Pediatric Surgery Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
Universitat Autònoma de Barcelona, Barcelona, Spain.
Ultrasound Obstet Gynecol. 2018 Oct;52(4):452-457. doi: 10.1002/uog.19104. Epub 2018 Sep 10.
Fetoscopy for closure of open neural tube defects (NTD) remains controversial, as the use of patches or single-layer closure is not considered to meet the standards of good neurosurgical reconstruction. In this study, we describe a fetoscopic two-layer (myofascial and skin) closure technique for the treatment of NTD in five patients and report the preliminary anatomical outcome at birth.
From February to September 2017, five pregnant women with a fetus with a NTD, including three cases of myelomeningocele and two cases of myelocele, were operated on using a fetoscopic two-layer closure technique. In this technique, with the uterus exteriorized and using three 10-Fr ports, the placode is dissected from the surrounding tissue and detethered, removing the cystic tissue. The skin is undermined by blunt dissection and the defect is sutured to the midline in two layers (myofascial and skin) using a running 4/0 resorbable barbed suture.
Median gestational age at the procedure was 24 + 3 (range, 23 + 5 to 27 + 3) weeks. Surgery was successful in all cases, without any intraoperative complications. Median time in surgery was 180 (range, 140-180) min and median time for fetoscopy was 105 (range, 65-120) min. In terms of obstetric complications, three cases of premature rupture of membranes and one case of chorioamnionitis were recorded. Median gestational age at delivery was 34 + 1 (range, 25 + 4 to 37 + 2) weeks and two patients delivered vaginally. The closed defect was watertight with good quality tissue in all cases.
Fetoscopic two-layer closure of NTD may improve the quality of the tissue covering the defect, diminishing the need for postnatal surgical revision, and preserving the well-documented beneficial effects of prenatal closure on the neural tissue and hindbrain herniation. However, this technique may not be appropriate for those cases with wide diastasis of the myofascial layer or with a low quantity of available tissue. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
羊膜腔镜下神经管缺陷（NTD）的闭合术仍然存在争议，因为使用补片或单层闭合术不符合良好神经外科重建的标准。在这项研究中，我们描述了一种羊膜腔镜下双层（筋膜和皮肤）闭合技术，用于治疗 5 例 NTD 患者，并报告了出生时的初步解剖结果。
2017 年 2 月至 9 月，对 5 例 NTD 胎儿的孕妇（3 例脊髓脊膜膨出和 2 例脊髓膨出）进行了羊膜腔镜下双层闭合术。在该技术中，通过子宫外显化并使用 3 个 10Fr 端口，将胎膜从周围组织中分离出来并松解，去除囊性组织。通过钝性解剖将皮肤切开，并使用连续的 4/0 可吸收带刺缝线将缺陷缝合至中线双层（筋膜和皮肤）。
中位手术时的孕龄为 24+3（范围 23+5 至 27+3）周。所有病例手术均成功，无术中并发症。中位手术时间为 180 分钟（范围 140-180 分钟），中位羊膜镜时间为 105 分钟（范围 65-120 分钟）。在产科并发症方面，记录了 3 例胎膜早破和 1 例绒毛膜羊膜炎。中位分娩时的孕龄为 34+1（范围 25+4 至 37+2）周，2 例患者经阴道分娩。所有病例的封闭缺陷均为水密性，组织质量良好。
NTD 的羊膜腔镜下双层闭合术可能改善覆盖缺陷的组织质量，减少产后手术修复的需要，并保留产前闭合对神经组织和后脑疝有益的已有记录。然而，对于筋膜层间隙较大或组织量不足的病例，该技术可能并不适用。版权所有©2018 ISUOG。由 John Wiley & Sons Ltd 出版。
