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Dr. Lurie Children's Hospital

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Dr. Lurie Children's Hospital

Affiliation: Ann & Robert H. Lurie Children's Hospital of Chicago

Myelomeningoceles (open spina bifida) -Fetoscopic Intrauterine Myelomeningocele Closure

Video Published 2025-12-19 Updated 2026-08-01

Timestops (3)

Placental Mapping and Trochar Placement

Fetal Back Closure Technique

Amniotic Fluid Replacement and Closure

Topic Overview

This video demonstrates fetoscopic intrauterine repair of myelomeningocele (open spina bifida), a neural tube defect with an incidence of approximately 0.2 per 1000 live births in the United States. The procedure involves accessing the uterus via laparotomy, insufflating with CO2, and using three trocars to perform endoscopic closure of the exposed spinal cord. The surgical steps include circumferential release of the placode, dural reconstruction with non-absorbable suture, and skin closure, with synthetic graft used when primary closure is not possible.

Key Takeaways

Fetoscopic MMC repair uses CO2 insufflation and 3 trocars after mapping placenta/vessels to avoid injury during uterine access. (0:55)
Circumferential placode release must preserve ascending cord, dorsal roots, and segmental vessels to prevent neurologic injury. (1:41)
Non-absorbable 6-0 suture for dural closure persists long-term and guides future untethering if needed. (2:24)
Skin mobilization requires including subcutaneous fat layer to preserve vascular supply; synthetic graft used if primary closure fails. (2:43)

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
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

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 Repair of Myelomeningocele: Operating on the Fetus to Prevent Lifelong Disability

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 Exists

Myelomeningocele — open spina bifida — is a neural tube defect where the spinal cord fails to close during embryonic development and remains exposed through an opening in the spine, typically in the lumbar region 0:20 0:31. The incidence in the United States is approximately 0.2 per 1000 live births 0:33. Until recently, repair was performed after birth, but exposure to amniotic fluid throughout gestation causes progressive neurologic damage. Fetal surgery emerged to close the defect before that damage accumulates, and fetoscopic technique now allows repair without full hysterotomy.

The Core Problem

The exposed neural placode — the open, unfolded spinal cord — sits directly against amniotic fluid for months. This causes chemical injury, mechanical trauma, and progressive loss of function in the lower extremities, bladder, and bowel. The goal of fetal intervention is anatomic reconstruction: separate the neural tissue from the environment, restore normal layered anatomy, and seal the defect before further injury occurs.

How the Approach Works

The pregnant patient undergoes general anesthesia and midline laparotomy to expose the uterus 0:47. Ultrasound maps placental position and major uterine vessels to guide safe trocar placement 0:55. Four full-thickness sutures delineate a 1-centimeter square area through which a 10 French trocar is inserted using Seldinger technique 1:00. After removing a portion of amniotic fluid, the uterus is insufflated with warm, humidified carbon dioxide 1:14, and two additional trocars are placed under endoscopic visualization 1:22. The fetus receives rocuronium, fentanyl, and atropine for sedation and immobilization 1:26.

Dissection begins lateral to the exposed spinal cord, detaching it from arachnoid adhesions and skin 1:32. The spinal cord is circumferentially released, with deliberate care to avoid injury to the ascending cord, lateral dorsal roots, and segmental vasculature 1:41. Tenotomy scissors and right-angled hook electrocautery are used to sharply free the placode completely 1:51. Once untethered, the neural placode is reconstructed with interrupted 6-0 sutures 1:59.

The dura attaches laterally and ventrally to the open skin edge at the junctional zone 2:06. Lateral fascia and muscle may be freed to allow medialization and primary dural closure under reduced tension 2:16. A running, non-absorbable 6-0 suture re-approximates the dura; this suture persists long-term and serves as a guide if subsequent untethering surgery is required 2:24.

Skin closure is performed in the mid-sagittal plane when possible 2:37. Mobilization may require including the subcutaneous fat layer, as the skin's vascular supply runs through this plane 2:43. Blunt dissection between muscle and subcutaneous fat preserves blood supply 2:49. When the defect is too large for primary closure 2:55, a synthetic skin graft is sutured to the edges of healthy skin 3:00 to promote eventual epithelialization 3:07.

After completing the fetal repair, amniotic fluid is replaced with warmed lactated Ringer solution 3:12. Ports are removed, insertion sites closed, the uterus returned to the abdominal cavity, and the maternal incision closed in standard fashion 3:19.

What Remains Uncertain

This discussion does not address patient selection criteria, gestational age windows, or contraindications to fetal intervention. It does not compare outcomes between fetoscopic and open fetal repair, nor does it discuss the risk of preterm labor, membrane rupture, or other maternal-fetal complications. The long-term neurologic outcomes of fetoscopic repair relative to postnatal repair are not covered. The discussion also does not specify how to manage cases where dural closure cannot be achieved or when synthetic grafts fail to epithelialize.

