6-hour surgery, 5-week planning: India’s first-of-its-kind fetal repair performed at AIIMS

Five weeks of planning, a team of over 30 medical professionals, including doctors and nurses, and a six-hour surgery: a new record was set at the All India Institute of Medical Sciences (AIIMS) in Delhi on November 12 as the specialists performed India’s first open fetal repair of a lumbosacral myelomeningocele, the most severe form of spina bifida.

The first-of-its-kind fetal repair in the country was performed at 25 weeks of pregnancy. Doctors said the defect, which causes the spinal cord and its coverings to push out through a gap in the spine, can cause paralysis, fluid build-up in the brain and lifelong neurological problems.

Explaining more about the surgical procedure, Dr Deepak Gupta, who led the neurosurgical team, told The Indian Express, “This is not a cure, and the child may still need long-term neurosurgical, urological, orthopaedic and rehabilitation care.” He added, “However, international evidence, including the landmark 2012 MOMS (Management of Myelomeningocele Study) trial (at AIIMS), shows that prenatal repair can reduce the need for treatment of hydrocephalus and improve early motor outcomes in carefully selected babies." The uterus is then closed, and the pregnancy is closely supervised.

"It is better to nip the problem in the bud. While foetal surgery is being practised for some time in other countries, the effort to do it in India is to be appreciated. Surgery before being born reduces the incidence of both hydrocephalus and Chiari malformations," said Professor PS Chandra, Head Neurosurgery, AIIMS, who facilitated the entire surgical execution by the team.

During the five weeks of planning for this first-of-its-kind surgery at AIIMS, experts ensured detailed fetal imaging, counselling of the parents, anaesthetic preparation and surgical simulation. “Fetal surgery cannot be treated as a single operation," Dr Gupta said.

“It requires a complete maternal-fetal care programme, with rigorous selection, non-directive counselling, ethical oversight, operative protocols, emergency preparedness and lifelong follow-up planning.” The team, including professionals from neurosurgery, maternal-fetal medicine, obstetrics, anaesthesia, plastic surgery, radiology and neonatology departments, worked at the Neurosciences Centre, using high-end microscopy and continuous ultrasound techniques.

Professors Dr Neena Malhotra and Dr K Aparna Sharma led the maternal-fetal medicine and obstetric work. The mother, Dr Gupta added, accepts real surgical and future obstetric risks for a possible benefit to her unborn child.

That makes informed decision-making central. A dedicated fetal surgery programme was envisaged at AIIMS in 2012, after the results of the Management of Myelomeningocele Study (MOMS) came out. The trial compared fetal surgery with repair after birth.

At 12 months, 40% of children operated on before birth needed a cerebrospinal-fluid shunt, against 82% of those operated on after. The shunt drains excess fluid from the brain. Prenatal surgery also improved motor outcomes and cut hindbrain herniation linked to Chiari II malformation.

The surgery, however, has certain risks. It can raise the chance of premature delivery and leaves a scar on the uterus that can complicate future pregnancies. That is why it is offered only to carefully selected pregnancies at specialised centres.

The gains to India are a lot. Gupta estimates around 1.2 lakh babies a year are born with neural tube defects, including 20,000 to 30,000 with open defects like this one. A 2024 review of 27 Indian studies put the pooled prevalence at 9.46 per 1,000 births and called for stronger national surveillance.

Dr Gupta further explained, “The neural tube closes about 28 days after conception, often before a woman knows she is pregnant. Prevention, especially periconceptional folic-acid supplementation and food fortification, remains essential”.

The procedure was done for free under the Centre's Janani Shishu Suraksha Karyakram. Can other government hospitals do this? Yes, Dr Gupta said, but only through designated tertiary referral centres. "This should never be an occasional or isolated procedure," said Dr Gupta.

Such centres would need maternal-fetal medicine specialists, paediatric neurosurgeons, specialised anaesthesia teams, neonatal intensive care, emergency delivery facilities and long-term rehabilitation. AIIMS could set the benchmark, he said, through structured training, simulation, ethical oversight and a national referral and follow-up pathway.