As the COVID-19 pandemic continues to have a global impact, surgeons at Texas Children’s Fetal Center® have turned to technology to continue teaching their innovative, minimally-invasive technique for repairing spina bifida in-utero to fetal surgeons worldwide. Pioneered by a team at Texas Children’s in 2014 led by Dr. Michael Belfort, obstetrician-in-chief at Texas Children’s Pavilion for Women and chairman of the Department of Obstetrics and Gynecology at Baylor College of Medicine, the paradigm-shifting technique allows surgeons to access the fetal spine in a minimally-invasive way to repair neural tube defects. This world-first fetoscopic approach involves placing two very small ports (4 mm) into the uterus to allow the use of a fetoscope and tiny surgical instruments to repair the fetal spine. Texas Children’s has shown the benefits to the baby with this approach are the same as those obtained by teams using the large-scar approach, but, in contrast, after a fetoscopic spina bifida repair, the risk of preterm birth is significantly reduced. In fact, the average gestational age at birth of patients at Texas Children’s is 37-38 weeks compared with 34-35 weeks with the large-scar approach. Additionally, mothers can deliver vaginally since in the more than 90 cases done at Texas Children’s, there were no signs of harm to the uterus. Texas Children’s has done the most fetoscopic spina bifida repairs in the world, with 93 patients having undergone the procedure.
Major fetal surgery innovations, first researched and developed at Texas Children’s are now used worldwide by teams performing fetoscopic spina bifida repairs. Fetal surgeons at Texas Children’s have proctored and mentored many international fetal surgery teams and performed their fetoscopic technique in a number of countries including Israel, South Africa, Argentina, Belgium, Mexico, Colombia and Iran. In December 2019, the hospital held its first simulation training course for fetoscopic spina bifida repair, with 12 international teams of fetal surgeons attending from virtually every continent to learn how to perform the technique.
Recently, a team of fetal surgeons from Giesen/Marburg in Germany reached out to Texas Children’s to request training in the hospital’s fetoscopic approach. Several options were considered and a telemedicine approach was developed. In partnership with Storz, a multinational endoscope manufacturer, a secure real-time video connection was established between the operating room at Texas Children’s Pavilion for Women in Houston and a conference room in Germany. A sophisticated Storz robot with four separate cameras allowed full visual and verbal communication between the team performing the surgery and the team in Germany. A split screen showed real-time ultrasound images, an overall view of the operating room, an overhead view of the surgeon’s hands and the view from the endoscope inside the mother’s uterus. This was the first international broadcast of a fetoscopic spina bifida repair. The surgeons in Marburg were able to take notes, ask questions during and after the surgery, and were able to fully understand the procedure itself, as well as the team dynamic required. The team in Germany will continue their training on simulation models with virtual help from Texas Children’s as they progress toward their first case.
“Our mission has always been focused on providing the best possible outcomes to our patients and we are privileged to share our innovative techniques worldwide, so more children have a better chance at living with less complications from spina bifida,” Belfort said. “During a time where teams cannot travel to us, we continue to find ways to use technology to share our expertise with fetal surgeons nationally and internationally, so progress isn’t halted and more babies worldwide can have better outcomes.”
About spina bifida
Neural tube defect repair surgeries are performed on babies with Myelomeningocele, a developmental defect in which the spine is improperly formed and the spinal cord is open to and fused with the skin. The condition, also known as spina bifida or an open neural tube defect (NTD), occurs in 3.4 out of every 10,000 live births in the U.S. and is the most common permanently disabling birth defect for which there is no known cure.
NTDs are usually associated with motor impairment and hydrocephalus, or the buildup of cerebrospinal fluid in the brain, which requires surgical treatment to drain the fluid via an implanted device called a shunt. It’s common for children with spina bifida to have abnormal function of their bladder, bowels and legs. The goal of fetal surgical repair of spina bifida is to preserve leg function and reduce the need for a postnatal shunt.
The standard of care for spina bifida is neurosurgical closure of the defect in the first days of life; however, advances in fetal surgery and the landmark clinical trial, known as the Management of Myelomeningocele Study (MOMS Trial), proved a fetal surgical repair leads to decreased rates of hydrocephalus and improved leg function compared to a postnatal repair.
Through their research and outcomes data, Belfort and his team have shown performing the surgery fetoscopically yields the same outcome for the baby as the open repair, while being significantly less invasive for the mother. With a fetoscopic repair, the mother avoids having a large scar on her uterus, which decreases her risk of uterine rupture and preterm labor. It also lowers her risk of a potentially life-threatening condition called placenta accreta, in future pregnancies. Additionally, women who undergo fetoscopic repair are candidates for a vaginal delivery, which is not possible when open fetal surgery is performed.