The team came up with a plan

Dr. Galan used ultrasound to

The mother, who traveled from

that called for Dr. Behrendt

help guide Dr. Behrendt, who

a small town in Nebraska to

and all three other fetal

had to perform the ablation

get the procedure, had been

surgeons— Henry Galan, MD;

visualizing in reverse.

referred by Dan Connealy,

Kenneth Liechty, MD; and Michael Zaretsky, MD— in the operating room. Typically only two would scrub in.

They settled on a technique adopted from myelomeningocele repair, an open fetal procedure. They started by opening the patient’ s abdomen with a transverse incision and then opened the fascia vertically.

That gave them the access they needed to flip the posterior uterus forward, outside of the maternal abdomen, using a c-section tool called an Alexis O retractor. Drs. Zaretsky and Liechty held the uterus while

“ We basically had to turn our brains upside down, since we were entering through the back of the uterus. Once we were able to do that, we had to reorient ourselves, almost like we were treating a posterior placenta,” he says.“ Techniquewise, though, it went great, because we were able to get that perpendicular access that we would have otherwise never been able to get for this patient.”

When it was done, they sutured the access port shut, placed the uterus back in the patient’ s abdomen and closed the layers they started with.

MD, a maternal fetal medicine specialist in Omaha, and the team worked closely with him to develop a modified followup care plan that would keep her closer to home for the rest of her pregnancy. She carried the twins another 13 weeks and 6 days to deliver at 35 weeks, about three weeks longer than the average for twins with TTTS who get laser treatment.

“ Every case of TTTS has some uniqueness to it,” says Dr. Behrendt.“ This was just another one of those things— but being able to think through it together, and having the practice and expertise to

NICHOLAS BEHRENDT, MD

Maternal fetal medicine, obstetrics & gynecology Colorado Fetal Care Center

Assistant professor, maternal fetal medicine, obstetrics & gynecology University of Colorado School of Medicine

do both open and minimally

invasive procedures, allowed

us to modify a technique we

use for a totally different

procedure, and I think we did it well.” •