>> SOMETIMES POTENTIAL RISKS TO THE BABY ARE SO GREAT THAT IT
NECESSITATES, KIND OF, A TEAM APPROACH TO DELIVERY.
>> TWO ADJACENT OPERATING ROOMS — ONE OPERATING ROOM FOR
THE MOTHER AND THE OBSTETRICAL TEAM WITH A NUMBER OF
OBSTETRICIANS, ADVANCED PRACTICE NURSES, ANESTHESIOLOGISTS,
AND SO FORTH.
AND THEN THE ADJACENT OPERATING ROOM WHERE THE PEDIATRIC
SURGEON, THE NEONATOLOGIST, APPROPRIATE NEONATAL SURGICAL
NURSES, ADVANCED PRACTICE NURSES,
ARE READY TO RESUSCITATE THE BABY AND, IF NEED BE,
IF THERE'S AN ISSUE WITH THE TUMOR
SUCH AS A RUPTURE, TO DEAL WITH IT ON AN EMERGENT BASIS.
SO WHEN WE MAKE THE DIAGNOSIS OF SACROCOCCYGEAL TERATOMA,
PLANNED CESAREAN DELIVERY IS RECOMMENDED WITH THE TEAM THERE
TO RESUSCITATE THE NEWBORN, IF THAT'S REQUIRED.
>> IT'S UNDERAPPRECIATED HOW LARGE THESE TUMORS ARE,
AND HOW DIFFICULT THEY ARE TO DEAL WITH THROUGH STANDARD SORTS
OF HYSTEROTOMIES, OR INCISIONS IN THE UTERUS.
>> SOMETIMES THE MASSES ARE SO BIG THAT WE ... THE ONLY OPTION WE
HAVE FOR DELIVERY IS TO DO A CESAREAN SECTION WHERE WE MAKE
A CLASSICAL-TYPE INCISION, WHICH IS THE VERTICAL UP AND DOWN,
INCISION THAT PROVIDES US WITH MORE ROOM TO DELIVER THE BABY
AND THE VERY, VERY LARGE MASS.
>> WE'LL SOMETIMES OPEN A UTERUS OVER ITS ENTIRE LENGTH TO
DELIVER ONE OF THESE TERATOMAS AND THAT PREVENTS RUPTURE AT
THE TIME OF DELIVERY, WHICH CAN ALSO BE A LETHAL EVENT.
>> THE GOAL IS TO DO A SMOOTH DELIVERY WITH AN INTACT TUMOR,
A STABLE BABY, AND THEN TRANSFER THE BABY TO THE INTENSIVE CARE
NURSERY.
>> WHERE THE BABY CAN STABILIZE GOING FROM FETAL LIFE
TO NEWBORN LIFE AND BECOME A MUCH BETTER SURGICAL PATIENT.
>> DELIVERIES FOR CERVICAL TERATOMA ARE A SPECIAL
CIRCUMSTANCE.
IF YOU CAN IMAGINE A TUMOR THAT'S REALLY THIS SIZE AND
BENDING THE FETAL HEAD BACKWARD, IT COMPRESSES THE AIRWAY.
>> IN SOME CIRCUMSTANCES IT IS IMPOSSIBLE DESPITE LARYNGOSCOPY,
BRONCHOSCOPY TO GET AN ENDOTRACHEAL TUBE THROUGH
THE MOUTH BEYOND THE TERATOMA BECAUSE THE AIRWAY IS FREQUENTLY
CRUSHED BY THE TERATOMA.
>> AND THAT'S A SCENARIO WHERE WE MIGHT TALK ABOUT
AN EXIT DELIVERY.
>> THE EXIT PROCEDURE IS A PROCEDURE THAT'S DEVELOPED
TO ALLOW US TIME TO PLACE AN AIRWAY ON A FETUS.
>> IT'S REALLY A HUGE TEAM EFFORT WITH ANESTHESIOLOGISTS
AND SURGEONS AND OBSTETRICIANS AND FETAL ECHOCARDIOGRAPHY
SUPPORT TO MAKE SURE THAT THE BABY IS VERY,
VERY STABLE AND EVERYBODY PLAYS A LITTLE BIT DIFFERENT ROLE.
>> THE FETAL HEAD, THE TERATOMA IN THE NECK,
THE ARMS ARE DELIVERED OUT OF THE UTERUS.
THE BOTTOM HALF OF THE FETUS STAYS IN THE UTERUS AND THE
FETUS IS STILL HOOKED UP TO THE PLACENTA VIA THE UMBILICAL CORD
TO MAINTAIN THAT MATERNAL-PLACENTAL-FETAL
CIRCULATION, BASICALLY HEART-LUNG BYPASS FOR THE FETUS,
IF YOU WILL.
>> THE PLACENTA NORMALLY PROVIDES OXYGENATION FOR THE
FETUS AND, AS LONG AS THE PLACENTA IS RECEIVING BLOOD
FLOW, THEN THE FETUS IS FINE.
>> SO THE EXIT APPROACH IS A WAY TO CONVERT WHAT COULD BE AN
EMERGENCY OR CATASTROPHE INTO A CONTROLLED SITUATION IN WHICH
AIRWAY CONTROL CAN BE OBTAINED.
>> AND THEN ONCE THAT AIRWAY'S ESTABLISHED,
WE CAN DIVIDE THE UMBILICAL CORD AND TAKE THE BABY TO AN ADJACENT
OPERATING ROOM AND ACTUALLY REMOVE THE TUMOR UNDER
CONTROLLED CIRCUMSTANCES.
>> WE HAVE EXPERIENCE WITH MORE THAN 70 EXIT PROCEDURES,
THE LARGEST EXPERIENCE IN THE WORLD, AND MANY OF THOSE CASES
WERE FOR CERVICAL TERATOMAS.
>> THE SAME CAN BE SAID FOR MEDIASTINAL TERATOMAS.
IF YOU CAN IMAGINE A TUMOR INSIDE THE CHEST THAT'S TAKING
UP SPACE, COMPRESSING ADJACENT STRUCTURES AWAY FROM IT,
IT CAN COMPRESS THE INTRATHORACIC OR THE AIRWAY
WITHIN THE CHEST CAVITY.
AND THAT'S REALLY THE SAME SORT OF A SITUATION.
>> IN THOSE CASES WHEN WE LOOK AT DELIVERY,
WE HAVE TO PLAN DELIVERY TO GET THE MASS OUT.
AND THAT'S ANOTHER SCENARIO WHERE AN EXIT DELIVERY WOULD
BE APPROPRIATE IN MANY CASES.
>> WE ACTUALLY OPEN THE FETAL CHEST AND RELIEVE THE
COMPRESSION OF THE TUMOR AND THEN WE'RE ABLE TO ESTABLISH
AN AIRWAY.
MOST OF THE TIME WE ACTUALLY GO AHEAD AND REMOVE THE MEDIASTINAL
TERATOMA DURING THE EXIT PROCEDURE SO IT'S ALL DONE ON
MATERNAL BYPASS, IF YOU WILL.