Thai Vu1, Lovepreet K Mann1, Stephen A Fletcher2, Ranu Jain3, Jeannine Garnett1, Kuojen Tsao4, Mary T Austin4, Kenneth J Moise1, Anthony Johnson1, Manish N Shah5, Ramesha Papanna6. 1. Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School - University Health Science Center at Houston, the Fetal Center and the Memorial Hermann Hospital, Houston, TX. 2. Pediatric Neurosurgery, Department of Pediatric Surgery, McGovern Medical School - University Health Science Center at Houston, the Fetal Center and the Memorial Hermann Hospital, Houston, TX; Department of Anesthesiology, McGovern Medical School - University Health Science Center at Houston, the Fetal Center and the Memorial Hermann Hospital, Houston, TX. 3. Department of Anesthesiology, McGovern Medical School - University Health Science Center at Houston, the Fetal Center and the Memorial Hermann Hospital, Houston, TX. 4. Department of Pediatric Surgery, McGovern Medical School - University Health Science Center at Houston, the Fetal Center and the Memorial Hermann Hospital, Houston, TX. 5. Pediatric Neurosurgery, Department of Pediatric Surgery, McGovern Medical School - University Health Science Center at Houston, the Fetal Center and the Memorial Hermann Hospital, Houston, TX. 6. Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School - University Health Science Center at Houston, the Fetal Center and the Memorial Hermann Hospital, Houston, TX. Electronic address: Ramesha.papanna@uth.tmc.edu.
Abstract
PURPOSE: Despite proven benefits of in-utero spina bifida (SB) repair, ≥30% of children at birth have Chiari II malformation or cerebrospinal fluid (CSF) leakage from the repair site. Our study's purpose was to determine CSF pressures in the myelomeningocele sac during mid-gestation in order to design an in-vitro model for evaluating different surgical methods used for watertight closure during in-utero SB repair. METHODS: CSF pressures were measured during in-utero SB repair at mid-gestation. An in-vitro chicken thigh model, simulating fetal tissue, tested watertight closure when attached to the base of a water column. Primary closure methods were evaluated using defect sizes of 20 × 3 mm for minimal traction or 20 × 8 mm for moderate traction. Additionally, 3 common in-utero repair patches were compared using 15 × 15 mm defects. RESULTS: Using 6-12.5 cm pre-determined CSF pressures, 165 in-vitro experiments were performed. Regardless of methodology we found that in 66 primary-based closures that minimal versus moderate wound edge traction provided better seals. The locking method was superior to the non-locking technique for watertight closure in 99 patch-based closures. CONCLUSIONS: Minimal wound edge traction was best for primary closures, and locking sutures ideal for patch-based closures, however surgical techniques should be individualized to improve upon clinical outcomes.
PURPOSE: Despite proven benefits of in-utero spina bifida (SB) repair, ≥30% of children at birth have Chiari II malformation or cerebrospinal fluid (CSF) leakage from the repair site. Our study's purpose was to determine CSF pressures in the myelomeningocele sac during mid-gestation in order to design an in-vitro model for evaluating different surgical methods used for watertight closure during in-utero SB repair. METHODS: CSF pressures were measured during in-utero SB repair at mid-gestation. An in-vitro chicken thigh model, simulating fetal tissue, tested watertight closure when attached to the base of a water column. Primary closure methods were evaluated using defect sizes of 20 × 3 mm for minimal traction or 20 × 8 mm for moderate traction. Additionally, 3 common in-utero repair patches were compared using 15 × 15 mm defects. RESULTS: Using 6-12.5 cm pre-determined CSF pressures, 165 in-vitro experiments were performed. Regardless of methodology we found that in 66 primary-based closures that minimal versus moderate wound edge traction provided better seals. The locking method was superior to the non-locking technique for watertight closure in 99 patch-based closures. CONCLUSIONS: Minimal wound edge traction was best for primary closures, and locking sutures ideal for patch-based closures, however surgical techniques should be individualized to improve upon clinical outcomes.