Despite advances in neonatal and surgical care, the outcome of severe congenital diaphragmatic hernia (CDH) is still quite poor. Improvements in the ability to diagnose and risk stratify CDH prenatally have led to investigations into whether the more severe forms of CDH may benefit from in-utero intervention to ameliorate the accompanying pulmonary hypoplasia. Fetal endoscopic tracheal occlusion (FETO) is an example of a prenatal surgical intervention that was made possible by the technological advancements in endoscopic surgery. FETO is generally performed in fetuses with more severe forms of CDH to stimulate prenatal lung growth. While FETO is still considered investigational therapy and has not attained standard of care status, the results from published data to date have been promising. The complexity of FETO, coupled with the surgical and anesthetic risk to the mother and fetus requires a highly functional multidisciplinary fetal team, which includes obstetrics, pediatric surgery, and anesthesiology. This chapter will provide an in-depth understanding of the history of fetal endoscopic tracheal occlusion for CDH, the operative and anesthetic approach to FETO and associated perioperative considerations. Congenital diaphragmatic hernia continues to be a disease that perplexes obstetricians, neonatologists, surgeons, anesthesiologists, and the entire care team.

Prenatally diagnosed congenital lung malformations represent a wide variety of fetal pulmonary and airway anomalies, some of which may require close monitoring and perinatal follow-up. Historically these masses were only typically seen when they were very large, at which point they were associated with a high incidence of hydrops and a high termination rate; therefore a diagnosis of a fetal lung mass had a guarded prognosis. Widespread use of prenatal ultrasound improved detection of these masses and advances in surgical techniques have allowed for intervention in the fetal period. More recently, a better understanding of fetal physiology and the use of prenatal steroids has reduced the number of fetuses requiring in-utero intervention. When indicated, in-utero treatment requires a multidisciplinary approach with close attention given to the fetal physiology, risk of maternal complications, and unique anesthetic considerations.

Fetal surgery is surgery performed on the unborn child. This can be performed open (via a hysterotomy) [1], with minimal access (fetoscopic), or with image-guided techniques [2]. Open fetal surgery can be performed at the time of delivery – ex utero intrapartum treatment (EXIT procedure) [3] – or during the course of pregnancy where the fetus is allowed to continue its gestation in utero. The choice of approach to the fetal therapy varies by condition, gestational age and anticipated objective of the intervention.