Novel Application of Laparoscopic Ultrasound for Fetoscopic Laser Ablation in Twin-Twin Transfusion Syndrome with Complete Anterior Placenta.

Fetoscopic laser coagulation of the placental communicating vessels has become the standard treatment for monochorionic/diamniotic twin pregnancies complicated by severe twin-twin transfusion syndrome. Fetoscopic trocar placement can be performed with transabdominal ultrasound guidance with a posterior placenta and most anterior placentas that have a safe avascular window for entry. However, trocar insertion is challenging in cases of a complete anterior placenta without an avascular window. Current techniques to deal with this situation include mini-laparotomy with exteriorization to allow for dorsal entry, percutaneous lateral entry under transabdominal ultrasound/Doppler guidance, and laparoscopic assisted access with direct visualization of trocar entry. We describe a modified technique of laparoscopic assisted fetoscopic trocar placement using a laparoscopic ultrasound probe, which allows for precise, real-time guidance of trocar placement.