Content area
Full Text
Surg Endosc (2010) 24:432444 DOI 10.1007/s00464-009-0579-z
Partial amniotic carbon dioxide insufation (PACI) during minimally invasive fetoscopic surgery: early clinical experience in humans
Thomas Kohl Kristina Tchatcheva Julia Weinbach Rudolf Hering Peter Kozlowski Rdiger Stressig Ulrich Gembruch
Received: 20 January 2009 / Accepted: 18 May 2009 / Published online: 30 June 2009 Springer Science+Business Media, LLC 2009
AbstractBackground The technical performance of minimally invasive fetoscopic surgery may be severely hindered by poor visualization of intra-amniotic contents. Partial amniotic carbon dioxide insufation (PACI) allows the visual limitations of operating within the uid environment to be overcome.
Patients and methods When amniotic uid exchange failed to improve fetoscopic visualization, PACI was attempted during 37 fetoscopic procedures between 17 ? 5 and 33 ? 2 weeks of gestation. PACI was attempted with ltered carbon dioxide using a commercially available insufator via one to three trocars that were percutaneously introduced into the amniotic cavity. The maximum pressure during PACI was limited by the maximum insufation pressure (30 mmHg) generated by the insufator. Improvement of fetoscopic visualization as well as technical, maternal, and fetal safety aspects surrounding PACI were analyzed.
Results PACI could successfully be instituted in 36 of the 37 procedures. In one case, when in the presence of
increased uterine tone the opening pressure exceeded the maximum insufation pressure of the insufator, the strategy was abandoned. In all cases where PACI could be instituted successfully, the approach offered far superior visualization of the fetoscopic procedure than would have been possible within amniotic uid. Acute or chronic maternal or fetal complications were observed in only one case (intraoperative membrane rupture).
Conclusion PACI greatly improves fetal visualization during fetoscopic interventions when fetoscopy within uid meets with difculties. Continued assessment of its benets, risks, and safety margins at specialist centers is required.
Keywords Fetoscopy Fetal surgery Insufation
Carbon dioxide Spina bida Monochorionic twins
Umbilical cord ligation Twin-to-twin transfusion
syndrome (TTTS) Discordant gemini
The technical performance of minimally invasive fetoscopic surgery may be severely hindered by poor visualization of intra-amniotic contents. Intrinsic to this problem is the limited amount of light that can be transmitted into the amniotic cavity via small-caliber fetoscopes. This limitation commonly becomes further aggravated when the little light that the fetal surgeon has becomes absorbed or scattered within...