New approach in extraction of intratracheal balloon using polypropylene suture fixed to the balloon for the intrauterine fetoscopic tracheal occlusion for the treatment of severe congenital diaphragmatic hernia

Objective: Complications during the extraction of the tracheal balloon after the intrauterine fetoscopic treatment of the severe congenital diaphragmatic hernia (CDH) seriously reduce the neonatal survival. The treatment is associated with potentially severe risks which have to be weight against the potential benefits of the intervention. In this case, we report a new approach witch might reduce the risks of therapy.

Material and Methods: fetoscopic TO with balloon with “long tail = polypropylene suture” to treat the severe CDH with 15% o/e lung volume and additionally to facilitate the extraction of the balloon from the fetal trachea.

Case: A 35 years old woman, gravida 1 pare 0 was referred to out center of fetal surgery at 24/1 weeks of gestation because of severe congenital diaphragmatic hernia with 15% of the normal lung volume rate (fetal MRI) and liver, stomach and gut herniation through the CDH into the left thorax.

Operating Procedure: The TO was performed at 28/4 week of gestation. The fetus received 0.1 mg vecuronium and 0.01 mg atropine by intramuscularly injection under ultrasound guidance. A monofil 5 – 0 polypropylen suture with the length of 7 cm was fixed to the balloon before it was inserted into the trachea. After that a fetoscope with a diameter of 1.2 mm was percutaneously inserted through a sheath into the uterus with posterior placenta under local anaesthesia (20 ml Xylocain^® 1%). The light optic was removed from the sheath and the balloon was inserted with help of a catheter under 4-D ultrasound guidance. After placing the balloon above the endotracheal bifurcation it was inflated with 2.5 ml of sodium chloride and the catheter was removed.

The light optic was inserted through the fetoscope sheath to control the right position of the balloon and monofil 2 – 0 polypropylen suture. The polyhydramnion was drained and the fetoscope was removed from the uterus.

The L/H-Ratio increased from 0.52 to 2,8 at 34+1 weeks of gestation. The O/E Ratio increased from 21,1% to 134,2%.

Two month later the polypropylene suture was visualized in fetal month during the fetoscopy. The intratracheal balloon was successfully extracted from the trachea by traction to this suture. The patient was delivered nearly term and the CDH could be successful operated one day later.

Six months later the patents visited us in the clinic to present the well-being girl after the successful treatment of CHD.

Conclusion: Fixation of the 7 cm suture to the intratracheal balloon significantly facilitates the extraction of the balloon. It could also reduce the risk of EXIT-Procedure in case of emergency C-Section.