>> ONCE A FAMILY DECIDES TO PURSUE FETAL SURGERY,
THINGS HAPPEN PRETTY RAPIDLY.
>> ALL THE COMPONENTS OF OUR RATHER LARGE TEAM MEET
TO DISCUSS THE CASE AND THEN HAVE THE PARENTS COME IN,
AND WE GO THROUGH THE ENTIRE PROCESS ONCE AGAIN SO THAT
THERE'S A CLEAR UNDERSTANDING OF WHAT'S INVOLVED AND GIVE THEM
THE OPPORTUNITY TO ASK ANY ADDITIONAL QUESTIONS.
>> WE HAD TO BE DOWN HERE-- I DON'T KNOW IF IT WAS 5 O'CLOCK
OR 6 O'CLOCK, BUT IT WAS VERY EARLY IN THE MORNING.
I WAS SO NERVOUS.
>> AND, YOU KNOW, STILL A LOT OF CONSULTATIONS AND THINGS LIKE
THAT GOING ON AND, YOU KNOW--
>> FLURRY OF ACTIVITY.
THEY PUT AN EPIDURAL IN.
IT WAS THE FIRST THING THEY WERE GOING TO DO,
AND I HAD TO BE AWAKE FOR THAT.
YOU ARE KNOCKED OUT FOR THE SURGERY.
AND I REMEMBER BENDING OVER GETTING THAT EPIDURAL,
AND THEY'RE TALKING TO ME AND ALL OF A SUDDEN, YOU GO--
OH! I MEAN, IF IT HADN'T HIT US ALREADY,
IT HIT ME THEN:
THIS IS BIG TIME.
>> RIGHT.
>> SEVENTEEN DAYS BEFORE THAT LIFE WAS NORMAL,
AND ALL OF A SUDDEN HERE WE ARE IN FETAL SURGERY FOR SOMETHING
THAT'S CUTTING EDGE.
>> WE HAVE A SPECIAL OR THAT WE USE FOR FETAL SURGERY.
IT'S A VERY LARGE OR BECAUSE THERE'S A LOT OF EQUIPMENT
THAT'S THERE, AND THERE ARE A LOT OF PEOPLE INVOLVED IN THIS.
THERE ARE A COUPLE OF ANESTHESIOLOGISTS.
THERE'S THE FETAL TEAM.
>> TWO TO THREE SURGEONS IN THE ROOM.
THERE'S A CARDIOLOGIST IN THE ROOM WHO MONITORS THE BABY'S
HEART THROUGH THE ENTIRE PROCEDURE.
THERE'S A NEUROSURGEON WHO ACTUALLY DOES THE MYELOMENINGOCELE REPAIR.
THERE IS AN OBSTETRICIAN OR MATERNAL-FETAL MEDICINE
SPECIALIST IN THE ROOM WHO MONITORS THE MOTHER'S UTERUS
AND PERFORMS ULTRASOUND SO THAT WE MAKE SURE WE PUT
THE INCISION IN THE UTERUS WHERE WE NEED TO PUT IT.
>> AND IT ALL HAS TO BE CAREFULLY CHOREOGRAPHED,
SO THAT EVERYBODY IS FOCUSED ON WHAT THEIR ROLE IS,
WHAT THEY NEED TO DO, BUT EVERYBODY HAS TO WORK
SEAMLESSLY TOGETHER.
>> THE MOTHER GOES UNDER DEEP GENERAL ANESTHESIA.
DEEP GENERAL ANESTHESIA IS IMPORTANT FOR AT LEAST THREE REASONS.
IT ANESTHETIZES THE MOTHER, IT ANESTHETIZES THE FETUS,
AND ALSO GIVES US VERY GOOD UTERINE RELAXATION --
RELAXATION OF THE UTERINE MUSCLE, WHICH IS VERY IMPORTANT
FOR THE OPERATION.
AN ULTRASOUND IS DONE TO LOOK AT THE FETAL POSITION
AND THEN A SIDEWAYS WOUND IS MADE-- ALMOST HIPBONE TO HIPBONE
HALFWAY BETWEEN THE BELLY BUTTON AND THE PUBIC BONE
TO EXPOSE THE UTERUS.
