Myelomeningoceles (open spina bifida) -Fetoscopic Intrauterine Myelomeningocele Closure

Globalcast MD along with Anne and Robert H. Lurry Children's Hospital of Chicago, creating a healthier future for every child. In today's video from Luie Children's Hospital of Chicago, we will learn about myelomeningoceles or open spina bifida, and we will walk through fetoscopic intrauterine myelomeningocele closure. First, let's talk about myelomeningocele or open spina bifida, which is a neural tube defect. Myelomeningocele is when the spinal cord does not close and is exposed on surface through an opening in the spine. It usually occurs in the low back region. The incidence of neural tube defects is around 0.2 per 1000 live births in the United States. When diagnosed prenatally, these can be repaired during the fetal stage of life while in utero. Let's hear how the surgeons at Lurry Children's approach one such case. First, the pregnant patient is taken to the OR, placed under general anesthesia, and the uterus is then approached by a midline laparotomy. An ultrasound is used to map the location of the placenta and major vessels on the uterine surface. Under ultrasonic guidance, 4 full thickness sutures are placed through the uterine wall to delineate a 1 centimeter square area through which a 10 French trochar is inserted using Selinger technique. After removing a portion of the amniotic fluid, the uterus is insufflated with warm, humidified carbon dioxide. Next, two subsequent trochars are placed under endoscopic visualization. Prior to surgical intervention, the fetus is administered a sedative cocktail of rock uranium, fentanyl, and atropine. Dissection of the myelomeningocele begins lateral to the exposed spinal cord, detaching it from the arachnoid and skin. The spinal cord is circumferentially released, taking care not to injure the ascending spinal cord, lateral dorsal roots, or segmental vasculature. The surgeon next uses tenotomy scissors and right-angled hook electrocautery to sharply dissect through the tissue. This completely frees the placode. The neural placode is then reconstructed with interrupted 60 sutures after it is completely untethered from the skin. The dura attaches laterally and ventrally to the open skin edge at the junctional zone. The lateral extent of the dura is identified and detached. This can be an area of great tension. Thus, lateral fascia and muscle may be freed to allow medialization and primary closure of the dura under less tension. A running, non-absorbable sixo suture is utilized to re-approximate the delicate dura, which will persist long term and act as a useful guide if subsequent untethering is required. Next, the surgeon will need to close the skin, which should be performed in the mid-sagittal plane when possible. This may require mobilization of the skin, including subcutaneous fat layer, as the skin's vascular supply comes through this layer. Blunt dissection in the plane between the muscle and subcutaneous fat is the best method to preserve the blood supply. In some cases, the size of the skin defect may prevent primary skin closure. Consequently, a synthetic skin graft may be utilized and sutured to the edges of the healthy skin. This graft will then promote eventual epithelialization of the open defect. After completing the fetal back closure, the amniotic fluid is replaced in the uterus with warmed, lactated ringer solution. The ports are removed and the insertion sites are closed. The uterus is returned to the abdominal cavity and the abdominal incision is closed in the standard fashion. In summary, open spina bifida defects can be repaired in utero via fetoscopic technique. Global Cat MD along with Anne and Robert H. Lurry Children's Hospital of Chicago, creating a healthier future for every child.