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Fetal Surgery for Neck Masses Technique

  • Author: S Christopher Derderian, MD; Chief Editor: Hanmin Lee, MD  more...
 
Updated: Sep 24, 2013
 

Approach Considerations

No definitive management strategy has been delineated for fetuses identified with cervical masses and hydrops early in gestation, as successful fetal resection has been described only once.[7] The authors’ current practice is to offer an EXIT-to-airway procedure for viable fetuses with a concerning airway.

During the procedure, all necessary personnel should be present in the operating room.

EXIT deliveries can lead to tremendous blood loss, as tocolytics and inhaled anesthetics are used to obtain uterine atony, which, in turn, maintains placental blood flow. To minimize blood loss during the hysterotomy, a specific uterine stapler device with absorbable staples (US Surgical Corporation, Norwalk, CT) is required.

It is paramount to preserve placental blood flow, which requires profound uterine relaxation and caution when entering the uterus. Anterior placentas frequently require a posterior uterine incision in an attempt to avoid placental injury and chorioamniotic separation, which can disrupt utero-placental gas exchange. Additionally, caution should be taken to minimize manipulation of the umbilical cord, which may result in vessel spasm and compromised blood flow.

The head and one arm are then exposed through the uterine incision. A pulse oximeter is placed on the fetal hand to continuously monitor fetal oxygenation.

At this point, the mass and airway are evaluated with direct laryngoscopy. If endotracheal intubation is not possible, bronchoscopy may be attempted. If unsuccessful, the next step is tracheostomy.

Rarely, resection of the mass during the EXIT procedure is needed to establish an airway. All equipment including the laryngoscope must be sterile to minimize chances of maternal infection.

Once the airway is established, the fetus is delivered and the umbilical cord divided.

 
Contributor Information and Disclosures
Author

S Christopher Derderian, MD Post-doctoral Research Fellow, University of California, San Francisco, School of Medicine

S Christopher Derderian, MD is a member of the following medical societies: American College of Surgeons, American Medical Association, South Carolina Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Shinjiro Hirose, MD Assistant Professor, Clinical, of Surgery, Pediatrics, and Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, School of Medicine; Clinical Director, Division of Pediatric Surgery, Director of Surgical Services, Fetal Treatment Center, Surgical Director of ECMO Services, Division of Pediatric Surgery, Department of Surgery, UCSF Medical Center

Shinjiro Hirose, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, International Pediatric Endosurgery Group, Pacific Association of Pediatric Surgery, International Fetal Medicine and Surgery Society

Disclosure: Nothing to disclose.

Chief Editor

Hanmin Lee, MD Professor of Surgery, Pediatrics, Obstetrics/Gynecology and Reproductive Health Sciences, University of California, San Francisco, School of Medicine; Chief, Division of Pediatric Surgery, Director, Fetal Treatment Center, Michael R Harrison, MD, Endowed Chair in Fetal Surgery, Surgeon-in-Chief, UCSF Benioff Children’s Hospital

Hanmin Lee, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Pediatric Surgical Association, Association for Academic Surgery, Society of American Gastrointestinal and Endoscopic Surgeons, Society of University Surgeons, International Pediatric Endosurgery Group

Disclosure: Nothing to disclose.

References
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Cervical Teratoma in an infant delivered via EXIT procedure
 
 
 
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