Unborn baby’s ‘keyhole’ surgery to spine a first for Africa
A 25-week unborn Johannesburg baby has become the first foetus in Africa to receive an anaesthetic and undergo groundbreaking “keyhole” surgery to the spine.
The four-hour procedure, which involved removing the womb and resting it on the mother’s skin, was performed by a team led by US Baylor College of Medicine professor Mike Belfort, who was born and trained in SA.
Belfort and his team secured a licence for a day from the Health Professions Council of SA to perform the operation, which also required specialist anaesthetists to treat mom and baby so that the foetus didn’t move during surgery.
The world leader in surgery said operating made him “emotional”.
He trained as a doctor at Wits University and qualified as a gynaecologist through the University of Cape Town. “It’s an honour and a privilege.”
The baby was diagnosed with spina bifida, which could cause paralysis and lead to brain damage. The operation, at MediClinic Morningside in Sandton, repaired nerve damage to the spine, giving the foetus a better chance at walking one day.
It also lowers the risk of fluid building up in the brain after birth.
It is the first time the surgery has been performed on African soil. International surgeons opened the mother’s abdomen as they would for a caesarean section, then lifted the womb out and laid it on her skin. Then they made two small cuts into the womb to insert cameras and tiny instruments.
One of the assistants held the womb and foetus steady so surgeons could operate on a stable platform. The little patient received its own anaesthetic.
At 25 weeks, the baby would be close to 600g and not much longer than a school ruler.
Spina bifida is an abnormality in the development of the foetal spine where part of the vertebrae does not close properly. The defect and subsequent “exposure” of the nerve can cause nerve damage.
Side-effects include club feet, incontinence, death, paralysis of legs, and accumulation of fluid in the brain (hydrocephalus), which in turn can cause brain damage.
Belfort and three of his US team members led the operation and worked with a team of four SA doctors, whom he described as “outstanding”.
Wits professor of obstetrics Ermos Nicolaou called him about eight weeks ago, saying there was a patient in need of surgery and “can you help?” The reply came swiftly: “Yes.”
The Texas Children’s Hospital paid for the trip.
Belfort said foetal surgery reduced the 90% likelihood that the child, with this form of spina bifida, would need a shunt to remove fluid from the brain, to 45%. It also doubles foetal in SA the likelihood that the child will walk.
But it was not an for the parents.
The operation is life-threatening to the foetus and can cause premature labour.
On Saturday, a neonatologist was on standby in case the foetus was born.
At one point, SA anaesthesiologist Erni Welch counted 24 people in the operating theatre. There were nurses, representatives from equipment companies and two teams of doctors.
Welch, who worked alongside US anaesthesiologist Mario Patino, said anaesthetics in foetal surgery was particularly tricky. “You are dealing with two patients and one of the easy Nicolaou decision patients you can’t actually see.
“Not all drugs cross the placenta from the mom to baby so the baby needs its own anaesthetic ... you don’t want the baby to move or you can’t see where you need to operate.”
The operation raises ethical questions. The mother has to make the best decision for her child, whom she has never met. She also has to have surgery while pregnant, a risk with no direct benefit for her body.
Belfort explained: “You are asking the mother to take a risk for the baby. It is a complex ethical problem.”
Belfort’s foetal surgery team is supervised by four different medical authorities in the US, including the Food and Drug Administration.
Foetal surgery, exand plained, was usually done if the problem would lead to foetal death or severe handicap.
“One needs to mention that this is a very delicate surgery and the success varies.
“In utero laparoscopic repair can also have complications such as foetal death and premature labour. Careful evaluation and selection of these cases is very important.”
The biggest risk now is premature labour because the operation stimulates the uterus, a muscle that could start to contract. When the mother’s obstetrician called Welch on Monday night his first thought was: “I hope she hasn’t gone into labour.” The call, however, was a simple query.
Welch and Nicolaou say mom
You are asking the mother to take a risk for the baby. It is a complex ethical problem
baby are doing very well.
On Tuesday, the mom was sitting up and using her phone, and contemplating eating for the first time in more than 48 hours.
The doctors will not know how successful the surgery was until the child is born.
Belfort said it was not a cure and required monitoring and possibly surgery after birth.
But Belfort, who has performed keyhole surgery – which was invented by his team – about 60 times, said this was “quite frankly, one of my best cases ever”.
“Kudos to team.”
He said he hoped the SA team would soon visit Houston, Texas, to take part in more operations.
The world leader in foetal surgery said operating in SA made him emotional
the Morningside