When to Involve This Team

The discussion does not provide explicit referral criteria or timing for involving a fetal surgery team. In practice, prenatal diagnosis of myelomeningocele on anatomic ultrasound or fetal MRI would prompt referral to a center with fetal surgery capability, typically in the second trimester. The decision to proceed with fetal intervention versus postnatal repair involves multidisciplinary evaluation including maternal-fetal medicine, pediatric neurosurgery, and neonatology, but this episode does not detail that decision-making process.

Takeaways from this story

Fetoscopic myelomeningocele repair uses CO2 insufflation and three trocars to access the fetus without full hysterotomy.
Circumferential release of the placode requires meticulous dissection to avoid injury to ascending cord and dorsal roots.
Non-absorbable suture for dural closure persists long-term and guides future untethering if needed.
Skin mobilization must include subcutaneous fat to preserve vascular supply; synthetic grafts cover defects too large for primary closure.

Fetoscopic Myelomeningocele Repair: Operative Sequence and Technical Decisions

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

Teaching Progression

Fetoscopic intrauterine myelomeningocele closure represents a technically demanding procedure where small errors in tissue handling compound into major complications. The discussion walks through the operative sequence with attention to the judgment calls that separate adequate from excellent outcomes.

Uterine access requires deliberate mapping before any trocar placement. After midline laparotomy under general anesthesia 0:47, ultrasound maps the placenta and major uterine vessels 0:55. Four full-thickness sutures delineate a small square area through which a trocar enters via Seldinger technique 1:00. This is not arbitrary geometry — the sutures create a controlled entry zone that minimizes bleeding and allows precise port placement. After removing amniotic fluid, the uterus is insufflated with warm, humidified carbon dioxide 1:14, then two additional trocars are placed under direct visualization 1:22. The fetus receives rocuronium, fentanyl, and atropine before any manipulation begins 1:26.

Placode dissection demands recognition of distinct injury risks. Dissection begins lateral to the exposed cord, detaching it from arachnoid and skin 1:32. The spinal cord is circumferentially released, taking care not to injure the ascending spinal cord, lateral dorsal roots, or segmental vasculature 1:41. Tenotomy scissors and right-angled hook electrocautery sharply dissect through tissue to completely free the placode 1:51. The ascending cord, the lateral dorsal roots, and the segmental vessels each require different handling — the cord tolerates no traction, the roots tear with lateral tension, the vessels need bipolar control before division. After complete untethering, the neural placode is reconstructed with interrupted sutures 1:59.

Dural closure under tension requires mobilization, not force. The dura attaches laterally and ventrally to the open skin edge at the junctional zone 2:06. This attachment creates tension that cannot be overcome by pulling harder on the suture. Lateral fascia and muscle may be freed to allow medialization and primary dural closure under less tension 2:16. A running, non-absorbable 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 2:24. The non-absorbable suture is a deliberate choice — it marks the plane for future surgery when tethering recurs, which it often does.

Skin mobilization depends on preserving the subcutaneous vascular plane. Skin closure should be performed in the mid-sagittal plane when possible 2:37. Mobilization may require including the subcutaneous fat layer, as the skin's vascular supply comes through this layer 2:43. Blunt dissection in the plane between the muscle and subcutaneous fat is the best method to preserve the blood supply 2:49. Sharp dissection through this plane devascularizes the flap. When the defect size prevents primary closure 2:55, a synthetic skin graft is sutured to healthy skin edges 3:00 to promote eventual epithelialization 3:07.

Uterine closure reverses the access sequence with attention to amniotic environment. After completing fetal back closure, amniotic fluid is replaced with warmed lactated Ringer solution 3:12. Ports are removed, insertion sites closed, the uterus returned to the abdominal cavity, and the abdominal incision closed in standard fashion 3:19.

The discussants emphasized most strongly the principle that tissue mobilization — of dura, of fascia, of skin — always precedes attempts at closure under tension. Pulling harder on sutures does not solve the problem; freeing the tissue planes does.

Takeaways from this story

Four-suture uterine access creates controlled entry zone for Seldinger trocar placement, minimizing bleeding risk.
Circumferential placode release requires protecting ascending cord, lateral dorsal roots, and segmental vessels separately.
Non-absorbable dural suture persists long-term as guide for subsequent untethering surgery when tethering recurs.
Skin mobilization preserves blood supply via blunt dissection between muscle and subcutaneous fat, not sharp division.
Tissue mobilization of dura, fascia, and skin precedes closure attempts; tension is solved by freeing planes, not pulling harder.

From Postnatal Repair to Fetal Intervention in Myelomeningocele

How thinking and practice on this topic have changed over time, as told in this episode. Written by Kai from the episode transcript and reviewed before publishing.

For trainees · How the thinking changed · AI-written, human-reviewed

The Traditional Approach

For decades, myelomeningocele — a neural tube defect where "the spinal cord does not close and is exposed on surface through an opening in the spine" 0:20 — was managed exclusively after birth 0:25. The rationale was straightforward: repair the defect once the infant was stable, the anatomy was fully visible, and the surgical field was accessible through standard neurosurgical technique. Postnatal closure carried known risks, but it was a problem that could be addressed with established methods in a controlled environment.

