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Radiology
Fetoscopic Laser Surgery
Built from Obstetric Imaging
What’s inside
6 sections · 80 slides
Overview
- Scope of this topic
Shared Circulation and Twin-Twin Transfusion Syndrome
The problem the laser is designed to solve
- Monochorionic twin pregnancy
- Twin-twin transfusion syndrome
- Mechanism of twin-twin transfusion syndrome
- Natural history of untreated early-onset disease
- Fetoscope passed into the sac of one twin
- Principle of fetoscopic laser surgery
- Amnioreduction
- Laser surgery compared with amnioreduction
- Development of the technique
- Position of laser surgery among TTTS therapies
Performing the Operation
Team, anaesthesia, equipment and the steps at the placenta
- Operating room set-up and personnel
- Fetoscopic laser surgery in the operating room
- Anaesthesia and patient positioning
- Preoperative ultrasound mapping
- Uterine entry with cannula and trocar
- Amniotic fluid sampling at entry
- Selecting the fetoscope
- Zero-degree fetoscope with detached eyepiece
- Reading the zero-degree fetoscope
- Thirty-degree fetoscope with standard eyepiece
- Double-lumen operative sheath
- Tip of the double-lumen sheath
- What the sheath tip shows
- Laser fibre
- The laser fibre in practice
- Camera head and cable for the video display
- Light and video output
- Laser sources and energy settings
- Steps at the placental surface
- Identifying the twins and cord insertions
- Selective photocoagulation of anastomoses
- Dividing membrane between the two amniotic sacs
- Sequential selective photocoagulation
- Proposed order of vessel treatment
- The Solomon technique
- Evidence for the Solomon technique
- Amnioreduction and closure
- Immediate postoperative monitoring
Selecting Patients for Surgery
Indications, the stage I debate, and contraindications
- Indications for fetoscopic laser surgery
- Upstaging on cardiac findings
- Stage-based management pathway
- Stage I twin-twin transfusion syndrome
- Randomised trial in stage I disease
- 78%
- Management of stage I disease in practice
- Amnioreduction before 26 weeks
- Absolute contraindications
- Relative contraindications
Outcomes and Complications
What the trials found, and what can still go wrong
- Evidence before the Eurofetus trial
- The Eurofetus trial
- 76%
- Neurologic findings in the Eurofetus trial
- Contemporary survival after laser surgery
- 50-70%
- The Solomon randomised trial
- Two-year follow-up of the Solomon trial
- Long-term neurologic outcome in survivors
- Neurocognitive tests used in follow-up studies
- Major neurologic problems reported in survivors
- Reading the neurologic follow-up cohorts
- Neurologic Abnormality in Survivors of Selective Laser Photocoagulation for Twin-Twin Transfusion Syndrome: Selected Trials
- Abbreviations and footnotes in the follow-up table
- Cardiac dysfunction in the recipient twin
- Cardiac recovery after laser surgery
- 54.9%
- Procedure-related risks
- Risks explained
- Reported frequency of complications
- Surveillance after laser surgery
Summary
What to carry away
- Key points
- Summary of the operation
- References
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- Suggested readings
- Obstetric Imaging: Fetal Diagnosis and Care, 2nd Edition