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Fetoscopic laser surgery for severe twin-twin transfusion syndrome (TTTS) has become the optimal treatment choice since the release of the Eurofetus randomized clinical trial. These techniques have been adopted throughout the globe, and many institutions have instituted or will soon institute fetoscopic laser surgery procedures; however, laser sur- gery has a steep learning curve because of the following: challenging placental location, complex and unexpected com- municating anastomoses, residual anastomoses after surgery, or discolored amniotic fluid. We have been performing laser surgery since 2002 in Japan; to date, we have compiled a series of 170 cases. Our data indicates a 78% of overall survival with 5% neonatal morbidity, 63% of survival of both twins, and 93% survival of at least one twin. The recurrent TTTS rate was 1% and the residual vessel rate was 3%. To improve the learning curve of laser surgery, the employment of various techniques is recommended to achieve a suc- cessful surgical outcome: (1) Mapping: before laser ablation, a very thorough mapping of vascular anastomoses should be done, and should be repeated after ablation; (2) Sequential order: obliteration of arterio-venous anastomoses from donor to recipient should be done first to avoid donor hypotension and/or anemia; (3) Trocar (cannula) assisted technique: Trocar assisted technique: Using gentle indent the trocar to the placenta by withdrawing the scope shortly, then anastomoses could be ablated easily; (4) Line method: to avoid residual anastomoses, the laser should draw a virtual line at the hemo- dynamic equator; The operator must be careful not to miss small anastomoses. These techniques can help achieve a successful outcome for fetoscopic laser surgery and improve the outcome for cases of severe TTTS.

Fetoscopic Laser Photocoagulation for the Treatment of Twin-Twin Transfusion Syndrome in Monochorionic Twin Pregnancies