Minimal-access fetal surgery for twin-to-twin transfusion syndrome.
BACKGROUND
Laser ablation of placental vessels effectively halts severe twin-to-twin transfusion syndrome (TTTS), but fetal surgery remains a dangerous approach. The authors present the technical aspects of endoscopic fetal surgery in their initial clinical experience.


METHODS
Altogether, 11 women underwent endoscopic fetal surgery for severe TTTS. Access to the recipient's sac was obtained by the Seldinger technique via minilaparotomy. A 12-Fr peel-away introducer was used as a cannula to accommodate a custom-curved 9-Fr sheath containing a 1.9-mm semirigid fiber endoscope. Laser ablation was performed on all unpaired vessels crossing the intertwin membrane using a 400- micro m neodymium: yttrium-aluminum-garnet (Nd: YAG) fiber. The cannula was removed over a gelatin sponge plug.


RESULTS
The median operating time was 65 min (range, 45-105 min). No patient experienced amniotic leak postoperatively. The length of hospital stay was 2.8 +/- 1.6 days. Immediate improvement of the TTTS was noted in all but two patients. Pneumonia developed, in one mother leading to premature labor. There were no other major surgical complications. Fetal survival at 2 weeks was 73%.


CONCLUSIONS
The safety and efficacy of endoscopic fetal surgery for severe TTTS can be optimized with the application of current minimal-access techniques. The superiority of this approach over less invasive means is still being evaluated through prospective studies.
Bussey
J G
JG
Program in Fetal Medicine, Hasbro Children's Hospital, Brown Medical School, 2 Dudley Street, Suite 180, Providence, RI 02905, USA.
Luks
F
F
Carr
S R
SR
Plevyak
M
M
Tracy
T F
TF
D000328:Adult; D005260:Female; D005313:Fetal Death / Q000209:etiology; D005330:Fetofetal Transfusion / Q000150:complications / Q000601:surgery*; D005332:Fetoscopy / Q000379:methods*; D005865:Gestational Age; D006801:Humans; D053685:Laser Therapy / Q000379:methods*; D007902:Length of Stay; D019060:Minimally Invasive Surgical Procedures; D007752:Obstetric Labor, Premature; D011014:Pneumonia / Q000209:etiology; D011183:Postoperative Complications; D011247:Pregnancy; D011256:Pregnancy Outcome; D016896:Treatment Outcome; D014430:Twins, Monozygotic