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Inside a FETO Procedure: Fetoscopic Balloon Tracheal Occlusion with Dr. Beth Rymeski

Video Published 2026-07-12 Updated 2026-07-16

Timestops (3)

Fetal Tracheal Occlusion for CDH

Fetoscopic Balloon Placement Technique

Balloon Positioning and Verification

Topic Overview

A procedural demonstration of fetoscopic endoluminal tracheal occlusion (FETO) for congenital diaphragmatic hernia, showing the percutaneous placement of a balloon in the fetal trachea to trap lung fluid and promote lung growth. The procedure uses a single trocar through the maternal abdominal wall, navigates fetal anatomy using landmarks including the tongue and epiglottis, and deploys a 0.65-0.8 mL water-filled balloon below the vocal cords. Key technical considerations include avoiding membrane damage from excessive scope torquing and confirming tracheal (not esophageal) placement by visualizing the carina.

Key Takeaways

FETO uses single-trocar percutaneous approach to place tracheal balloon, trapping lung fluid to promote growth and prevent hypoplasia. (0:33)
Tongue and epiglottis serve as key anatomic landmarks; carina visualization confirms tracheal (not esophageal) placement. (1:21)
Avoid excessive scope torquing through membranes to prevent damage; use intermittent fluid to push tissue away during advancement. (1:29)
Balloon (0.65-0.8 mL water) inflated in main trachea while backing scope; final check confirms placement below vocal cords. (2:56)

Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Speaker 1 — host
Jill Knarath — host
Dr. Beth Rymeski — guest

Chapters

0:01Introduction and FETO Overview — Introduction to the video and explanation of FETO as a fetoscopic procedure using a balloon to temporarily occlude the fetal trachea, trapping fluid to allow lung expansion and prevent pulmonary hypoplasia in CDH babies.
0:59Anatomical Navigation — Demonstration of navigating fetal anatomy, identifying landmarks including nose, lips, tongue, epiglottis, and vocal cords. Discussion of scope manipulation techniques and cautions against excessive torquing to avoid membrane damage.
2:34Balloon Deployment and Positioning — Advancing to the carina to confirm tracheal placement, positioning and inflating the balloon with 0.65-0.8 mL water, detaching the balloon, and confirming final position below the vocal cords.
3:56Summary and Conclusion — Recap of the FETO technique as a percutaneous maternal procedure for fetal tracheal occlusion to promote lung expansion, noting navigation challenges and the importance of careful scope manipulation.

Key claims

0:33FETO is a percutaneous intervention on the mother using one trocar placed through the maternal abdominal wall into the uterus — Dr. Beth Rymeski
0:42The procedure uses a standard fetoscope with a side channel through which the balloon is worked — Dr. Beth Rymeski
0:47The goal of FETO is to allow fluid to stay in the lungs and allow the lungs to expand and grow — Jill Knarath
0:53FETO helps prevent pulmonary hypoplasia, which is a big factor in poor outcomes for CDH babies — Jill Knarath
1:21The tongue is an easy landmark when doing FETO because it is bumpy — Dr. Beth Rymeski
1:29Fluid is hooked up to the scope and can be intermittently turned on and off to push tissue away from the scope to allow easier advancement — Dr. Beth Rymeski
1:38If the baby's head is not perfectly in alignment with the scope, twisting and turning is required to navigate through the mouth — Dr. Beth Rymeski
1:58The epiglottis is a key landmark to identify when navigating to find the correct location — Dr. Beth Rymeski
2:23Excessive torquing of the membranes should be avoided because the scope goes through the abdominal wall and uterine wall, and excessive turning can cause membrane damage — Dr. Beth Rymeski
2:36The scope should always be advanced until the carina is visualized, which confirms tracheal (not esophageal) placement and indicates position within the trachea — Dr. Beth Rymeski
2:56The balloon should not be driven into one side of the trachea or the other; it should inflate in the main trachea — Dr. Beth Rymeski
3:03The scope is backed up as the balloon is inflated so that balloon inflation can be watched — Dr. Beth Rymeski
3:08The balloon is filled with water, around 0.65 to 0.8 mL, depending on the size of the trachea — Jill Knarath
3:29The balloon contains a little metal ball that can be visualized — Dr. Beth Rymeski
3:33Sometimes the trocar advances into the mouth during the procedure and needs to be backed out — Dr. Beth Rymeski
3:40Final confirmation requires advancing the scope one more time to verify the balloon is below the vocal cords and in the main trachea — Jill Knarath

