Spina Bifida (SB) is a disease in which a defect is present in the bony component of vertebra. It is a congenital disease which occurs before birth. It is diagnosed by screening tests during pregnancy. It is worrisome for a pregnant woman when SB is diagnosed in her developing baby. She worries about the pregnancy, fetus, and the congenital disease of the baby.
One of the options to manage SB is the termination of the baby and that could be very painful for the mother. Now, new options are available for treating SB in utero as surgery has been started in utero to treat spina bifida .
Written below are the details of every step of surgery that is performed to correct the SB during pregnancy :
First of all anesthesia is selected for a patient. There are two options: general anesthesia and spinal anesthesia. General anesthesia has many complications, such as, fetal distress because oxygen saturation is decreased during general anesthesia. Spinal anesthesia is the safest anesthesia for this type of surgery.
Spinal anesthesia is given while the patient is sitting on the operation table. Before anesthesia is given, all the baseline investigations are carried out to check whether any problem is present or not. Then systematic evaluation of the patient is done. If there is no problem,, then the patient is ready for anesthesia to be given.
The patient is brought to the operation theatre and laid on the operation table. All vitals, i.e. pulse, blood pressure, temperature, respiratory rate and oxygen saturation are checked. Folley’s catheter is placed. The patient is preloaded with intravenous fluids. In a sitting position, the back of the patient is exposed and antiseptic measures are performed. An accurate spinal space is identified. A specialized long thin needle called a lumbar puncture (LP) needle is inserted into the located space. When cerebrospinal fluid (CSF) dribbles out of the needle, an injection of anesthesia is injected. After that LP needle is removed and the position of the patient is changed to a supine position immediately, to avoid falling of blood pressure. Vitals are strictly monitored during the operation.
When the effect of anesthesia appears, the surgeon embarks on the surgery. The patient is exposed and antiseptic measures are performed. An incision is made in the patient’s abdomen where an incision for a C-section is made. The skin and the tissue below the skin are cut. Muscles are retracted. The uterus is identified and located. It is pulled out of the abdominal cavity. And now, the main steps of surgery commence. The position of the baby is located with the help of ultrasound and the baby is positioned in such a way that surgery can be performed easily. It is a very delicate surgery; therefore, fine surgery is required.
Magnifying glasses are required to perform this procedure. Sutures used during the surgery are so tiny that they cannot be seen with the naked eye. A special type of cannula called Tulipan-Bruner’s trocar is used to drain the protective fluid around the unborn baby (amniotic fluid) and to place other surgical instruments inside the uterus. Trocar is placed on the uterine wall and amniotic fluid is drained to a warmer. Amniotic fluid is saved in a warmer because it is to be placed again into the uterus after completing the procedure.
When the baby is positioned as needed, a small and tiny incision is made on the uterus to open the uterus. Now a tiny baby is in your hand. The defect in the lumbar region on the back of the baby is identified. It is a small jelly like sac. An ultrasound probe is placed on the sac and the type of defect is assessed. An incision is made on the out-pouching. The spinal cord and spinal nerves are positioned back into the spinal canal. The spinal cord is covered with its sheath. The sac is closed with tiny sutures. The bony defect is repaired. The skin of the baby is closed with sutures. Now the main surgery to repair the defect is completed. The baby is placed back into the uterus. Now uterus is ready for closure. Before closure of the uterus, the amniotic fluid that is kept safe in warmer is placed back into the uterus. Now the uterus is closed with fine absorbable sutures.
After closing the uterus, it is placed back into the pelvis and positioned properly. All the pedicles are assessed. All bleeding and oozing of blood is secured. Now it is time to close the abdominal cavity. The peritoneum is stitched. The retracted muscles are also stitched. Fibrous tissue and the tissue below the skin are stitched. In the end, the skin is closed with fine sutures. Antiseptic dressing is placed on the wound.
On the completion of the surgery, post-operative anesthesia assessment is made. Pulse, blood pressure, respiratory rate and oxygen saturation are checked. The response of the patient to the stimulus is checked. If the patient is responding well then she is shifted to the recovery room.
This is, a full description of in utero surgery for spina bifida. It is a very difficult procedure. Very fine surgery is required to perform this operation.
Here are some pictures of the surgery for the repair of spina bifida while the baby is in mother’s womb.
Figure 1: This is a picture of spina bifida surgery in utero. In this picture, the uterus is shown outside of the abdominal cavity with an incision made on it. The tiny hand of the fetus is out of the uterus to shake it with the surgeon’s hand to appreciate him for his achievement (Source: www.singularityhub.com)
Figure 2: In this picture, the spina bifida defect repair is shown. A red circle is made around the procedure. The spinal cord is placed into the spinal canal and the spinal covering (duramatter) is stitched (Source: www.spinabifidaeffects.com).
Figure 3: In this picture, the abdominal cavity is opened and the fetus with a spina bifida sac is shown in the uterus. For fetal surgery the uterus is opened and the fetus is placed in such a way that spina bifida sac comes in view of the surgeon. A red circle is made around the sac and incision of the uterus (Source: www.reference.medscape.com).
1. Adzick NS. Fetal surgery for spina bifida: past, present, future. Semin Pediatr Surg2013;22(1):10-7.
2. Foster MR. Surgery for spina bifida. Available at: http://emedicine.medscape.com/article/2040493-overview. [Last updated May 30, 2014; Accessed on Nov 29, 2014]