Fetal Surgery

Fetal surgery refers to the surgical treatment of the developing baby in the womb to rectify congenital defects. Surgery of the fetus is performed to fix the prenatally diagnosed anomalies. However fetal surgery is a complicated procedure and comes with lot of risks to both mother and the baby. Yet, doctors recommend fetal surgery, if the risks associated with continuing the pregnancy, without surgical intervention, outweighs the risks that come with fetal surgery. Certain abnormalities, if left to progress in the womb, may turn fatal and infant may die soon after the birth. However fetal intervention is initiated only after taking the safety of the mother into consideration. The common risks that are associated with fetal surgery are premature delivery, infection of the uterus, leaking of amniotic fluid through the membrane, potential infertility and the risk of anesthesia.

There are various techniques followed to diagnose fetal anomalies. The diagnostic method can be non invasive such as ultrasound, fetal echocardiography, MRI, Radiography, Measuring MSAFP (maternal serum alpha-fetoprotein) and Measuring maternal serum beta-human chorionic gonadotropin (HCG) or invasive procedure such as amniocentesis, Chorionic villus sampling and Percutaneous umbilical blood sampling (PUBS) are used to detect the birth defects.

Types of Fetal Surgery

Depending on the incision level, fetal surgery is classified into three types.

Open Fetal Surgery

Open fetal surgery is almost similar to cesarean section and involves a total opening of the uterus. In this type of surgery, a long incision is made in the mother's abdomen and then on the uterus to reach the fetes. Once the surgical correction is performed on the fetus to treat the birth defect, the uterus and abdominal is closed back leaving the fetus intact. Open fetal surgery is performed under general anesthesia. Surgery is performed using special instruments containing staples to prevent bleeding from uterus. During the operation, warm saline water is infused to maintain the position of placenta and umbilical cord and surgeon will keep a vigil on the pulse and heart rate of the baby with the help of the oximeter. After the surgery, the mother is hospitalized for close to a week to facilitate close monitoring. One should remember that, with open fetal surgery, mother will forgo the option of vaginal delivery for the present and future deliveries. She can deliver the baby only through C-section. She may be given some medication to avoid pre term labor. Open fetal surgery is followed for the conditions like chest mass, neck mass, spinbifida, myelomeningocele and Sacrococcygeal teratoma (SCT) (a tumor at the base of the child's tail bone).

There is one more variation to the open fetal surgery called the EXIT (Ex Utero Intrapartum Treatment) Procedure. EXIT surgery is performed at the end of the full term and just before the delivery. In this method the baby is partially delivered by bringing out only a part of the fetes from uterus and keeping rest of the fetes attached to placenta and umbilical cord to allow blood circulation. Once the defect is rectified, the baby is delivered fully. Exit procedure is essentially followed to correct the airway blockage in the baby.

Fetoscopic surgery

Fetoscopic surgery is minimally invasive and unlike open fetal surgery, fetes remains inside the uterus while operating. Surgeon uses special instruments such as laser and makes a small incision with the help of the fetoscope to correct the birth defects. Fetoscopic surgery has shown high success rate in conditions such as Twin-Twin Transfusion Syndrome (TTTS), Twin Reversed Arterial Perfusion (TRAP), Amniotic band syndrome, and Tracheal occlusion for CDH. Fetoscopic surgery does not pose a risk of pre term labor and also eliminates most of the risks associated with open fetal surgery. This is essentially why fetoscopic surgery is the preferred choice, yet one should note that few complicated birth defects can be corrected only through open fetal surgery.

Fetal image guided surgery

Fetal image guided surgery is the least invasive of all wherein surgery is performed with the guidance of images of fetus produced on the external screen by ultrasound. Very thin instruments are inserted through a small opening in the abdomen and the correction is made without any endoscopic view and the whole procedure is guided by the sonogram images.

Various congenital conditions treated through fetal intervention

Congenital diaphragmatic hernia (CDH): Congenital diaphragmatic hernia (CDH) refers to the opening in the diaphragm through which the contents of the abdomen enter the chest cavity leaving no space for the lungs to develop properly. This is a serious condition and may lead to respiratory failure after birth. This condition, depending upon its severity, is treated through fetal intervention.

Spina bifida: Spina bifida refers to a condition wherein spinal column of the baby does not close properly around the spinal cord and the nerves start to protrude through the opening. Spina bifida can range from mild to severe form, and the severe cases lead to serious neurological problems after the birth. Only the severe form of spina bifida like Meningocele and Myelomeningocele call for fetal intervention through open fetal surgery.

Neck masses: Neck masses are the tumors of the neck that may obstruct the airway and esophagus of the child and also increase the level of amniotic fluid surrounding the baby. Typically, tumors of any kind are treated after birth. In rare cases they grow very large and may even cause heart failure. In such cases fetal intervention becomes necessary to remove the tumors.

