In-utero repair of open neural tube defects, lesion closure techniques and the choice of patch

In 2011, the landmark Management of Myelomeningocele Study (MOMS) demonstrated unequivocal benefits for children undergoing prenatal closure of myelomeningocele. In addition to reducing the need for CSF diversion following delivery, the procedure was also shown to improve independent ambulation at school age and beyond, typically yielding a functional neurological level at least 2 better than the anatomic level in these patients. While prenatal myelomeningocele (MMC) closure can be more technically challenging and demanding than postnatal closure, the same basic surgical principles are typically employed during fetal intervention to obtain a multi-layered, water-tight closure with recapitulation of the normal anatomic relationships. Here we describe commonly utilized operative techniques for intrauterine MMC closure, with illustration of both open and endoscopic variations to perform the procedure. As maternal-fetal centers across the globe continue to gain experience with intrauterine MMC closure, it is incumbent that we constantly strive to improve both the efficacy and safety of the procedure, mitigating the potential complications of prenatal closure such that the benefits for the child far outweigh the associated risks for both mother and baby.