Hey there, listeners. This is Rob Gerardo, research resident at Cincinnati Children's Hospital Medical Center. Whether you're watching us on YouTube, listening to us on Apple Podcasts, Stitcher, Spotify, SoundCloud, the best way to listen is on the Stay Current Pediatric Surgery app. It's brought to you by Cincinnati Children's Hospital Medical Center, Children's Mercy at Kansas City, and the Journal of Pediatric Surgery. It's in the Apple App Store, it's in the Google Play Store. Download it today, but until then, Enjoy the episode. Do you guys remember a few years back when there's that meme going around the internet? Everyone was freaking out that they did surgery on a grape? Well, I had that same feeling of amazement when I found out that we can do surgery on a fetus, like an intrauterine fetus. To learn more about that, we're gonna hear from Doctor Fung Lim. He's the surgical director of the Fetal Care Center at Cincinnati Children's Hospital Medical Center. And we're gonna do a few of these episodes, but for this first one, we're gonna talk about how they treat congenital diaphragmatic hernia, intrauterine. Here's Doctor Lim. This animation shows a prenatal intervention of a congenital diaphragmatic hernia or CDH using phytoscopic endoluminal tracheal occlusion or fetal. One thing to note is that it's difficult to determine with imaging exactly how large the hole in the diaphragm is. When he says imaging, he means ultrasound and MRI. Now, ultrasound is usually the screening tool that we can use to find congenital diaphragmatic hernia in the fetus. But if you want the higher resolution imaging, you have to get the MRI. From that, you can get a lot of information about the pulmonary status of the fetus. What you are seeing here is a fetus who has no defect in the diaphragm and the anatomy is normal. In a mild diaphragmatic hernia as shown here, the left lung starts to shrink in size. Moving up the scale of severity, next we see a fetus with moderate diaphragmatic hernia. The left lung is getting smaller as the intestines and part of the liver push upwards. In the most severe cases, as shown here, the liver is occupying a good portion of the chest. The left lung is very small and even the right lung is shrinking. Now, fetuses with this severity of CDH are good candidates for feto. So, Doctor Lim, when is this procedure performed? The tracheal occlusion procedure is commonly performed at the gestation age of between 27 weeks and 29 weeks and 6 days. Anesthesia is induced by ultrasound guidance. A local anesthetic with numbing medication is injected into the mother. We then insert an introducer into the amniotic space. This allows us to place a feedoscope or a small camera through the introducer into the amniotic space. Once we locate the baby's mouth, we advance the fetoscope carefully into the fetal trachea or the windpipe, ensuring the scope is in good position. The ideal position is in the main trachea below the vocal cords, but above the carina before the trachea splits into the two main bronchi. We then insert a balloon into the airway. The balloon is inflated to completely occlude the trachea before it is detached and left in place. Because think about it, the fetal lung tissue is constantly creating this fluid. That escapes through the trachea normally, but if we occlude the trachea, then that fluid will continue to build up, the pressure will build up in that trachea, and for some reason, that seems to help the lungs develop. We confirm the proper position of the balloon before the feetoscope is removed. How long is the balloon left in place? The balloon is left in place for a few weeks to accelerate lung growth. Usually at about 34 weeks gestation, then we're gonna try and get rid of this balloon, and there are two ways to do that. If the baby is in proper position, we can puncture the balloon under ultrasound guidance as shown here. The deflated balloon is pushed out of the baby's trachea by the lung fluids and poses no risk to the baby's health. And if the baby's position doesn't allow for a needle puncture, we use a grasper to hold onto the balloon while a needle punctures the balloon. The deflated balloon is then removed from a baby's airway using the grasper. The mother and fetus are then monitored carefully for the remainder of the pregnancy. Ideally, the baby is delivered vaginally a term with a C-section reserved for the usual obstetrical reasons. So there you have it, one of many fetal procedures that we can do with advances in technology these days. So, did you hate this? Did you love it? Either way, leave us a comment, no matter where you are, whether you're on YouTube, Apple Podcasts, Stitcher, Spotify, SoundCloud, or the stay current pediatric surgery app. Download it today. It's in the Apple App Store, it's in the Google Play Store. If you're on YouTube, like and subscribe to our channel. We got a lot more video podcasts like this, and we got some great content cooking for you in the future. So, until next time, I'm Rod from Cincinnati Children's, and remember, knowledge should be free.
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