Lung lesions: Lung lesions refer to the abnormal growth of lung tissue and these lesions can be cystic (fluid filled) or solid. There are various types of lung lesions and treatment depends upon their size and location. During pregnancy, continuous monitoring is necessary to keep vigil on the size of the lesion. Most often lung lesions shrink and make way for normal development. Lesions of smaller and moderate size are best treated after delivery. But if the size of the lung tumor is abnormally huge and poses a risk of hydrops (excess accumulation of fluid in the fetus) fetal intervention is initiated. Cystic lesions are normally removed through needle aspiration under the constant guidance of ultrasound images, but solid lesions require more elaborate procedure such as EXIT.

Congenital heart diseases: Not all congenital heart defects call for fetal intervention. Sometimes the septum (wall separating the right and left side of the heart) of the heart develops a hole while in the womb. However septum defects are typically treated after the birth of the child and rarely require fetal surgery. But if the heart develops severe obstructive cardiac disorders such as aortic stenosis, pulmonary stenosis and coarctation of the aorta,a fetal image-guided procedure may be necessary to open or enlarge the narrowed valve. This procedure involves placing a balloon catheter by inserting it through the uterus and into the fetal’s heart.

Amniotic Band Syndrome: This is a condition where fetus is entrapped in fibrous amniotic bands in the womb, restricting blood flow to the affected portion of the fetes. It normally affects legs, arms, toes and fingers. In utero surgery may be performed to rectify the condition if there is risk of amputation of the limb after the birth.

Twin-to-twin transfusion syndrome (TTTS): TTTS is a condition that occurs in identical twins wherein unbalanced exchange of blood takes place between the twins. One receives higher amount of blood whereas the other receives less amount. The fetus with less blood supply may become anemic and the one with excess blood supply may suffer heart failure due to excess fluid. Fetal surgery through laser fetal intervention is the preferred option to correct the condition. This procedure involves inserting a laser along with small telescope into the uterus and separating the blood vessels on the placenta that are connected to both twins.

Congenital high airway obstruction syndrome (CHAOS): Congenital high airway obstruction syndrome (CHAOS) refers to the blocking of fetal airway resulting in enlarged lungs, windpipe and bronchial tube. A complete or near to complete blockage may lead to a heart failure. Though congenital high airway obstruction syndrome (CHAOS) is treated after birth, in severe cases where fetes is at high risk such as hydrops, fetal surgery is performed.

Plastic Surgeon

A surgeon, who can correct deformity, scars and disfigurement caused by accidents, birth defects and treat diseases like skin cancer (melanoma), is called a plastic surgeon. A plastic surgeon also performs surgeries purely based on cosmetic purposes, e.g. rhinoplasty. The first plastic surgeon of the U.S. was Dr. John Peter Mettauer who performed his first surgery of cleft palate in the year 1827. Plastic surgeons perform various levels of surgeries on human body to beautify and restructure it. The main surgeries performed by plastic surgeons:

Reconstructive surgeries: The most common surgeries in the reconstructive section are breast reconstruction, palate surgery, cleft lip, surgery for patients suffering from burns called contracture surgery. Another technique called microsurgery is performed where tissue is transferred from one place to another where tissue is damaged and needs replacement.

Cosmetic surgery: The most famous and common surgery in the area of plastic surgery is cosmetic surgery and is performed purely from beautification point of view. Cosmetic surgery also known as aesthetic surgery is done just to enhance the beauty of any part and may possibly be a reconstructive surgery. The surgery improves the beauty or looks of any part of the body and is usually referred with the name of that particular part of the body. For e.g. Abdominoplasty (tummy tuck - reconstruction of the abdomen), Blepharoplasty (eyelid surgery) - application of permanent eyeliner or reshaping the eyelids.

Cosmesis: Another common procedure called as cosmesis is a blend of reconstructive plastic surgery and cosmetic plastic surgery. In the process of reconstructive surgery, cosmetic surgery techniques are utilized thus improving cosmesis.

In addition to these branches of plastic surgery, there are also surgeries such as craniofacial surgery - mainly dealing with pediatric deformities, maxillofacial surgery - improvement of the jaw and the face.

The risk of handing over your beauty lies with the plastic surgeon. Ensure your surgeon is

• Certified by a board, e.g. American Board of Plastic surgery.
  
• The surgeon is rightly qualified, cross check his qualifications with the right body. He should have completed medical school and then specialized for five years in the field of general surgery and then plastic surgery. After this should have cleared oral and written examinations held by the board.
  
• Has the right infrastructure and facilities to handle surgeries. They should be well-equipped with the latest gadgets and facilities thereby making the procedure easy.
  
• Has enough experience in the field of plastic surgery.

Latest trends in plastic surgery

• Use of lasers and fiber optic telescopes to in the field has led to better results and satisfying customers. The outcome of the surgery is more enduring than earlier times.
  
• This method has made plastic surgery more economical and trouble-free as a result reduced side effects.
  
