ФЕТОСКОПИЧЕСКАЯ КОРРЕКЦИЯ МИЕЛОМЕНИНГОЦЕЛЕ – ПЕРВЫЙ РОССИЙСКИЙ ОПЫТ

Abstract

This study presents the first successful experience of fetoscopic repaire of myelomeningocele (MMC) in the Russian Federation, performed in the fetus at the 27th week of gestational age (GA). The article presents a clinical case of fetoscopic treatment of MMC in a fetus at 27 weeks' gestation. At 18–19 weeks. gestation, an ultrasound examination revealed a congenital malformation of the fetal CNS – spina bifida, MMC of the lumbosacral spine (L2–S1), Arnold-Chiari anomaly type II, hindbrain hernia, occlusive hydrocephalus. Basic endotracheal anesthesia was used in the mother and additional anesthesia in the fetus, which was carried out immediately after insertion of instrumental ports into the uterus. The spinal cord was released by making an incision along the edge of the skin-epithelial zone existing between the placode and the skin, allowing the neural plate to literally fall to the bottom of the spinal canal. Then, a Durepair® prosthesis (Medtronic, USA) was implanted into the edges of the defect. The skin flaps were brought together along the midline using a continuous suture made from the innovative Stratafix® notched suture material (Ethicon, USA). After birth, the results of the control ultrasound and magnetic resonance imaging, as well as motor function in the lower extremities and the state of the sphincters of the bladder neck and rectum were evaluated. A girl was born with a body weight of 2200 g, GA – 36 weeks. The APGAR score was 8–9 points. The results of the primary medical examination revealed a slight decrease in the tone of the muscles of the lower extremities, however, spontaneous movements were noted in both lower extremities. The newborn had a dosed discharge of urine and meconium, she did not need bladder catheterization and enemas. Examination of the surgical site revealed a well-formed scar with no signs of CSF leak and no pseudomeningocele formation. Spontaneous, symmetrical movements were noted in all limbs, including movements of the hips, knees, and ankles. Magnetic resonance imaging revealed moderate ventriculomegaly, reversal of the hindbrain hernia, and no signs of spinal cord fixation to the dura mater prosthesis. By the 1st year of life, the child walked independently and did not need assistance with walking, as well as additional neurosurgical interventions that are required to correct hydrocephalus, including correction of urinary and stool diversion disorders, orthopedic deformities. Fetoscopic surgery is a promising alternative to open prenatal treatment of MMC, it significantly reduces the risks for the pregnant woman and the fetus, but is a technically difficult operation.