Because of advances in ultrasound and surgical procedures, operating on fetuses has become possible. However, because of risks to the mother, infant, and subsequent pregnancies, procedures are only performed in centers with well-trained teams and only when there are no reasonable alternatives. Several types of surgeries may be performed, including placing shunts to remove fluid from organs and cavities. For example, in obstructive urinary disease of the urethra, a pigtail shunt may be inserted into the fetal bladder. One problem is diagnosing the condition early enough to prevent renal damage. Ex utero surgery, where the uterus is opened and the fetus operated upon directly, has been used for repairing congenital diaphragmatic hernias, removing cystic (adenomatoid) lesions in the lung, and repairing spina bifida defects. Repairs of hernias and lung lesions have good outcomes if proper selection criteria for cases are employed, and one of these is the fact that without surgery, fetal demise is almost certain. Surgery for neural tube defects is more controversial because the abnormalities are not life threatening. Also, the evidence is not conclusive that repair of the lesion improves neurological function, although it does alleviate the accompanying hydrocephalus by freeing the tethered spinal cord and preventing herniation of the cerebellum into the foramen magnum (see Chapter 19; p. 445).
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