Advancing Fetal Intervention Simulation Plans: A Multidisciplinary Training Approach

Eval Krispin, MD
Phillip DeKoninck, MD, PhD
Co-Chairs, Fetal Therapy SIG

Fetal interventions have transformed the management of severe congenital anomalies, offering the potential to improve outcomes for conditions once deemed untreatable in utero. The success of these complex procedures relies not only on advanced surgical techniques but also on robust simulation training to prepare multidisciplinary teams. In this update, we highlight the evolving field of fetal intervention simulation, with examples spanning neural tube defects and other fetal conditions requiring prenatal intervention.

Background

Different prenatal diagnosis, including but not limited to, twin pregnancies complicated by twin-to-twin transfusion syndrome (TTTS), congenital fetal anomalies such as myelomeningocele, and congenital diaphragmatic hernia, pose significant risks to fetal and maternal health. These can be treated prenatally. Nonetheless, given the technical challenges, relative rarity of these cases, and high-stakes nature of these procedures, simulation-based training provides a critical platform for skill acquisition, team coordination, and procedural rehearsal.

Evolution of Fetal Intervention Simulation

Simulation in fetal interventions has evolved significantly over the past two decades. Early training models focused on basic task-based learning, such as ultrasound-guided needle placement [1]. Today, high-fidelity synthetic models, virtual reality (VR), and 3D-printed patient-specific anatomical replicas are used to replicate complex fetal conditions and surgical scenarios [2]. Here are some examples of available simulators:

Fetoscopic Spina Bifida Repair Simulators

Advancements in simulation technology have played a significant role in enhancing fetoscopic repair of open spina bifida, offering hands-on training opportunities to refine surgical skills.

1. Low-Cost Models
   Reusable models made from avian tissue, readily available from grocery stores, or other accessible materials that simulate neural and subcutaneous layers, offer an affordable solution for widespread training. While accessible, these models often lack comprehensive surgical performance metrics and intermediate evaluations for issues like watertightness [1,3,4].
2. High Fidelity Modular Systems
   Synthetic models with adjustable placental positioning replicate patient-specific anatomical variations. These models support training in fetoscopic approaches, addressing the diversity in surgical techniques that may be new to the operating team [5,6].
   In addition, advanced synthetic simulators incorporate replaceable defect units, enabling repeated training sessions without compromising anatomical accuracy. These models also feature modular components for specific surgical steps, such as neural placode dissection and patch placement [Figure 1] [4]. There is a broad range of commercially available simulator, yet the acquiring costs can be very substantial.
3. Animal-Based High-Fidelity Models
   Animal models provide a realistic platform for practicing complex procedures. Competency is often assessed through cumulative testing methodologies. However, ethical concerns and scalability issues limit the broader adoption of these models [2].

Simulators for Other Fetal Interventions

In addition to open spina bifida repair, simulation models, both low- and high-fidelity, have been designed for a range of fetal conditions [Figure 2.3]. Here are some notable examples:

• Intrauterine Needle Procedure Simulators: Various synthetic models that accommodate ultrasound guided needle interventions such as intrauterine transfusions or thoraco-amniotic shunt placements are available. Practice improves hand-eye coordination an essential skill to safely perform such procedures. [7,8]
• TTTS Simulators: Virtual reality systems and high fidelity placental phantoms enable precision practice in placental laser ablation for monochorionic twin pregnancies. These tools help refine techniques and reduce the risk of residual anastomoses [9].
• Congenital Diaphragmatic Hernia Simulators: Synthetic models mimic diaphragmatic defects, allowing surgeons to practice fetoscopic tracheal balloon occlusion and removal [9] as well as post natal removal of the balloon in urgent scenarios [10].
• EXIT Procedure Training: Mannequin-based simulators replicate challenges of maintaining uteroplacental circulation while securing fetal airways, emphasizing team coordination and communication [8].

Components of Effective Simulation Programs

1. Multidisciplinary Collaboration
   Effective fetal intervention relies on the seamless integration of various disciplines depending on the fetal condition, including but not limited to maternal-fetal medicine, pediatric surgery, pediatric neurosurgery, pediatric otolaryngologist, anesthesiologists, and nursing. Simulation training emphasizes communication and role clarity, critical for managing intraoperative complications.
2. Safe training platform
   Fetal surgery simulations serve as a critical platform for training healthcare professionals in complex procedures. Utilizing high-fidelity models, 3D-printed anatomical replicas, and virtual reality systems, these simulations replicate the intricate anatomy and conditions encountered during fetal interventions. This allows practitioners to gain hands-on experience and familiarize themselves with specialized techniques in a safe and controlled environment.
3. Maintaining and Enhancing Skills Through Fetal Surgery Simulations
   Fetal surgery simulations are crucial for improving and maintaining surgical skills, particularly in a field where procedures are infrequent due to the rarity of eligible cases. These simulations provide a consistent platform for surgeons to practice intricate techniques, ensuring that their expertise remains sharp even when opportunities for real-world procedures are limited. By enabling hands-on training and repetition, simulations help practitioners retain proficiency and confidence in performing highly specialized interventions.
4. Objective Skill Assessment
   Evaluation frameworks with measurable tools and open feedback are integral to simulation programs. These systems assess technical and non-technical competencies, offering detailed feedback on precision, efficiency, and teamwork.

Challenges and Future Directions

Despite significant progress, challenges remain in creating cost-effective, accessible, and reproducible simulation models. Emerging technologies, such as 3D printers, artificial intelligence (AI)-driven training modules and haptic feedback systems, offer promising avenues for improvement. Furthermore, ongoing research is needed to validate the correlation between simulation training and clinical outcomes.

Figure 1: Low Fidelity low cost fetoscopic spina bifida repair simulator developed at Boston Children’s Hospital
Immersive Design Systems
Fetal Care and Surgery Center

Figure 2: High Fidelity fetoscopic laser photocoagulation for twin-twin transfusion syndrom developed by Surgical Touch Inc.

Figure 3: High fidelity fetal mannequin for thoracoamniotic shunt placement.
Surgical Touch Inc.

Conclusion

Simulation-based training represents a cornerstone in the preparation of multidisciplinary teams for fetal interventions. By providing a safe, risk-free environment for skill development and team rehearsal, these programs enhance procedural safety and efficacy, ultimately improving outcomes for mothers and their fetuses. Continued investment in simulation technology and research will further advance this critical field, ensuring that practitioners are well-equipped to meet the challenges of fetal therapy.

References

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