Fetal Surgery for Neck Masses Technique
- Author: S Christopher Derderian, MD; Chief Editor: Hanmin Lee, MD more...
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. 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.
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