Fetal operations in the head and neck area: current state

Abstract

Fetal surgery is defined as prenatal surgical intervention. Such intervention is currently considered in selected cases of fetal malformations that endanger the child's life prenatally or postnatally, such as death or severe impairment. Current indications are reviewed, with special emphasis on success rates and complications, including concomitant ethical problems. Data sources are based on personal experience and medical information systems (especially MEDLINE). In the head and neck areas, especially the upper respiratory tract, such procedures can be indicated in selected cases. They include exposure and temporary obstruction of the fetal trachea to reduce the viscera and to prevent pulmonary hypoplasia in congenital diaphragmatic hernia, prenatal tracheotomy in laryngeal atresia, and intranatal establishment of an airway in airway-obstructing embryonic tumors. The latter surgery can be performed after delivery of the fetal head and neck and before umbilical cord severance. This method ensures oxygenation of the fetus by the maternofetal circulation until completion of the surgical intervention (so called EXIT procedure = Ex-Utero Intrapartum Treatment). The relatively high surgical risk of fetal surgery, in particular postoperative preterm labor, may be reduced by the use of minimally invasive endoscopic techniques. By reducing operative risks even further, prenatal surgical interventions may even be used in nonlethal conditions. Consequently, more diseases of the head and neck area could thus be included in the spectrum of indications, such as prenatal correction of the cleft lip palate. Because fetal wound healing incurs no scarring up to a certain stage in pregnancy, such fetal surgical correction could be a perspective.