OFTIMES THE OBSTETRICIAN WILL MOVE THE FETUS WITHIN THE UTERUS
SO THAT THE MYELOMENINGOCELE, OR SPINA BIFIDA LESION,
IS RIGHT UNDERNEATH WHERE WE'RE GOING TO MAKE THE CUT
IN THE UTERUS BECAUSE THE BABY BASICALLY STAYS INSIDE
THE UTERUS DURING THE OPERATION.
THE CUT IN THE UTERUS IS DONE AGAIN UNDER ULTRASOUND GUIDANCE,
STERILE, INTRAOPERATIVE, ULTRASOUND GUIDANCE
WITH A UTERINE STAPLING DEVICE THAT FIRES
ABSORBABLE STAPLES THAT PINCH OFF ALL THE BLOOD VESSELS
AND KEEP THE MEMBRANES AROUND THE BABY TACKED UP TO THE MUSCLE
LAYER OF THE UTERUS.
DURING THE OPERATION THE FETAL CARDIOLOGIST DOES MONITORING
OF THE FETAL HEART BY ECHOCARDIOGRAPHY.
>> WE'RE ABLE TO LOOK AT BLOOD FLOW PATTERNS THROUGH THE HEART,
THE VARIOUS STRUCTURES, AND THE FLOW TOWARDS
THE DIFFERENT ORGANS. HEART FUNCTION.
WE LOOK AT THE HEART RATE.
ARE ABLE TO FEED THAT INFORMATION BACK TO THE SURGEONS
AND TO THE ANESTHESIOLOGIST THAT'S MANAGING THE MOTHER.
>> THE NEUROSURGEON THEN COMES IN, AND HE AND I
DO THE MYELOMENINGOCELE REPAIR EXACTLY LIKE YOU WOULD DO
IN A NEWBORN AFTER BIRTH.
>> I TRIM THE SAC OF ABNORMAL SKIN AWAY FROM THE NERVE TISSUE.
IT'S IMPORTANT TO DO THAT BECAUSE THAT SKIN TISSUE,
IF I LEAVE IT BEHIND, CAN BECOME A CYST.
IT CAN BE A PROBLEM LATER ON.
WE THEN PUT THE NERVE TISSUE BACK INTO THE SPINAL CANAL
WHERE IT'S SUPPOSED TO BE AND THEN I TRY TO GET
A THREE-LAYER CLOSURE.
THE FIRST LAYER IS THE DURA-- THAT'S THE NORMAL COVERING
OF THE BRAIN AND THE SPINAL CORD.
THE SECOND LAYER IS THE FASCIA-- THAT'S KIND OF LIKE MUSCLE-TYPE
TISSUE AND THEN THE THIRD LAYER IS THE SKIN.
>> THE GOAL IS TO COVER THE UNPROTECTED SPINAL CORD
SO THAT IT'S A WATERTIGHT PROTECTIVE CLOSURE.
IT NEEDS TO BE WATERTIGHT FOR TWO REASONS.
ONE, IS THAT YOU WANT TO STOP THE DAMAGE CAUSED BY AMNIOTIC
FLUID EXPOSURE FOR THE REST OF THE PREGNANCY.
AND YOU ALSO WANT TO STOP THE LEAKAGE OF CEREBROSPINAL FLUID
OUT THROUGH THE BACK THAT PLAYS AN IMPORTANT ROLE IN
THE DEVELOPMENT OF HINDBRAIN HERNIATION AND HYDROCEPHALUS.
SO IF YOU STOP THE LEAK BACK HERE, THE HINDBRAIN CAN GO BACK,
AND THE HYDROCEPHALUS IS LESS OF AN ISSUE.
ONCE THE UTERINE WOUND IS CLOSED, THE MATERNAL ABDOMEN
IS CLOSED, INCLUDING THE SKIN, WITH A PLASTIC SURGICAL CLOSURE.
ALL THE LAYERS ARE CLOSED WITH AN ABSORBABLE STITCH
THAT WILL DISSOLVE ONCE THE MOTHER'S WOUND IS HEALED.