close scrutiny. Early human endoscopic series in the 1990s involving patching or single-layer closure were discouraging, with significant fetal morbidity and mortality (19,20). More recent evidence describing a two-layer technique boasts a safer profile for the mother while achieving wound-related and functional outcomes for the infant similar to those observed following open fetal myelomeningocele repair.
• Emerging technique: Researchers at some centers offer one of the more promising new techniques, using a two- or three-port approach. Under purely endoscopic guidance, the placode is untethered and a patch graft onlayed. A dura-fascial flap is created on either side of the canal and closed, followed by the skin layer (7,8). Long-term outcomes of these newer, less invasive procedures are pending.

Two-port technique: Surgeons at Texas Children’s Hospital conduct fetoscopic closure of a myelomeningocele using a two-port technique. (Used with permission from William E. Whitehead, MD, MPH.)

Two-layer closure: The dura-fascial complex is mobilized using electrocautery, reflected over a dural patch (artificial tissue patch, indicated by blue arrow) covering the descended placode, and closed in the midline. Later (not shown) the skin is mobilized and closed in a watertight fashion. (Used with permission from William E. Whitehead, MD, MPH.)

Minimally invasive uterine access: The two small port sites (indicated by blue arrows) are demonstrated following fetoscopic closure. A primary goal of the endoscopic approach is to minimize patient morbidity by reducing the risk of premature rupture of membranes and increasing the possibility of future vaginal deliveries. (Used with permission from William E. Whitehead, MD, MPH.)