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

Video Published 2026-07-13

Timestops (3)

FETO Procedure Overview and Lung Expansion

Scope Navigation and Anatomical Landmarks

Balloon Placement and Detachment Technique

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 (tongue, epiglottis, vocal cords, carina), and deploys a 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 a single percutaneous trocar to place a water-filled balloon in the fetal trachea, trapping lung fluid to promote growth. (0:33)
Always advance the scope to visualize the carina—this confirms tracheal (not esophageal) placement and guides balloon positioning. (2:36)
Minimize scope torquing through membranes to prevent damage; use intermittent fluid irrigation to push tissue away during navigation. (1:29)
Balloon inflation (0.65-0.8 mL) should occur in the main trachea below the vocal cords, not driven into one side of the airway. (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 Procedure Overview — Introduction to FETO procedure and its mechanism: percutaneous trocar placement through maternal abdominal wall, fetoscope with side channel for balloon delivery, goal of trapping lung fluid to prevent pulmonary hypoplasia in CDH.
1:03Anatomical Navigation — Step-by-step navigation through fetal anatomy: identifying nose, mouth, tongue as landmark, advancing scope with intermittent fluid, locating epiglottis, avoiding esophagus, advancing through vocal cords to carina while minimizing membrane torque.
2:36Balloon Positioning and Deployment — Advancing scope to carina for confirmation, backing up to position balloon in main trachea, inflating with 0.65-0.8 mL water while watching deployment, detaching and confirming final position below vocal cords.
3:48Summary and Conclusion — Final confirmation imaging and procedural summary emphasizing careful scope manipulation for successful placement.

Key claims

0:33FETO is a percutaneous intervention on the mother using one trocar placed through the 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 during 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 and allow easier advancement — Dr. Beth Rymeski
1:38If the baby's head is not perfectly aligned with the scope, twisting and turning is required to navigate through the mouth — Dr. Beth Rymeski
1:58The epiglottis is sought as a landmark to guide navigation — Dr. Beth Rymeski
2:23Excessive torquing of the membranes should be avoided because the scope goes through the abdominal and uterine walls and could cause membrane damage — Dr. Beth Rymeski
2:36The scope should always be advanced until the carina is visualized to confirm tracheal position and determine location within the trachea — Dr. Beth Rymeski
2:56The balloon should not be driven into one side of the trachea but should inflate in the main trachea — Dr. Beth Rymeski
3:03The scope is backed up as the balloon is inflated to allow visualization of balloon inflation — 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 small metal ball that can be visualized — Dr. Beth Rymeski
3:48Final confirmation requires visualizing that the balloon is below the vocal cords and in the main trachea — Dr. Beth Rymeski

Cases discussed

1:03Live FETO procedure demonstration on a fetus with CDH

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 Fetal Anatomy to Promote Lung Growth in CDH

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. The resulting pulmonary hypoplasia — not the hernia itself — drives mortality in severe cases 0:53. Fetoscopic endoluminal tracheal occlusion (FETO) addresses this by temporarily trapping lung fluid in utero, using hydrostatic pressure to expand the compressed lung and stimulate growth before birth 0:47.

The Core Problem

The fetal lung secretes fluid continuously. In normal development, this fluid drains through the trachea and is swallowed. In CDH, the herniated viscera occupy thoracic space that the lung needs to expand into. FETO reverses the usual physiology: by occluding the trachea with a balloon, the procedure converts the lung's own secretions into an expansion force 0:47 0:53.

How the Approach Works

FETO is a single-trocar percutaneous procedure performed on the mother 0:33. A trocar is placed through the maternal abdominal wall into the uterus, and a standard fetoscope — equipped with a side channel for instrument passage — is advanced through it 0:42. The entire procedure hinges on navigating fetal anatomy at a scale where a few millimeters of misalignment matters.

Anatomical Navigation

The fetoscope enters through the fetal mouth. The tongue serves as the first reliable landmark — its bumpy surface is unmistakable on the scope 1:21. Intermittent fluid flow through the scope pushes tissue away and clears the visual field 1:29. If the fetal head is not aligned with the scope axis, the operator must twist and turn the instrument to advance 1:38.

The critical distinction is between trachea and esophagus. The epiglottis, once identified, guides the scope toward the airway 1:58. Even experienced operators occasionally enter the esophagus first; the maneuver is to back out and reorient [q2]. The scope is then advanced through the vocal cords.

Once past the cords, the operator always advances to the carina — the bifurcation of the mainstem bronchi 2:36. Visualizing the carina serves two purposes: it confirms tracheal (not esophageal) position, and it establishes where in the trachea the scope sits [q4]. This is not optional; it is the only way to be certain of location.

Scope Manipulation Constraints

The fetoscope traverses the maternal abdominal wall, the uterine wall, and the amniotic space before entering the fetus. Excessive torque on the scope can damage the membranes 2:23. "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" [q3]. The operator must balance the need for precise positioning against the mechanical limits of the access route.

