Fetal surgery

Abstract

Maternal fetal surgery for correction of an anatomic defect was first performed 30 years ago by Michael Harrison. At that time, the concept of the fetus as a patient was the subject of philosophical and ethical debate and the rationale and pre-requisites for prenatal surgical treatment were in evolution. Over the past three decades, the concept of the fetus as a patient has become commonly accepted and the ethical framework for maternal fetal intervention is now well developed. Improvements in prenatal diagnosis now provide certainty for the primary diagnosis and, in competent hands, can identify or exclude virtually all significant associated anomalies. Clinical experience with prenatally diagnosed fetuses has provided insight into the natural history of specific anomalies, improved our ability to predict the outcome for an individual fetus, and allowed more accurate selection of fetuses that will benefit from prenatal surgery. While application of open fetal surgery has remained limited to only a few anomalies, it is important to appreciate that the development of this field has accelerated technological progress in prenatal diagnosis and intervention, led to improved understanding of the pathophysiology and natural history of candidate disorders, allowed comprehensive counseling of prospective parents in centers with focused expertise in fetal anomalies, and driven the evolution of less invasive therapeutic approaches. In this chapter we will discuss the rationale and current indications for open fetal surgery, the evidence supporting its efficacy, and basic physiologic and technical considerations common to all fetal surgical interventions.