• An endoscopic method for facelifts and forehead corrections.
  
• Modern techniques mean smaller incisions and practically no scars left behind after the surgery.
  
• Also modern sedation techniques like the intravenous sedation save a lot of trouble and risk for the patients.
  

Cataract Surgery

Cataract surgery has made extraordinary and exciting advances over the past 20 years. Last year, approximately 2.7 million Americans underwent cataract surgery. Greater than 95% of those patients now enjoy improved vision. State-of-the-art cataract surgery is now a safe, effective, and comfortable procedure performed almost exclusively on an outpatient basis.

Most cataract surgeries are now performed using microscopic size incisions, advanced ultrasonic equipment to fragment cataracts into tiny fragments, and foldable intraocular lenses (IOLs) to maintain small incision size. Cataract surgery today is the result of extraordinary technological and surgical advancements that allows millions of people to once again enjoy crisp and clear vision. A true marvel of modern medicine, cataract surgery may restore vision to levels you may have never thought possible.

When a cataract is removed, it is replaced with an artificial intraocular lens (IOL). There are a variety of IOLs that can be used in cataract surgery, and they each have their own set of advantages and disadvantages. No single IOL works best for everyone, and only your ophthalmologist can determine the most appropriate IOL for your needs. The FDA approval process for IOLs is among the most rigorous in the world. You can rest assured than any IOLs used in the U.S. have undergone very extensive testing for safety and efficacy. These same IOLs are also used for a refractive surgery procedure known as refractive lens exchange. In refractive lens exchange, the IOL is used solely in an attempt to reduce or eliminate the need for glasses or contact lenses. This article outlines some of the choices of IOLs that are available for use in cataract surgery and refractive lens exchange.

Fixed Focus Monofocal IOLs are used in the majority of cataract procedures. These lenses have the advantage of excellent quality distance vision under a variety of lighting conditions. Since these lenses have a fixed focal point which is generally set for distance vision, reading glasses are typically required for good near vision. For patients willing to use reading glasses for near tasks, these IOLs are an excellent choice. Several million lenses of this variety have been used for decades with an excellent safety record. Recent refinements in the optical quality of these lenses have allowed an even higher quality of vision than previously achievable.

Accommodating Monofocal IOLs are used in situations where both good distance and good near vision are desired without the use of spectacles. These IOLs have a single focal point, however, the focal point can shift position in space so that objects at distance are clear when the eye focuses on them, but when the eye looks at a near object the IOL will shift its focal point to bring the near object into focus. Accommodating Monofocal IOLs achieve this by physically moving inside the eye in response to the focusing action of the muscles of the eye. The only FDA approved IOL of this type is called the Crystalens™. Patients implanted with the Crystalens IOL generally enjoy near vision without glasses that is much better than those implanted with Fixed Focus Monofocal IOLs(2). In fact, results of the FDA trial for the Crystalens demonstrated that 98% of patients could see well enough to pass the driver's test and read a newspaper without glasses. Vision at the intermediate (computer screen) distance is superb with the Crystalens, making this an excellent IOL for those who spend a great deal of time on a computer.Cataract surgery today is typically performed using a microincisional procedure. To the patient, this means minimal discomfort during or after surgery, a more speedy recovery of vision, and reduced risk of induced astigmatism. This means less dependence on glasses afterwards.

Below, we've detailed the major steps of cataract surgery using a microincision procedure, phacoemulsification (ultrasonic cataract removal), and a foldable lens implant. This type of procedure is considered state-of-the-art for cataract surgery today. The procedure demonstrates basic principles only, however, and eye surgeons use many variations of the general theme, even from one case to another, depending on the type of cataract being removed. After discharge from the surgery center, patients will usually be asked to return for a follow-up visit later that day or the next day, however, this will be based on individual circumstances. Also depending on the type of incision and surgeon preference, some patients will be asked to wear a shield over the eye, particularly while sleeping. The eye should not be rubbed, or pressure placed directly on the eye through the eyelid, during the first few weeks following surgery. Eye drop medications will be required, usually consisting of antibiotic and anti-inflammatory medicines. These will often be tapered off during the first month after surgery.

The best vision may not be obtained until several weeks following surgery, but individual results vary considerably, depending on many variables. The great majority of patients may resume normal activities on the day of or day after surgery. Activities such as reading, watching television, and light work will not hurt the operated eye. Most surgeons arbitrarily recommend waiting 4 to 6 weeks before new glasses are obtained. This allows the eye to achieve considerable stability from a refractive standpoint and, therefore, the glasses prescription should be accurate and relatively stable.

Many patients are surprised at how clear their vision is after cataract surgery. Some patients may have better vision than they ever did before cataract surgery. Furthermore, depending on the degree of refractive error (need for glasses) prior to surgery, many patients will be much less dependent on glasses for far vision than they were before surgery. Patients will often notice that colors are brighter and more brilliant. The results are often dramatic.