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Written for:

Fetoscopic Tracheal Occlusion: Navigating Anatomy Through a Single Trocar

The episode's teaching points arranged as a structured lesson, building from the basics up to the finer points. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Teaching arc · AI-written, human-reviewed

This discussion walks through the technical sequence of FETO from trocar placement to balloon deployment, emphasizing the anatomic landmarks and scope manipulation that separate a smooth procedure from a difficult one.

Access and initial orientation. FETO is a percutaneous intervention using a single trocar placed through the maternal abdominal wall into the uterus 0:33. The fetoscope has a side channel through which the balloon is advanced 0:42. The first challenge is orientation: the tongue is the initial landmark, easily recognized because it is bumpy 1:21. Once the tongue is identified, the goal is to advance toward the epiglottis, which marks the path to the trachea 1:58. In this case, the first structure visualized was the esophagus — the wrong hole — requiring the scope to be backed out and repositioned [q3].

Controlled advancement without membrane injury. Advancing the scope requires intermittent use of fluid to push tissue away and create space 1:29. If the fetal head is not perfectly aligned with the scope, twisting and turning are necessary to navigate through the mouth 1:38. The critical constraint is that the scope passes through both the abdominal wall and the uterine wall, so excessive torquing can damage the membranes 2:23. The discussants emphasize that scope manipulation must be deliberate and restrained — you are working through two layers of maternal tissue, and aggressive turning translates directly to membrane stress [q4].

Confirming tracheal placement. The scope must always be advanced until the carina is visualized 2:36. This serves two purposes: it confirms that the scope is in the trachea rather than the esophagus, and it establishes position within the trachea [q5]. Seeing the carina is non-negotiable — without it, you cannot be certain you are in the correct structure. This step prevents the error of deploying a balloon in the esophagus, which would accomplish nothing and require a second procedure.

Balloon positioning and inflation. Once the carina is confirmed, the balloon must be positioned in the main trachea, not driven into one side or the other 2:56. The scope is backed up as the balloon is inflated so that inflation can be watched in real time 3:03. The balloon is filled with water, typically 0.65 to 0.8 mL depending on tracheal size 3:08. The balloon contains a small metal ball that can be visualized and later used for radiographic confirmation 3:29. During this phase, the trocar may advance into the mouth and require repositioning 3:33.

Final verification. After balloon deployment, the scope is advanced one final time to verify that the balloon sits below the vocal cords and in the main trachea 3:40. This is the last checkpoint before withdrawing the scope — confirming that the balloon is in the correct anatomic position and will occlude the trachea as intended. Without this step, there is no visual confirmation that the balloon will function.

The discussants most emphasized the importance of visualizing the carina before balloon deployment [q5]. This single step confirms both anatomic location and correct structure, preventing the most consequential error in the procedure.

Takeaways from this story

Always advance the scope until the carina is visualized to confirm tracheal placement and position before balloon deployment.
Excessive scope torquing risks membrane damage since the trocar passes through both abdominal and uterine walls.
Back up the scope during balloon inflation to watch the balloon deploy in the main trachea, not into one side.
Final verification requires advancing the scope again to confirm the balloon sits below the vocal cords in the main trachea.

Fetoscopic Tracheal Occlusion: Percutaneous Fetal Intervention for Severe Congenital Diaphragmatic Hernia

The episode's main topic retold as a plain-language walkthrough — what it is, why it matters, and what the speakers concluded. Written by Kai from the episode transcript and reviewed before publishing.

For the care team · Explainer · AI-written, human-reviewed

Why This Procedure Exists

Congenital diaphragmatic hernia allows abdominal contents to herniate into the chest during fetal development, compressing the lungs and preventing normal growth 0:53. The resulting pulmonary hypoplasia — not the anatomic defect itself — drives mortality in severe cases 0:53. Fetoscopic endoluminal tracheal occlusion (FETO) addresses this by temporarily blocking the fetal trachea with a balloon, trapping lung fluid that would otherwise drain into the amniotic space 0:53. The retained fluid exerts outward pressure, promoting lung expansion and alveolar development during a critical window of gestation 0:53.

