FETAL ENDOSCOPIC TRACHEAL OCCLUSION (FETENDO-PLUG) FOR CONGENITAL DIAPHRAGMATIC-HERNIA

Despite recent advances in surgical technique, posthysterotomy preterm labor remains a major determinant of postoperative fetal morbidity an d mortality after in utero repair of congenital diaphragmatic hernia ( CDH). Temporary fetal tracheal occlusion, or ''PLUG'' (Plug the Lung U ntil it Grows), reverses the pulmonary hypoplasia seen in experimental models of CDH and provides an alternative treatment strategy for some fetuses with CDH. Adaptation of current, minimally invasive surgical technology to the PLUG technique allows treatment of CDH without openi ng the uterus. In this report the authors describe a video-fetoscopic, intrauterine technique of tracheal occlusion (called Fetendo-PLUG) th at could be used in human fetuses with CDH. The technique was develope d in four fetal lambs that underwent video-fetoscopic intervention at 110 days' gestation (full term, 145 days), having undergone open creat ion of diaphragmatic hernias at 75 days. After maternal laparotomy and uterine exposure, the fetal head was located and a 5-mm curved, ballo on-cuffed trocar was introduced through a uterine puncture directly in to the fetal oral cavity. A steerable ''bronchoscope'' (with an instru ment channel) was used to endoscopically intubate the trachea through the trocar, and the trocar was advanced over the bronchoscope and its balloon inflated to provide secure tracheal access below the vocal cor ds. Next, a 10 mm trocar was placed directly over the fetal neck, and the amniotic space was expanded with warm saline. A 5-mm laparoscope w as introduced, and under simultaneous, dual video-fetoscopic (endotrac heal and endoamniotic) visualization, a 1-mm nephrostomy puncture wire was advanced along the instrument channel of the bronchoscope, throug h the anterior wall of the trachea and fetal neck, into the amniotic s pace, then through the uterine wall to the outside. Withdrawal of the bronchoscope over the wire left a 5-mm endotracheal ''trocar channel'' along which a compressed, gelatin-encapsulated, polymeric foam insert (outer diameter, 4.8 mm) could be delivered by suture attachment to t he guide wire. Once the foam was in its final endotracheal position, d issolution of the gelatin membrane allowed expansion of the foam to pr oduce a water impervious tracheal occlusion. This two-trocar video-fet oscopic PLUG technique was performed successfully in all four fetuses, with a sequential decrease in operating time (median, 3.5 hours). Alt hough two fetuses aborted postoperatively, the other two were carried successfully to term and demonstrated the anticipated physiological ef fects of adequate tracheal occlusion at the time of delivery. Copyrigh t (C) 1996 By W.B. Saunders Company