The Combined Method: A Novel Access Technique for Fetal Endoscopic Surgery By Tatsuo Kuroda, Morihiro Saeki, Kiyoshi Tanaka, Makoto Komura, Toshiro Honna, Miwako Nakano, Masahiko Sugiyama, Satoshi Nakagawa, and Katsuyuki Miyasaka Tokyo, Japan Be&ground/Purpose: To develop practical and less invasive techniques for fetal endoscopic surgery, new methods of lifting the uterine wall to allow fetal surgery without maternal laparotomy were developed and assessed. Methods: Fetal endoscopic surgical procedures, including tracheostomy and umbilical vascular cannulation, were per- formed using one of the three methods to enter the uterus without maternal laparotomy in pregnant goats (n = 6; 105 to 115 days’ gestation): (1) direct uterine lifting with an air- cushion device; (2) indirect uterine lifting, in which the uterine wall was fixed to the maternal abdominal wall using balloon tip ports inserted percutaneously by Seldinger’s method, then the maternal abdomen was lifted mechanically; and (3) combined method, in which low pressure CO2 (5 mm Hg for initial inflation and 2 mm Hg for maintenance) was insufflated into the uterus in addition to the indirect uterine lifting cited above. Results: The direct uterine lifting caused massive injury of myometrium and uterine membranes. The creation of intra- uterine space and the protection of the membranes were not accomplished effectively by the indirect uterine lifting only. The combined method provided the adequate intrauterine space and excellent endoscopic visibility for completion of the endoscopic procedures with minimal uterine injury. Conclusion: The fetal endoscopic surgery may be accom- plished simply and safely by the combined method, a novel technique of uterine lifting to allow fetal surgery without maternal laparotomy. J Pediatr Surg 33:7647-7644. Copyright o 7998 by W.B. Saunders Company. INDEX WORDS: Fetal endoscopic surgery, gasless laparo- scopic method. F ETAL ENDOSCOPIC SURGERY is expected to be an alternative to open fetal surgery in the future, because the technique may enable the in utero repair of the selected anomalies with minimal invasion and less fetal risk.1,2 Although several methods of fetal endoscopic surgery have been described,3-7 the optimal method to approach the fetus has not yet been established. As an initial step toward developing endoscopic fetal surgery, a novel method to approach the fetus without maternal laparotomy and uterine exposure has been developed. To minimize the effects on uteroplacental blood flow and fetal oxygenation, a gasless laparoscopic technique was used for the maternal abdomen, because the gasless method rarely affects the respiration and hemodynamics8 This technique also was adopted for the creation of the intrauterine space. The purpose of the current study is to assess the feasibility of our new access methods. MATERIALS AND METHODS Pregnant goats (105 to 115 days’ gestation; full term, 150 days) were placed in semilateral position and anesthetized with sevoflurane (1 .O% for initial induction and 0.5% for maintenance) in 100% oxygen and pancuronium bromide (0.4 mg/kg bolus intravenous as the initial dose and 0.6 mg/kg/h for maintenance) with endotracheal mtubation, while fetal heart rate was monitored through the maternal abdomen or directly using a probe. The uterus was entered using one of the following methods (n = 6). (1) In the direct uterine lifting method (Fig 1 A), the uterine wall was lifted directly in the maternal abdomen with an air-cushion device (Airlift, Origin Med Systems Inc, CA) mechanically, which was inserted into the uterus through a l-cm-long incision on the maternal abdomen and uterus. The endoscope (Olympus A5290A. 5.5 mm in diameter, Olympus, Japan) was inserted into the amniotic cavity through the center hole of device followed by two additional ports (5-mm Gas less Trocar, Origin Med Systems Inc, CA). (2) In the indirect uterine lifting method (Fig lB), the gravid uterus was punctured with a 16-gauge needle through the maternal abdominal wall under ultrasonographic guidance, then a 0.046-inch guide wire was inserted through the needle into the amniotic cavity. A balloon tip port with a holder-sponge (lo-mm Blunt Tip Trocar, Origin Med Systems Inc, CA) was inserted into the amniotic cavity by Seldinger’s method after a small mcision was made over the wire. The port was placed on the uterine wall aided by a purse string suture with 2-O polypropylene. The anterior uterine wall and the maternal abdominal wall were held and fixed together by the inflated balloon and the holder sponge of the port. Three balloon tip ports were inserted percutaneously in a similar way. The anterior uterine wall was lifted indirectly by the mechanical lifting of the maternal abdominal wall using Laparolift system (Origin Med Systems Inc. CA) for creating intrauterine space. The endoscope could then be inserted through either one of the ports. (3) In the gas-lifting hybrid or combined method (Fig lC), three balloon tip ports were From the Department of Surgery, National Children’s Hospital and Pathophysiology Laboratory, National Children’s Medical Research Center; Tokyo, Japan. Presented at the 3lst Annual Meeting of the PaciJc Association of Pediatric Surgeons, Maul, Hawaii, June 9-13, 1998. Address repnnt requests to Tatsuo Kuroda, MD, Department oj Surgery, National Children’s Hospital, 3-35-31 Taishido, Setagaya-ku, Tokyo 154-8509, Japan. Copyright 0 1998 by WB. Saunders Company 0022.3468/98/3311-0013$03.00/O Journal ofPediatric Surgery, Vol33, No 11 (November), 1998: pp 1641-1644 1641