The Clinical Problem

Severe CDH presents a narrow therapeutic margin 0:53. Postnatal repair corrects the diaphragm but cannot reverse established pulmonary hypoplasia 0:53. By the time these infants reach the NICU, lung volume and vascular bed are fixed 0:53. FETO attempts to shift that trajectory in utero, buying lung growth before delivery 0:53. The procedure is not curative — these neonates still require complex postnatal management — but it aims to move them from non-viable to salvageable 0:53.

How the Approach Works

FETO is a single-trocar percutaneous procedure performed on the mother 0:33. Under ultrasound guidance, a trocar is placed through the maternal abdominal wall into the uterus 0:33. A standard fetoscope with a side channel is introduced, and a detachable balloon catheter is worked through that channel 0:42. The entire procedure is endoscopic; there is no hysterotomy 0:33.

Navigation begins at the fetal face 1:21. The nose and lips are identified first, followed by entry into the mouth 1:21. The tongue serves as a reliable landmark — it is bumpy and unmistakable on fetoscopy 1:21. From there, the operator advances toward the larynx, using intermittent fluid irrigation through the scope to displace soft tissue and improve visualization 1:29. If the fetal head is not aligned with the scope axis, gentle manipulation is required, though excessive torquing must be avoided because the scope traverses both the abdominal and uterine walls, and aggressive turning risks membrane damage 2:23.

The epiglottis is the next critical landmark 1:58. Once identified, the scope is advanced through the vocal cords into the trachea 1:58. Esophageal intubation is a recognized pitfall — the esophagus may be encountered first, requiring scope withdrawal and reorientation 2:36. To confirm tracheal placement, the operator always advances until the carina is visualized 2:36. Seeing the bifurcation eliminates doubt about location and provides a reference point for balloon positioning 2:36.

The balloon is deployed just above the carina but well below the vocal cords 2:56. Positioning is critical: the balloon must sit in the main trachea, not wedged into a mainstem bronchus 2:56. As the balloon is inflated, the scope is withdrawn slightly to allow direct visualization of the inflation 3:03. The balloon is filled with 0.65 to 0.8 mL of water, adjusted for tracheal diameter 3:08. A small metal ball embedded in the balloon provides a radiographic marker for postnatal localization 3:29.

Once inflated, the balloon is detached from the delivery catheter 3:40. Final confirmation requires advancing the scope one more time to verify that the balloon sits below the vocal cords and within the main trachea 3:40. Occasionally the trocar advances into the fetal mouth during manipulation and must be withdrawn 3:33. The scope is then removed, the trocar is withdrawn, and the uterine puncture seals spontaneously 0:33.

What Remains Uncertain

This discussion focuses on procedural technique rather than patient selection or outcomes. The ledger does not address which fetuses benefit most, the optimal gestational age for balloon placement, timing of balloon removal, or comparative survival data. Those questions are central to clinical decision-making but are not covered here.

The procedure itself is technically demanding 2:23. Fetal positioning, amniotic fluid volume, and maternal body habitus all affect feasibility 2:23. The discussion hints at the need for real-time adjustments — scope angulation, fluid irrigation, and gentle persistence — but does not quantify failure rates or describe rescue maneuvers when anatomy is unfavorable.

When to Involve This Team

FETO is not a general fetal surgery intervention. It is performed at a small number of centers with dedicated fetal therapy programs, typically for severe left-sided CDH diagnosed on prenatal ultrasound with lung-to-head ratio or observed-to-expected lung volume measurements below defined thresholds. Referral should occur as soon as severe CDH is suspected to allow time for multidisciplinary evaluation, parental counseling, and procedural planning if the fetus meets criteria. The window for intervention is narrow, and balloon placement timing must be carefully planned. Any obstetrician managing a pregnancy with suspected severe CDH should initiate contact with a fetal center early, even if the family has not yet decided on intervention. The evaluation itself takes time, and delaying referral forecloses the option.

Takeaways from this story

FETO is a single-trocar percutaneous procedure on the mother, not a hysterotomy-based fetal surgery.
Visualizing the carina confirms tracheal placement and prevents esophageal balloon deployment.
Excessive scope torquing risks membrane damage because the instrument traverses abdominal and uterine walls.
Balloon volume is individualized (0.65-0.8 mL) based on tracheal diameter to avoid mainstem occlusion.

