Fetal surgery for anesthesiologists

We aimed to review the current clinical status and advances in endoscopic and open surgical interventions on the fetus in terms of indications, technical aspects and reported outcomes.

In numbers, there has been a move away from open toward fetoscopic surgery. The indications for each access modality are, however, different, and hence cannot substitute each other. Complications of monochorionic twinning are the leading indication today. Other increasingly frequent indications are severe congenital diaphragmatic hernia and myelomeningocele, and to a certain extent valvuloplasty by needle puncture. Although maternal safety is not at stake, rupture of the membranes and preterm delivery remain a problem. Today, there is level I evidence that fetoscopic laser surgery for twin-to-twin-transfusion syndrome is the preferred therapy. This has triggered the interest of several units to embark on fetoscopic surgery, although the complexity and the overall rare indications act as a limitation to sufficient turnover.

Fetal surgery seems safe and has therefore become a clinical reality. With the current state of technology, open and endoscopic interventions do not compete, each having their indications. Although the stage of technical experimentation is over, most interventions remain investigational. Inclusion of patients into trials whenever possible should be encouraged rather than building up casuistic experience. Healthcare providers and individual centers should be encouraged to consider viability and efficacy of new treatment programs.