Fetal Surgery for Sacrococcygeal Teratoma Periprocedural Care

Updated: Mar 09, 2023
  • Author: William Gar Ho Hiroshi Lee, MD; Chief Editor: Hanmin Lee, MD  more...
  • Print
Periprocedural Care

Patient Education and Consent

After evaluation at a fetal treatment center, families should undergo extensive multidisciplinary counseling. Specialists should include fetal/pediatric surgeons, obstetricians, perinatologists, and anesthesiologists, as well as a social worker and nurse coordinator to discuss the risks and benefits of fetal intervention. Potential risks of fetal intervention include the following [20] :

  • Uterine disruption
  • Rupture of membranes
  • Side effects of tocolytics (used to prevent preterm labor)
  • Maternal pulmonary edema
  • Fetal demise

Additional risks of fetal surgery include bleeding, need for blood transfusion, and wound infection.


Preprocedural Planning

An experienced operative team is essential and usually includes the following [20] :

  • Two pediatric surgeons
  • Perinatologist
  • Ultrasonographer/echocardiographer
  • Experienced operating room personnel
  • Pediatric/obstetric anesthesiologist

The team should also have blood products prepared for potential intraoperative transfusion. Patients needing fetal intervention usually have highly vascular solid tumors, which were shown to have increased transfusion requirements in a retrospective study that evaluated 112 cases of operative management of sacrococcygeal teratoma (SCT), including six in-utero repairs. [52]



Open fetal surgery and ex-utero intrapartum treatment procedure

The following are used for maternal perioperative monitoring in open fetal surgery and the ex-utero intrapartum treatment (EXIT) procedure:

  • Blood pressure cuff
  • Large-bore intravenous (IV) catheters
  • Bladder catheter
  • Electrocardiographic (ECG) leads
  • Sequential compression devices
  • Pulse oximeter

Also necessary for open fetal procedures are the following:

  • Intraoperative ultrasound device
  • Uterine stapler
  • Large ring retractor
  • Sterile neonatal pulse oximeter and IV catheter for the fetus
  • Fluid warmer
  • Sterile neonatal laryngoscope and endotracheal tube (for the EXIT procedure)

Minimally invasive techniques

Equipment for minimally invasive techniques includes the following:

  • Intraoperative ultrasound device
  • LeVeen radiofrequency probe (8 prong) for radiofrequency ablation (RFA)
  • Fetoscope (1.9 mm, 60°) for laser ablation
  • Neodymium-doped yttrium-aluminum-garnet (Nd:YAG) laser fiber (0.4 mm) for laser ablation

Patient Preparation

Patients are usually admitted to the obstetric ward the evening before fetal surgery.  Preoperatively, indomethacin, magnesium sulfate, or both are given to prevent uterine contraction during the procedure, and antibiotics are given prophylactically to prevent infection.


Anesthesia for open fetal surgery includes maternal epidural and general anesthesia. This provides anesthesia to both the mother and the fetus and ensures uterine relaxation during the procedure. [20, 53]  Volatile anesthetics can cross the placenta and decrease fetal cardiac function; maternal anesthesia with IV nitroglycerin and/or epidural anesthesia can limit the amount of volatile anesthetic required. [54]  Epidural anesthesia also decreases uterine contractions during the postoperative recovery period.

Anesthesia options for minimally invasive techniques can range from spinal anesthesia with local anesthetic to general anesthesia, depending on the patient and the circumstances for fetal intervention. During the procedure, intramuscular injection of pain medication and a paralytic agent can be administered to the mother under ultrasonographic (US) guidance. [55]

In a systematic review of anesthetic techniques for fetal operative procedures, 168 studies up to December 2021 demonstrated no difference in perioperative outcomes between maternal-only anesthesia (MA) and maternal-and-fetal anesthesia (MFA) [56] ; however, evaluation of open fetal surgery cases (including open fetal SCT resection) identified increased rates of premature rupture of membranes (PROM) and fetal death in cases using MFA. The agents most commonly used for fetal anesthesia are fentanyl, atropine, and curare paralytic agents (vecuronium or pancuronium). [56]


The mother is placed in a supine position on the operating room table, with the right side elevated to decrease the pressure of the uterus on the inferior vena cava (IVC). [20]


Monitoring & Follow-up

Depending on the postoperative course, patients can be discharged within a week after fetal surgery, though they will need to stay at a facility near the fetal treatment center. Activity is gradually modified if there is minimal uterine irritability. US is performed twice a week to assess fetal development and resolution of hydrops. Because of the location of the hysterotomy, the mother will require cesarean delivery for all future deliveries.