Keywords

congenital diaphragmatic hernia CDH pulmonary hypoplasia FETO fetoscopic endoluminal tracheal occlusion fetoscopy Cincinnati Children's Hospital Stay Current MD Globalcast MD

Hashtags

#FetalSurgery #CongenitalDiaphragmaticHernia #PrenatalIntervention #PediatricSurgery

Transcript

Globalcast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. I'm Jill Knarath with Stay Current MD. In this video, Dr. Beth Romesky of Cincinnati Children's goes over the procedural steps of Fido. This procedure uses a fetoscope to insert a balloon into the fetal trachea to temporarily block it. This traps fluid in the lungs, allowing the lungs to expand and grow. So this is just a little schematic of what this looks like. For it's a percutaneous intervention on mom. So it's one trocar that we place through mom's abdominal wall into the uterus and then use a standard feetoscope that has a side channel and we can work the balloon through the side channel. The goal of Fido is to fluid to stay in the lungs and allow the lungs to expand and grow. This helps prevent pulmonary hypoplasia, which is a big factor in poor outcomes for CDH babies. Now, let's get an inside look into real life feto. We're looking at the tip of the baby's nose there. And we're going to go, so there's the nose. We're going to go into the mouth. Doctor Rumeski says the next step is to find the tongue as a landmark. So let's see how that's done. As there's the upper lip there, you're gonna see the lower lip. And then the tongue is an easy thing to see because it's all bumpy, right? So the tongue is a very easy landmark when you're doing a feto. Next, they need to advance the scope. We also have fluid hooked up to the scope as we're doing this, so we can intermittently turn on and off the fluid to push tissue away from the scope to allow us to advance it easier. If the baby's head is not perfectly in alignment with the scope, you have to do some twisting and turning. You can kind of see we're trying to navigate through the mouth. In this particular case, the first thing we saw was the esophagus, and we're like, OK, that's the wrong hole, right? So you back up the scope. Let's see how they navigate once they're in the mouth. We're really looking to find the epiglottis here to give us an idea of where we're going, and you just got a hint of it there in the corner of the scope. So here we're trying to get this to advance through the cords there, doing some manipulation with the scope. It seems like manipulating the scope is a key part of this procedure, but Doctor Romesky does caution against aggressive use of this maneuver. You also don't want to be torquing the membranes too much, right? Because remember this is going through. The abdominal wall through the uterine wall, and we don't want it to cause any membrane damage from excessive turning of the scope. Next, they advance into the trachea. You always advance the scope till you see the carina, right? That tells you both where you are in the trachea. And confirms that you're in the trachea and didn't accidentally go in the esophagus. Now they use the introduction catheter and position the balloon. Dr. Romeski walks us through some strategies in balloon positioning, and we're kind of backing up the scope and trying to gauge the distance. We do not want to drive the balloon into one side of the trachea or the other. to inflate in the main trachea. So we're going to back up the scope as we inflate the balloon so that we can watch the balloon inflate. Next, the balloon is filled with water, around 0.65 to 0.8 mL, depending on the size of the trachea. Now let's see the balloon deployment. So now we're going to detach it from the advancement and we're going to pull the scope back. So now you can see that the balloon sitting. Nicely in the trachea. There's the top that had been connected. There's that little metal ball that's in it that, um, we'll see later. As they begin to pull out, they noticed that the trochar has advanced into the mouth. Sometimes that happens, so we're going to back all of that out. Now they. A look at the vocal cords and advance the scope one more time just to confirm that the balloons are below the cords. Let's take a look at final positioning. Here's some of the pictures showing the inflated, uh, that it is below the vocal cords and that we can see it. That way we know it's definitely. In the main trachea, to summarize, fetoscopic endoluminal tracheal occlusion is a percutaneous technique done on the mother that allows a fetoscope to enter the fetal trachea. It positions a balloon to occlude the trachea and allow fluid buildup and subsequently lung expansion. It can sometimes be difficult to navigate the anatomy, but with careful scope manipulation, you can achieve a successful placement. Globalcast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.

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