Current Status of Minimal Access Surgery (MAS) in the Field of Maternal-Fetal Medicine

Abstract

Advances in medical imaging have led to an improvement in prenatal diagnosis of congenital anomalies. This has been made possible through the incorporation of new ultrasound technologies, use of doppler and real time imaging. These have resulted in improvement in resolution and quality of ultrasound images. Concurrent use l Magnetic Resonance Imaging (MRI) in fetal imaging has resulted in better definition of pathology and diagnosis in situation where ultrasound imaging turns to be inconclusive.1 Together with the accolades gained by medical science in the understanding of the pathophysiological basis of diseases, clinicians have never been better equipped in making accurate diagnosis and better positioned in counselling their patients regarding prognosis and options available for the fetal condition in question, as is the case now. Sir William Albert Liley is regarded as the ‘father of fetal medicine’. His successful intrauterine transfusion of fetus affected by Rhesus disease in New Zealand, in 1963, opened a multitude of possibilities and opportunities for fetal medicine specialists.2,3 This has been followed by different developments, animal studies and refining of skills. The Fetal treatment center at the University of California, San Francisco (UCSF), under the leadership of Michael Harrison (a pediatric surgeon by training), has been at the forefront of this development.4 This center has been in limelight for performing fetal open fetal surgery and later inversion of minimal fetal approach dubbed ‘FETENDO’ (use of small instruments and manipulating them inside the uterine cavity was viewed as similar to playing video games, hence the name). Other groups like the children’s hospital of Philadelphia (CHOP), and the fetal center at Leuven, etc joined suite.2 There are now few specialized centers in different countries dedicated to this cause. The end result has been research and refinement of skills as new knowledge is acquired.4-6 The observation that postnatal therapy was not the answer to all fetuses, has led to the emergence of fetal surgery over the last 30 years. The vision has been an attempt to salvage the few fetuses with conditions that are known to result in stillbirth if left untreated, arrest the pathophysiological process or reverse fetal damage that is not amenable to postnatal correction. Currently three approaches are available for intrauterine management of fetal conditions, open approach via hysterotomy or minimal access using endoscopy or Fetal Image Guided Surgery (FIGS).6 The latter approach is what is generally referred to as percutaneous approach. This procedure uses needles to access the fetus under ultrasound guidance. Fetal surgery has undergone evolution from the first successful intrauterine transfusion in New Zealand, hysterotomy for vascular access and intrauterine transfusion (Puerto Rico, 1964), diagnostic fetoscopy (Yale, 1974), Laser ablation of placental vessels (Milwaukee, London,1995) right to the use of amniotic collagen plug (Leuven, 2007) and sclerotherapy for congenital cystic adenomatous malformation (CCAM) performed in Venezuela in 2007. A comprehensive review of these milestones is well articulated in the article by Jancelewicz and Harrison.2 Abstract