Fetal Care Center Successfully Completes Over 30 Open Fetal Surgeries to Repair Spina Bifida In Utero

The internationally recognized experts at the Orlando Health Winnie Palmer Hospital Center for Maternal-Fetal Medicine and the Pediatric Neurosurgery team at the Orlando Health Arnold Palmer Hospital for Children’s Leon Pediatric Neuroscience Center of Excellence have achieved a major milestone. In collaboration with an integrated team of highly skilled surgical and intensive care nurses as well as specialists from anesthesiology and neonatology, more than 30 open fetal surgeries to repair myelomeningocele in utero have now been successfully performed. In 2018, Orlando Health opened the first and only program in Florida to offer this complex surgery to patients who qualify based on satisfaction of the evidence-based inclusion and exclusion criteria.

Open neural tube defects (myelomeningocele and myeloschisis) occur in approximately 4 out of every 10,000 live births in the United States. In utero repair offers an alternative to traditional postnatal closure of the defect. To determine surgical candidacy, patients are evaluated using the stringent criteria established by the Management of Myelomeningocele Study (MOMS) Trial that began in 2003 and was funded for eight years by the National Institutes of Health.

“At present, open fetal surgery is the only approach that has been scientifically proven by a prospective randomized controlled trial to be safe and have efficacy — significantly reducing the development of shunt dependent hydrocephalus,” says Cole Greves, MD, board-certified maternal-fetal medicine specialist and co-director of Fetal Surgery at Orlando Health. “Based on data collected at 3-5 years of age, it appears the motor function of the lower extremities may also be significantly improved through this intervention.”

Orlando Health’s fetal surgery team is led by Samer Elbabaa, MD, a world-renowned pediatric neurosurgeon considered one of the most skilled and experienced in this procedure. In total, Dr. Elbabaa has performed over 90 successful myelomeningocele interventions in his career.  Leveraging his ongoing collaboration with computer science experts and the Orlando Health Strategic Innovations division, Dr. Elbabaa also has introduced three-dimensional print technology to his pre-procedural fetal surgical planning and counseling of patients.

“This is a delicate surgery under the best of circumstances requiring a committed patient, optimal intrauterine environment and a stable maternal-fetal dyad,” says Dr. Greves. “What really separates the truly exceptional programs is how they handle adversity when it’s encountered intraoperatively. We have a strong track record of ensuring both maternal and fetal safety with outcomes data that, in many respects, meets or exceeds the results of the MOMS trial.”  The average gestational age at delivery is 34 weeks (median — 35 0/7 weeks; mode — 37 0/7). Only 25 percent of babies have required shunt placement thus far.

Dr. Elbabaa continues to look toward the future as he has thoughts on the fetoscopic approach to repair spina bifida. “I do think a less invasive approach will be the direction of the future.  Even now, with our microneurosurgical technique, we can perform this surgery through incisions as small as 3-4 centimeters,” he says. “Once there is evidence from a prospective randomized trial suggesting clear benefit of the fetoscopic approach, I am willing to pursue this, but not before it has passed the test of time and a clinical trial.” In his neurosurgical practice, Dr. Elbabaa has evaluated and performed revision procedures on children who have undergone fetoscopic and open procedures, which gives him a longer-term perspective on the safety and efficacy of each approach. “Primum non nocere,” Dr. Elbabaa says, “first do no harm.” 

It is clear that a passion for the work and a commitment to improving outcomes have brought the team to this place. “When you open the uterus and see the fetus for the first time — for a moment, time stands still,” Dr. Greves says. “Suspended somewhere between the impossible and reality, you imagine that this must be what it’s like to see the Earth for the first time from space. It is truly awe inspiring.”

Orlando Health Winnie Palmer Hospital for Women and Babies is recognized among the nation’s best by The Leapfrog Group, which selected the facility as a top teaching hospital in its most recent rankings.