title: Operative techniques and strategies for minimally invasive fetoscopic fetal cardiac interventions in sheep.
abstract: BACKGROUND
  Recent efforts to develop procedures for fetoscopic fetal cardiac interventions have been prompted by the development of severe secondary damage to the fetal heart due to semilunar valvar obstructions and the poor outcome of therapy-refractory fetal arrhythmias. The purpose of our manuscript is to analyze and share our experience with the creation of an operative setup for these procedures in sheep.
  
  
  METHODS
  We studied a total of 48 fetal sheep between 81 and 106 days of gestation (term, 145 days). After entering the amniotic cavity by a percutaneous approach, we performed various fetoscopic fetal cardiac procedures. We analyzed the success of percutaneous fetal access, methods of trocar support, the incidence and management of trocar dislodgement or accidental insertion into the chorioamniotic space, problems related to amniotic insufflation and trocar placement, as well as techniques for fetal posturing and uterine closure.
  
  
  RESULTS
  Percutaneous fetal access was achieved in all sheep. The use of resterilizable trocars substantially decreased the costs of our procedures. Utilizing a percutaneous transuterine purse-string suture for trocar support helped to minimize the number of nonabsorbable T-fasteners remaining inside the uterus postoperatively. As complications such as trocar dislodgement, insertion of the trocar into the chorioamniotic space, and problems with intraamniotic insufflation and gas loss were mastered, conversion to an open operative approach was never required. A novel strategy that we devised for percutaneous fetal posturing permitted adequate fetal posturing with ease and minimal trauma to the fetal skin.
  
  
  CONCLUSIONS
  As operative techniques have become more refined, the feasibility of performing fetoscopic fetal cardiac interventions in human fetuses now depends mainly on technical improvements in imaging and interventional catheters, as well as advances in pacemaker equipment.
authors.affiliation: Department of Pediatric Cardiology, University of Münster Medical School, Albert Schweitzer Strasse 33, 48149 Münster, Germany.
authors.forename: T
authors.initials: T
authors.lastname: Kohl
authors.forename: R
authors.initials: R
authors.lastname: Witteler
authors.forename: D
authors.initials: D
authors.lastname: Strümper
authors.forename: W
authors.initials: W
authors.lastname: Gogarten
authors.forename: B
authors.initials: B
authors.lastname: Asfour
authors.forename: J
authors.initials: J
authors.lastname: Reckers
authors.forename: G
authors.initials: G
authors.lastname: Merschhoff
authors.forename: A E
authors.initials: AE
authors.lastname: Marcus
authors.forename: M
authors.initials: M
authors.lastname: Weyand
authors.forename: H
authors.initials: H
authors.lastname: Van Aken
authors.forename: J
authors.initials: J
authors.lastname: Vogt
authors.forename: H H
authors.initials: HH
authors.lastname: Scheld
mesh_terms: D000818:Animals; D005260:Female; D005318:Fetal Heart / Q000601:surgery*; D005332:Fetoscopy / Q000379:methods*; D007327:Insufflation; D011187:Posture; D012756:Sheep; D014599:Uterus / Q000601:surgery