February, 2001 Volume 7 Issue 1 Editor: James E. Carter, MD Regional Editors: Togas Tulandi, MD  István Rakoczi, MD and Prashant Mangeshikar MD

The Use of Endoscopy in Fetal Medicine
Jan A Deprest, MD, PhD
Telephone : 32 16 34 42 15
Facsimile: 32 16 34 42 05
e-mail: Jan.Deprest@uz.kuleuven.ac.be 

Today, fetoscopy has gained clinical acceptance in fetal medicine, due to technical innovations in millimetric endoscopes combined with increasing insight into the pathophysiology of some conditions that can be diagnosed prior to birth. Two types of fetoscopy are to be considered: obstetrical endoscopy and endoscopic fetal surgery. 

Obstetrical procedures include surgical interventions on the placenta, umbilical cord and fetal membranes. The most common procedure today is laser coagulation of chorionic plate vessels for severe mid-gestational feto-fetal transfusion syndrome (FFTS), and to a lesser extent cord occlusion in monochorionic pregnancy with one non-viable fetus. In the former, the placenta is inspected by fetoscopy and selected vessels involved in the transfusion process are coagulated by means of Nd:YAG or diode laser energy. This procedure is causative as it addresses, at least in theory, the pathophysiology of FFTS. Experience is large (over 500 cases registered in Europe) with survival rates of 65 – 70 % and an increasing number of pregnancies with two survivors. Prospective follow-up of live born fetuses showed a reduced risk for neurologic morbidity as detected by neonatal brain scans (5 % in contrast to >20 % in case of amniodrainage). There are however no solid data to support the view that laser coagulation would be superior to amniodrainage, and therefore a multicentre, open randomized trial has been initiated by the EUROFOETUS research consortium (over 40 patients enrolled, protocol at http://www.eurofoetus.org). Patients and data can be entered via the Internet and a well-defined neurologic follow-up has been proposed. Fetoscopy has also been used to guide cord occlusion as a technique for selective feticide in case of monochorionic twins in a variety of conditions. We recently described ultrasound-guided bipolar coagulation of the umbilical cord, which offers an alternative for fetoscopic laser coagulation at a more advanced gestational age. Survival is over 75 % today, with a risk for ruptured membranes (PPROM) of < 20 %. Fetoscopy has also been suggested to section amniotic bands. Via http://www.eurofoetus.org,  any fetoscopic procedure can be registered. This world wide registry, funded by the European Commission, has as primary target the assessment of maternal and fetal safety.

The second type of fetoscopic intervention addresses some rare fetal conditions requiring in utero fetal surgery. These interventions have a different historical and experimental background but share technical aspects as well as potential side effects with obstetrical endoscopic procedures. We suggest that future developments of fetal endoscopic operations will involve a mixture of concepts from both fetoscopy types to reduce maternal invasiveness and complications, eventually improving acceptance by parents and doctors. Most experience has been gathered with congenital diaphragmatic hernia. Fetuses with herniated liver and severe pulmonary hypoplasia have been shown to have an extremely poor prognosis, and are therefore the best candidates for in utero intervention. Today’s approach involves tracheal obstruction as a trigger for lung growth. Different techniques have been described, including fetoscopic tracheal clipping an endo-luminal tracheoscopic balloon plugging, first described by our team. Even as the debate on the best timing and duration of TO is ongoing, clinical cases have been done, with encouraging outcomes. This type of experimental surgery can only be done in experienced centers within appropriate protocols or trials. At present, in the USA, the NIH funds a RCT comparing in utero TO and standard postnatal therapy.

Painless Laparoscopy?
Larry Demco, MD Calgary Canada
Email: larrydemco@home.com  

Laparoscopy has brought many changes in our approach to surgery, with a gradual movement from the traditional laparotomy approach to surgery with in the abdomen to a minimally invasive approach. Although this has affected the doctors, the main benefactor of this technology has been the patient. Post-op recovery times were reduced from 6 weeks to 1 to 2 weeks with the laparoscopic approach. Although a quantum leap in the post-op recovery period was recognized, surgery still involved a painful recovery. A laparotomy scar was replaced with the shoulder pain of laparoscopy. The shoulder tip pain was thought to be due to the reaction of the carbon dioxide gas reacting with the water to form carbonic acid. This in turn irritated the nerves in the diaphragm resulting in the shoulder pain. Recent work has determined that this premise was not correct. The actual cause of the shoulder pain is the result of the cellular death caused by the combination of a temperature change from the gas at 21 C and the drying effect of the gas at .0002%. Just as the cold dry wind of a Canadian winter causes exposed skin to freeze in less than a minute, the same cold dry gas of laparoscopy kills the peritoneal cells resulting in the shoulder pain. Just as the Canadians flock to the warm moist air of Florida to escape the pain of frost bite of a Canadian winter, heating and humidifying the gas during laparoscopy can prevent the cellular dearth of the peritoneum and result in less shoulder pain. With out shoulder pain, the patient's recovery is markedly affected. There is little need for pain medication and a shorter post-op recovery time. 

We are now seeing another quantum leap in the patient's perception of surgery. From surgery with shoulder and trocar site pain, to trocar site pain, prevented by local injection of anesthetics, and shoulder pain prevented by heating and humidifying the gas. The result is laparoscopy far less painful to the point of painless.

These advancements have also resulted in a resurgence of performing laparoscopy with the patient awake. Tubal ligation and diagnostic laparoscopy, utilizing the technique of pain mapping, has resulted in new information about the causes and referral patterns of pain associated with endometriosis and other conditions. This has also allowed the physician to confirm, with the patient, the exact cause of the pain, and that the therapy planned will treat the cause of the pain. The patient is no longer a person to be operated on, but rather a person to be operated with, as a equal partner in the operating team.

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