Centers that specialize in fetal diagnosis and intervention are becoming increasingly common. Due to the efforts of experts in the field, the technology is advancing rapidly; though currently the indications for actual in utero fetal intervention remain few. Nevertheless, fetal diagnostic and surgical centers serve several important roles and, as such, have contributed greatly to the care of newborns with congenital anomalies: (1) genetic and obstetrical counseling, (2) state-of-the-art imaging and interventional diagnostics available in one location, (3) a source of reliable information for pregnant women and their families when a congenital anomaly has been identified antenatally, (4) the opportunity to pursue in utero intervention when indicated, (5) the ability to make plans for appropriate medical and surgical therapeutics for when the baby is born, and (6) the option of actually delivering the child in a children’s hospital where care can be delivered without the delay associated with transfer (which at this time is available at only one center in the US).
Despite the fact that the results of fetal surgery for congenital diaphragmatic hernia have been disappointing in that the results have been no better than that achieved by the standard of care, the work has nonetheless contributed greatly to the understanding of this condition and effective fetal interventions appear to be finally within grasp. Operations for other conditions (congenital lung disease, sacrococcygeal teratoma, cervical masses) have proven somewhat more successful but only when the life of the fetus is in jeopardy. Several technical problems encountered early on have been resolved, including achieving hemostasis of the hysterotomy incision, maintaining uterine volume and temperature during the procedure, balancing the needs of the mother and the fetus related to anesthetic issues, and avoiding injury to the placenta, which occupies a large proportion of the internal surface area of the uterus. Postoperative preterm labor remains a common and frustrating occurrence after fetal intervention. Nevertheless, it is inevitable, however, that someday soon fetal surgery will become more routine as the few remaining hurdles are removed.
Fetal operations, including procedures performed using the EXIT approach, involve a large team of dedicated specialists all working together to maintain the health and well-being of the fetus(es) and, most importantly, the mother. The planning and coordination of the team are clearly important to achieving this goal. During a typical fetal operation or EXIT procedure, the operating theater is filled with personnel, more than for any typical operation, each contributing something specifically important to the task at hand: pediatric surgeons, obstetricians, anesthesiologists, neonatologists, and nurses representing each of the specialties involved. Two operating rooms are usually required, one for the mother and another for the infant. The result is a tense but well-orchestrated process and usually a successful outcome. Eventually, it is likely that nearly every congenital anomaly will be detectable antenatally, in which case newer and better treatments will become available because of the ground-breaking work of the select few who are today’s fetal surgeons.