Myelomeningoceles (open spina bifida) -Fetoscopic Intrauterine Myelomeningocele Closure

Who's speaking

• Speaker 1 — host
• Speaker 2 — guest

Chapters

• 0:00Introduction and Myelomeningocele Overview — Introduction to the video topic and definition of myelomeningocele as a neural tube defect where the spinal cord does not close and is exposed through an opening in the spine, typically in the low back region.
• 0:47Initial Surgical Access and Preparation — Patient preparation under general anesthesia, uterine access via midline laparotomy, ultrasound mapping of placenta and vessels, trocar placement, amniotic fluid removal, and uterine insufflation with CO2. Fetal sedation is administered.
• 1:32Myelomeningocele Dissection and Neural Reconstruction — Circumferential dissection and release of the spinal cord from arachnoid and skin, placode reconstruction with interrupted sutures, and dural identification and closure with non-absorbable suture.
• 2:37Skin Closure and Grafting — Skin mobilization and closure in the mid-sagittal plane, with blunt dissection to preserve vascular supply. Synthetic skin graft may be used when primary closure is not possible.
• 3:12Closure and Summary — Amniotic fluid replacement with lactated Ringer solution, port removal, uterine and abdominal closure, and summary statement about fetoscopic repair of open spina bifida.

Key claims

• 0:20Myelomeningocele is a neural tube defect where the spinal cord does not close and is exposed on surface through an opening in the spine — Speaker 1
• 0:31Myelomeningocele usually occurs in the low back region — Speaker 1
• 0:33The incidence of neural tube defects is around 0.2 per 1000 live births in the United States — Speaker 1
• 0:39When diagnosed prenatally, myelomeningoceles can be repaired during the fetal stage of life while in utero — Speaker 1
• 0:47The pregnant patient is placed under general anesthesia and the uterus is approached by a midline laparotomy — Speaker 1
• 0:55An ultrasound is used to map the location of the placenta and major vessels on the uterine surface — Speaker 1
• 1:00Four 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 Seldinger technique — Speaker 2
• 1:14After removing a portion of the amniotic fluid, the uterus is insufflated with warm, humidified carbon dioxide — Speaker 2
• 1:22Two subsequent trocars are placed under endoscopic visualization — Speaker 1
• 1:26Prior to surgical intervention, the fetus is administered a sedative cocktail of rocuronium, fentanyl, and atropine — Speaker 1
• 1:32Dissection of the myelomeningocele begins lateral to the exposed spinal cord, detaching it from the arachnoid and skin — Speaker 2
• 1:41The spinal cord is circumferentially released, taking care not to injure the ascending spinal cord, lateral dorsal roots, or segmental vasculature — Speaker 2
• 1:51Tenotomy scissors and right-angled hook electrocautery are used to sharply dissect through the tissue to completely free the placode — Speaker 1
• 1:59The neural placode is reconstructed with interrupted 6-0 sutures after it is completely untethered from the skin — Speaker 1
• 2:06The dura attaches laterally and ventrally to the open skin edge at the junctional zone — Speaker 2
• 2:16Lateral fascia and muscle may be freed to allow medialization and primary closure of the dura under less tension — Speaker 1
• 2:24A running, non-absorbable 6-0 suture is utilized to re-approximate the dura, which will persist long term and act as a useful guide if subsequent untethering is required — Speaker 2
• 2:37Skin closure should be performed in the mid-sagittal plane when possible — Speaker 1
• 2:43Skin mobilization may require including the subcutaneous fat layer, as the skin's vascular supply comes through this layer — Speaker 1
• 2:49Blunt dissection in the plane between the muscle and subcutaneous fat is the best method to preserve the blood supply — Speaker 1
• 2:55In some cases, the size of the skin defect may prevent primary skin closure — Speaker 2
• 3:00A synthetic skin graft may be utilized and sutured to the edges of the healthy skin when primary closure is not possible — Speaker 2
• 3:07The synthetic skin graft will promote eventual epithelialization of the open defect — Speaker 2
• 3:12After completing the fetal back closure, the amniotic fluid is replaced in the uterus with warmed, lactated Ringer solution — Speaker 1
• 3:19The 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 — Speaker 1