Balloon Positioning and Deployment

After confirming position at the carina, the scope is withdrawn slightly. The balloon must sit in the main trachea, not be driven into one mainstem bronchus 2:56. As the balloon is inflated, the scope is backed up further to allow visualization of the deployment 3:03. The balloon is filled with water — typically 0.65 to 0.8 mL, adjusted for tracheal diameter 3:08. It contains a small metal ball, visible both endoscopically and on subsequent imaging 3:29.

Final confirmation requires seeing the balloon below the vocal cords and positioned in the main trachea 3:48. The scope is then withdrawn. The balloon remains in place, occluding the trachea and allowing lung fluid to accumulate.

What Remains Uncertain

This discussion focused on procedural technique rather than patient selection or outcomes. The episode did not address which CDH cases benefit most from FETO, at what gestational age the procedure is performed, when the balloon is removed, or how lung growth is monitored after placement. These are separate clinical questions.

When to Involve This Team

FETO is performed by specialized fetal surgery centers. The discussion did not specify referral criteria, but the procedure targets severe CDH cases where pulmonary hypoplasia is the limiting factor 0:53. Referral would occur prenatally, after CDH is diagnosed on fetal imaging and severity is assessed. The window for intervention is narrow — the balloon must be placed early enough to allow lung growth but late enough that the fetus can tolerate the procedure, and it must be removed before delivery to allow the infant to breathe.

For obstetricians managing a fetus with CDH, the relevant question is whether the predicted lung volume and liver position suggest severe hypoplasia. If so, contact with a fetal surgery center should occur as soon as the diagnosis is made, not after waiting to see if the lung grows on its own.

Takeaways from this story

FETO uses trapped lung fluid as an expansion force to counter pulmonary hypoplasia in severe CDH.
Visualizing the carina is mandatory—it confirms tracheal position and prevents esophageal misplacement.
Scope torque must be minimized because the instrument traverses maternal abdominal and uterine walls.
Balloon volume (0.65-0.8 mL) is adjusted to tracheal size and must sit in the main trachea, not a bronchus.

Navigating the Fetal Airway: Technical Essentials of FETO Balloon Placement

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 trainees · Teaching arc · AI-written, human-reviewed

This discussion walks through the technical sequence of fetoscopic endoluminal tracheal occlusion, emphasizing the judgment calls that distinguish competent from expert execution.

Landmark-driven navigation, not blind advancement

The procedure begins with identifying the tongue, which serves as the first reliable landmark because of its bumpy texture 1:21. From there, the epiglottis guides navigation toward the airway 1:58. The critical checkpoint is the carina — the scope must always be advanced until the carina is visualized 2:36. This serves two purposes: it confirms tracheal (not esophageal) placement, and it establishes where you are within the trachea 2:36. In one case shown, the first structure encountered was the esophagus — recognizing the wrong hole and backing out is part of the skill [q2]. The sequence matters: tongue, epiglottis, carina. Each landmark confirms the next move.

Fluid as a tool, not just irrigation

Fluid connected to the scope is not passive irrigation but an active instrument 1:29. It can be turned on and off intermittently to push tissue away from the scope tip, creating space for advancement 1:29. This is particularly useful when fetal head alignment is suboptimal and the scope requires twisting and turning to navigate through the mouth 1:38. The fluid gives you room to maneuver without forcing the scope through resistant tissue.

Torque awareness: the scope crosses three layers

The scope enters through the maternal abdominal wall, traverses the uterine wall, and reaches the fetus 0:33. Excessive torquing of the scope risks membrane damage because the rotational force is transmitted across all these layers 2:23. "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" [q3]. When the fetal head is not perfectly aligned, some twisting is necessary 1:38, but the operator must balance the need to navigate with the risk of membrane injury. This is not a rigid bronchoscopy where you can torque freely — the maternal and fetal tissues are in the path.

Balloon positioning: midline and visualized

The balloon must inflate in the main trachea, not be driven into one side 2:56. To achieve this, the scope is backed up as the balloon is inflated, allowing real-time visualization of deployment 3:03. The balloon is filled with water — typically 0.65 to 0.8 mL depending on tracheal size 3:08 — and contains a small metal ball that can be seen on imaging 3:29. Final confirmation requires two checks: the balloon must be below the vocal cords, and it must be in the main trachea 3:48. In the case shown, the team advanced the scope one more time after initial deployment specifically to confirm the balloon was below the cords [q4]. This is not optional — you must see both the cords and the balloon position before withdrawing.

The procedure's mechanical simplicity belies its precision demand

FETO is a percutaneous intervention using a single trocar placed through the maternal abdominal wall into the uterus 0:33. A standard fetoscope with a side channel allows the balloon to be worked through 0:42. The goal is straightforward: trap fluid in the lungs to allow expansion and growth, preventing the pulmonary hypoplasia that drives poor outcomes in congenital diaphragmatic hernia 0:47 0:53. But the mechanical simplicity — one trocar, one scope, one balloon — demands precision in every step. The airway is small, the fetus moves, and the maternal tissues are in the path. The discussants emphasized that confirming carina visualization is non-negotiable [q4], that fluid use is strategic 1:29, and that final positioning must be visually confirmed 3:48. These are not suggestions — they are the checkpoints that separate a deployed balloon from a correctly deployed balloon.