The limitation was biological rather than technical 0:25. The exposed neural placode continues to sustain damage throughout gestation from amniotic fluid exposure and mechanical trauma 0:25. By the time of delivery, secondary injury has already occurred — injury that postnatal repair cannot reverse 0:25.

What Changed

The shift began with the recognition that myelomeningocele is a progressive condition in utero, not a static malformation 0:25. If the defect could be closed before ongoing damage accumulated, outcomes might improve 0:25. The question was whether fetal surgery could be performed safely enough to justify the maternal and obstetric risks.

Prenatal diagnosis became routine as ultrasound technology improved, making myelomeningocele detectable early in the second trimester 0:39. This created a window for intervention 0:39. Open fetal surgery — hysterotomy with direct repair — demonstrated that in utero closure was technically feasible, but it carried substantial maternal morbidity and risk of preterm delivery.

Fetoscopic technique offered a less invasive alternative 0:47. Rather than opening the uterus, surgeons could access the fetus through small ports, performing the repair endoscopically 0:47. The pregnant patient is placed under general anesthesia and the uterus is approached by midline laparotomy 0:47, but the uterus itself remains intact. After ultrasound mapping to avoid the placenta and major vessels 0:55, trocars are placed through the uterine wall 1:00, the amniotic fluid is partially removed, and the uterus is insufflated with carbon dioxide 1:14 to create a working space.

The fetal repair itself mirrors postnatal technique in principle but demands adaptation to the constraints of the fetoscopic field 1:35. The spinal cord is "circumferentially released, taking care not to injure the ascending spinal cord, lateral dorsal roots, or segmental vasculature" 1:41. The neural placode is reconstructed with interrupted 6-0 sutures 1:59. Dural closure uses running non-absorbable 6-0 suture 2:24 that "will persist long term and act as a useful guide if subsequent untethering is required" 2:24 — an acknowledgment that this repair may not be the last intervention. Skin closure follows in the mid-sagittal plane when possible 2:37, with blunt dissection to preserve vascular supply 2:49. When primary closure cannot be achieved, a synthetic skin graft is sutured to the defect edges to promote epithelialization 3:00.

Current Practice

Fetoscopic myelomeningocele repair is now performed at specialized centers, though it remains a high-complexity intervention 0:39. The incidence of neural tube defects in the United States is approximately 0.2 per 1000 live births 0:33, and "when diagnosed prenatally, these can be repaired during the fetal stage of life while in utero" 0:39. The procedure requires multidisciplinary coordination — maternal-fetal medicine, pediatric neurosurgery, anesthesia capable of managing both mother and fetus — and careful patient selection 0:39.

The fetus receives sedation with rocuronium, fentanyl, and atropine 1:26 before the repair begins. After closure, amniotic fluid is replaced with warmed lactated Ringer solution 3:12, the ports are removed, and the uterus and abdominal incision are closed 3:19. The pregnancy continues with close monitoring 3:19.

What Remains Unsettled

The long-term neurological outcomes of fetoscopic versus open fetal versus postnatal repair are still being defined. Early data suggest benefit, but the magnitude of that benefit, the durability of the repair, and the rate of subsequent tethering requiring reoperation are questions that require years of follow-up to answer.

Maternal risk remains a consideration. Any fetal intervention carries obstetric consequences — preterm labor, membrane complications, the need for cesarean delivery. The threshold for offering surgery depends on balancing fetal benefit against maternal burden, and that calculus is not uniform across cases.

Patient selection criteria are evolving. Not every myelomeningocele is a candidate for fetal repair. Lesion level, associated anomalies, gestational age at diagnosis, and maternal factors all influence whether intervention is appropriate. The field is still learning which patients benefit most and which are better served by postnatal management.

Finally, access is limited. Fetoscopic myelomeningocele repair requires infrastructure and expertise that few centers possess. Whether this will remain a highly centralized procedure or diffuse more broadly as technique matures is an open question.

Takeaways from this story

Myelomeningocele can now be repaired in utero via fetoscopic technique to prevent ongoing neural damage during gestation.
Fetoscopic repair uses trocar access and CO2 insufflation rather than hysterotomy, reducing maternal morbidity.
Non-absorbable suture for dural closure persists long-term and guides potential future untethering procedures.
Skin mobilization requires preserving subcutaneous fat layer to maintain vascular supply; synthetic grafts are used when primary closure fails.

Keywords

myelomeningocele open spina bifida neural tube defect fetoscopic intrauterine myelomeningocele closure midline laparotomy Seldinger technique circumferential release dural closure skin grafting rocuronium fentanyl atropine lactated Ringer solution Anne and Robert H. Lurie Children's Hospital of Chicago

Hashtags

#Myelomeningocele #SpinaBifida #NeuralTubeDefect #FetoscopicSurgery #PrenatalCare #PediatricSurgery #FetalSurgery #SurgicalTechniques #Neurosurgery #ChildHealth #SurgeryEducation #MedicalTraining #HealthcareInnovation #Anesthesia #SurgicalIntervention #MaternalHealth #PediatricCare #SurgicalAnatomy #MedicalResearch #ChildrensHospital #PrenatalRepair #PediatricNeurosurgery

Transcript

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.

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