Laparotomy-assisted 2-port fetoscopic repair of spina bifida aperta: report of a single-center experience in Paris, France.

Background: Given the maternal morbidity of open fetal surgery, the development of prenatal fetoscopic repair for spina bifida aperta (SBA) is encouraged.Objective: We hereby report the early results from our center, using a laparotomy-assisted CO2-fetoscopic approach.Methods: This study was conducted in patients with an SBAS1, <26 weeks' of gestation, with Chiari II. Fetoscopic repair was performed using 2 operating trocars in the uterus exteriorized through a transverse laparotomy. Endoscopy was performed under humidified and heated CO2 insufflation. Following dissection of the lesion, a 1-layer approach was performed with a muscle/skin flap sutured over a patch of Duragen. Main outcomes were watertight repair at birth and the need for postnatal neurosurgical surgery including shunting within 6 months.Results: Of 87 women assessed for prenatal therapy, 7 were included. Surgery was performed at 24 (23-26) weeks' gestation. There was no fetal demise. Conversion to hysterotomy was not performed, although surgery could not be performed in one case because of fetal position. Severe preeclampsia developed postoperatively in one case. In the other 6 cases, follow-up was uneventful except for premature rupture membranes which occurred in 3/6 cases at 30, 34 and 36+5-weeks' gestation. Gestational age at delivery was 32+5 (31-36+5) weeks' gestation. Repair was watertight at birth except in two cases which required complementary postnatal surgical repair. Reverse hindbrain herniation during pregnancy was observed in 4/6 cases. In 3/6 cases, shunting was necessary within six months after birth. At 12 months, a functional gain >= 2 metameric levels, was observed in 3 cases of the 6 survivorsConclusion: Laparotomy-assisted fetoscopic repair is a reasonable option for women who choose and are eligible for antenatal surgery, both in terms of maternal and perinatal morbidity.