Takeaways from this story

Always advance the scope until the carina is visualized to confirm tracheal position and rule out esophageal placement.
Intermittent fluid flow pushes tissue away to facilitate scope advancement, especially when fetal head alignment is suboptimal.
Limit scope torquing to prevent membrane damage — the scope crosses maternal abdominal and uterine walls before reaching the fetus.
Back up the scope during balloon inflation to visualize deployment and confirm midline positioning in the main trachea.
Final confirmation requires seeing the balloon below the vocal cords and in the main trachea before withdrawing the scope.

Navigating the Fetal Airway: Technical Essentials of FETO Balloon Placement

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 operative sequence of fetoscopic endoluminal tracheal occlusion, emphasizing the judgment calls that separate smooth placement from prolonged manipulation or failed access 0:33 0:42.

Percutaneous access constrains all subsequent maneuvers

FETO is performed through a single trocar placed percutaneously through the maternal abdominal wall into the uterus 0:33. The fetoscope passes through this trocar with a side channel for balloon delivery 0:42. This fixed entry point means every adjustment inside the fetal mouth requires torquing the scope through maternal tissue 0:33 0:42. The critical implication: excessive twisting risks membrane damage 2:23. You cannot manipulate the scope as freely as you would in postnatal bronchoscopy 2:23. Every turn must be deliberate, and if fetal head position is unfavorable, you accept more difficulty rather than forcing alignment 2:23.

Landmark progression follows a strict hierarchy

The tongue is the first reliable landmark, identifiable by its bumpy texture 1:21. Once past the tongue, the epiglottis becomes the target for orienting toward the airway 1:58. Intermittent fluid flow through the scope pushes tissue away and facilitates advancement 1:29, but this is a finesse tool, not a substitute for proper alignment 1:29. If the initial view shows esophagus rather than larynx, the scope must be withdrawn and redirected 1:38. There is no shortcut past this sequence — attempting to advance without clear visualization of the epiglottis leads to prolonged manipulation and increased membrane stress 1:38 1:58 2:23.

Carina visualization is non-negotiable

The scope must always be advanced until the carina is visible 2:36. This serves two purposes: it confirms tracheal rather than esophageal position, and it establishes where you are within the trachea 2:36. Deploying a balloon without seeing the carina means accepting uncertainty about both location and orientation 2:36. The balloon must sit in the main trachea, not be driven into a mainstem bronchus 2:56. If you cannot see the carina, you cannot reliably position the balloon 2:36 2:56.

Balloon deployment requires coordinated withdrawal

As the balloon inflates, the scope is backed up to maintain visualization of the expanding balloon 3:03. The balloon is filled with a volume of water determined by tracheal diameter 3:08. The balloon contains a small metal ball that aids later radiographic confirmation 3:29. The key error here is inflating without withdrawing — if the scope tip remains advanced, you lose the view that tells you whether the balloon is expanding symmetrically in the main trachea or being pushed laterally into one wall 3:03 2:56.

Final confirmation demands a second look at the cords

After detachment, the scope is withdrawn to visualize the vocal cords, then advanced once more to confirm the balloon sits below the cords and within the main trachea 3:48. This is not redundant 3:48. The balloon can shift during detachment, and the trocar itself can advance into the mouth during manipulation 3:48. Confirming subglottic position after detachment is the only way to know the balloon will remain where you placed it 3:48.

The procedure's constraint is maternal, not fetal

The discussants returned repeatedly to membrane protection 2:23. The scope traverses the abdominal wall, the uterine wall, and then enters the amniotic space 0:33. Aggressive torquing to improve fetal airway visualization risks rupturing membranes or causing preterm labor 2:23. The technical challenge is achieving adequate fetal airway access while minimizing maternal tissue stress — a balance that requires accepting suboptimal angles rather than forcing ideal scope position 2:23. This is the judgment that separates operators who complete the procedure quickly from those who complete it safely 2:23.

Takeaways from this story

Excessive scope torquing risks membrane damage since the trocar traverses maternal abdominal and uterine walls
Always advance to visualize the carina — it confirms tracheal position and prevents mainstem balloon deployment
Back up the scope during balloon inflation to maintain visualization and ensure symmetric expansion in main trachea
Final confirmation requires re-visualizing vocal cords after detachment to verify subglottic balloon position

Keywords

congenital diaphragmatic hernia pulmonary hypoplasia FETO fetoscopic endoluminal tracheal occlusion percutaneous intervention Cincinnati Children's Hospital Stay Current MD GlobalCast MD

Hashtags

#FetalSurgery #CDH #FETO #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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