title: Minimally traumatic techniques for in utero access and fetal surgery.
abstract: OBJECTIVE
  Prenatal interventions may prevent some sequelae of congenital anomalies, yet open fetal surgery is limited by pre-term labor. We are developing amnioscopic strategies to reduce risks for in utero surgery.
  
  
  METHODS
  Seven fetal sheep were accessed percutaneously under ultrasound guidance, via maternal laparoscopy/transuterine trocars, or via laparoscopically assisted partial uterine exteriorization (mini-hysterotomy). Three fetal immobilization methods were investigated: 2 mm grasping forceps, 2-0 absorbable Roeder loop lasso, and detachable metal T-fasteners.
  
  
  RESULTS
  Percutaneous access with 2 mm trocars required accessible amniotic fluid pockets. The laparoscopically assisted method enabled 5 mm trocar placement under direct fetal visualization. Mini-hysterotomy avoided trocars and was leak-proof. 2 mm graspers enabled fetal manipulation with repeatable applications. Roeder loop sutures were not readily repositioned, and required two 3 mm or larger trocars. T-fasteners were easily deployed into fetal skin via the self-contained needle applicator with minimal hemorrhage. Cutaneous marks were present immediately from the grasper and T-fastener, but not at postoperative day 10. The Roeder loop produced no observable effects. All devices demonstrated adequate intrauterine performance.
  
  
  CONCLUSIONS
  Minimally invasive fetal surgery promises to lower maternal-fetal risks. All strategies permitted prolonged amnioscopy and fetal manipulation. The 2 mm grasper was easiest to use, producing no observable lasting trauma.
authors.affiliation: Division of Urology, Albany Medical College, New York 12208, USA.
authors.forename: C J
authors.initials: CJ
authors.lastname: Calvano
authors.forename: M E
authors.initials: ME
authors.lastname: Moran
authors.forename: B A
authors.initials: BA
authors.lastname: Mehlhaff
authors.forename: P P
authors.initials: PP
authors.lastname: Reddy
authors.forename: J
authors.initials: J
authors.lastname: Mandell
mesh_terms: D000818:Animals; D003559:Cystostomy / Q000295:instrumentation / Q000379:methods*; D004195:Disease Models, Animal; D005260:Female; D005333:Fetus / Q000601:surgery*; D020706:Laparoscopes; D010535:Laparoscopy / Q000379:methods*; D019060:Minimally Invasive Surgical Procedures / Q000295:instrumentation / Q000379:methods; D011247:Pregnancy; D012756:Sheep; D016896:Treatment Outcome; D016216:Ultrasonography, Prenatal; D014599:Uterus