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 .” •