Hippocrates has long been celebrated as the Father of Medicine, yet many may not know that he first proposed the then-revolutionary idea of preventive medicine. In Aphorisms, he writes, "Extreme remedies are very appropriate for extreme diseases." Although he many not have envisioned fetal surgery at the time, these eight words continue to affect surgeons today. Fetal surgery is the treatment of disease and correction of deformity or defect by manual and operative procedures on the fetus as it remains in the mother's uterus. Though a few doctors experimented with fetal surgery in the 1960 s, it was not until the early 1980 s that, after numerous trials in animals, Dr. Michael Harrison, director of the fetal treatment center at UCSF, began operating on fetuses with life-threatening tumors.

Harrison was the fist physician in the world to perform a successful repair surgery on a living human fetus. The first fetal patient suffered from an enlarged bladder that would prevent the normal maturation of the lungs, eventually leading to death soon after birth. By the mid-1990's, Dr. Bruner at Vanderbilt University decided it was time to try surgery on fetuses with non-lethal malformations; his first prenatal patient suffered from spina bifida. Though a lot of attention has been paid to the repair of this type of anomaly, surgery is also performed on fetuses with hydrocephalus and diaphragmatic hernia.

The goal is not so much to save lives anymore, but to improve the quality of the life for the fetus. By repairing defects early, doctors are able to prevent further damage to the fetus. Not only does fetal surgery raise a number of medical ethical issues, it also gives rise to controversy surrounding issues such as fetal rights and reproductive politics. Diagnostic tests are normally performed early in pregnancy. Routine blood tests and abdominal ultrasonography may warn physicians of a potential problem with the embryo or fetus. At that time he may elect to perform more tests such as amniography or amniocentesis to confirm or dispel suspicion of a potentially life-threatening ailment.

Once the diagnosis is conclusive, the parents must face termination or continuation of the pregnancy. If the parents elect to continue the pregnancy, and the fetus is a candidate for prenatal surgery, the parents will go through an interview process Prep The mother is given anesthesia which will eventually reach her developing fetus, and neither will feel pain during the procedure. Procedure The operation is conceptually simple. Through a Caesarean section, the uterus is pulled up and placed on the woman's abdomen. A tiny incision is made in the uterus, and the amniotic fluid is withdrawn through a needle and stored in the operating room to be put back later. The uterus is then cut open and the fetus is exposed so surgeons can repair the defect.

The operation to repair spina bifida defect takes a little over one hour Recovery The mother typically spends the next few months in close proximity to the hospital. Except for the twice-weekly visits to doctor, she is expected to remain on bed rest. During this time, the mother will wear a pump, which continually injects medications to prevent premature contractions until at least the 34 th week of pregnancy. The cost of these medications may be as much as $300. 00 per month. Outcomes (risk / benefits ) Affect on normal birth C-sections are necessary to deliver the baby.

Fetal surgery creates a fresh uterine wound; with vigorous contractions during labor the wound could rip, jeopardizing both mother and infant. The risks to both mother and fetus are considerable. The mother can suffer uterine rupture, hemorrhaging, bowel obstruction and infection as well as serious side effects from the drugs used to control premature labor. Virtually all infants who have fetal surgery are born prematurely by caesarean sections, increasing their chances of complications as newborns.

Long-term Despite short-term success rates, there exists no long-term data suggesting long-range outcomes. Vanderbilt University currently uses the Bayley Scale for infant development to assess its youngest patients. However, some believe that this test is outdated, and that children should be followed through school age with a full battery of psychometric tests (Senior). Where done? How many pt's to date? This kind of dramatic surgery is so new and required such specialized surgical team it is done only at Vanderbilt University Medical Center in Nashville, Tennessee, Children's Hospital of Philadelphia and the University of California at San Francisco. It also raises a number of medical ethical and insurance issues, partly because there is no long-term data. Success rates Cost/Insurance Open fetal surgery costs often exceed $30, 000.

00 and is frequently funded through research grants. Since this surgery is still considered experimental, many insurance companies fail to compensate surgeons or hospitals for the procedure. However, this may change in the future. Dr. Arnold Cohen is a former perinatologist and is now employed as corporate medical director for women's health at Aetna US Healthcare in Blue Bell, Pennsylvania.

In his interview for The Boston Globe, he states, "Beyond the enormous human cost, the economic cost of caring for a child [affected with a life-threatening deformity] is 'astronomical.' " Dr. Cohen was so awestruck with the fetal surgery performed at Vanderbilt University, that he called this type of surgery nothing short of "miraculous", and managed to convince Aetna to contract with Vanderbilt to pay for patients to have the procedure. "It intuitively makes sense," he adds. Future trends Although 'Open" fetal surgery is dramatic, doctors are increasingly turning toward closed or minimally invasive procedures in which thin instruments and a small TV camera are inserted through tiny incisions.

At times, they use ultrasound to guide instruments. Dr. Joseph Bruner, director of fetal diagnosis and therapy at Vanderbilt, predicts "a network of centers around the world offering fetal surgery for many disorders within five years." (Sinha) Others are optimistic and envision greater benefits as they exploit this type of technology. Susan Okie writes in The Washington Post, "Facial deformities might be corrected before the skin develops the ability to scar. Blood disorders such as sickle cell anemia might be treated with a fetal bone marrow transplant before the immune system becomes able to reject foreign cells." The possibilities seem endless. Pro-life view / pro -choice view Sociologists Fetal surgery, like many high-tech procedures, actually touch the lives of very few; yet like such treatments, it raises fundamental questions of whose babies we value and whom we want to reproduce Conclusion As advances in technology and knowledge extend the reach of medicine to areas once considered sacrosanct-the fetus within the womb-doctors and patients increasingly face complex ethical questions such as those raised by fetal surgery.

Whether patients agree to fetal surgery depends on individual beliefs and emotions, yet to anguished families, it seems unethical not to try everything possible, no matter how experimental or risky. Blum, Linda M. "The Making of the Unborn Patient: A Social Anatomy of Fetal Surgery." Contemporary Sociology 28. 6 (1999): 740-742. Davis, Robert. "Hand of a fetus touched this world Photo shakes up abortion debate." USA Today 2 May 2000: D 8.

Foreman, Judy. , et al. "FETAL SURGERY Miracle before birth; Procedures done in the womb both amaze and raise many questions." Boston Globe [City Edition] 2 Aug 1999: C 1. Gurney, Cynthia.

"Small wonder." Harpers Bazaar July 2000: 138-143. Market, Linda Rae. CONTEMPORARY TECHNOLOGY: Innovations, Issues, and Perspectives. Tinley Park: the Good heart-Wilcox Company, Inc.

, 1997. Okie, Susan. "Over the Tiniest Patients, Big Ethical Questions; Fetal Surgery's Growing Reach Raises Issues of Need and Risks." The Washington Post 12 Apr 2000: A 1. Senior, Kathryn. "Is the case for fetal surgery for spina bifida proven?" The Lancet 354. 9192 (1999): 1795.

Sinha, Gun jan. "Operation normal fetus." Popular Science 255. 4 (1999): 87.