Author: The Fetal Institute

Percutaneous mini-laparotomy fetoscopic treatment of Open Spina Bifida

Percutaneous mini-laparotomy fetoscopic treatment of Open Spina Bifida

Open spina bifida develops when the spine fails to close at some point along its length during fetal development.

Our group has worked on developing a minimally-invasive technique (so-called ‘keyhole surgery’) for the antenatal treatment of MMC, translating an experience of more than 10 years in the animal model to a viable clinical application. The technique does not require a hysterotomy (uterine incision). Instead, small instruments are placed into the womb through tiny incisions, and with the use of partial CO2 insufflation, the open spina bifida is repaired. This approach minimizes the risks of the surgery for the mother while preserving the potential benefits of the in-utero repair for the fetus.

Institute for Surgical Excellence Announces Eftichia Kontopoulos, M.D., Ph.D. Appointment to the Advisory Board of Directors

Surgical Excellence banner

WASHINGTONThe Institute for Surgical Excellence (ISE) today announced the appointment of Eftichia Kontopoulos, M.D., Ph.D., to its Advisory Board of Directors. ISE is a non-profit organization that convenes leading innovators, hospital executives, and surgeons to develop consistent, teachable and measurable surgical standards that directly improve patient outcomes.


Dr. Kontopoulos is an internationally recognized Fetal Surgeon. After completing a research fellowship at Harvard University, she conducted her residency in Obstetrics and Gynecology (Ob/Gyn) at the Robert Wood Johnson University of Medicine and Dentistry of New Jersey, she continued there with her fellowship in Maternal Fetal Medicine. Subsequently, she served in the Ob/Gyn and Maternal Fetal Medicine Department at the University of South Florida, where she received formal training in Fetal Surgery and Fetal Therapy. She is double boarded in Ob/Gyn and Maternal Fetal Medicine. Currently, Dr. Kontopoulos practices at The Fetal Institute Miami, which she co-founded in 2017 providing consulting and management of high-risk pregnancies through specialized treatments. 


“Dr. Kontopoulos will be an invaluable addition to the ISE Advisory Board of Directors as she will bring her shared vision of improving patient care and experience, and advancing surgical excellence,” said Dr. Martin Martino, ISE Executive Board Member and Gynecologic Oncologist.


“I am very honored to be part of the Advisory Board of the Institute for Surgical Excellence. Over the past twenty years, advancements in surgical techniques and technologies have provided the possibility of successful treatment of fetal conditions that previously were considered incurable. I am a firm believer that through solid research and proper surgical inventions, we can change the lives of our patients and their families. I am happy to share my vision with that of ISE.” said Dr. Eftichia Kontopoulos, M.D., Ph.D..


Together with her team, Dr. Kontopoulos has performed several pioneering surgeries and World’s first procedures. Dr. Kontopoulos has published chapters, books, and multiple peer-reviewed articles. Dr. Kontopoulos is a frequently invited speaker on Fetal Therapy, Fetal Surgery, and Advanced Endoscopic Surgical techniques in National and International meetings.


Robotic surgery is transforming the healthcare landscape. With precision and perfection, surgeons can challenge traditional operating procedures by reducing pain, risk, and recovery time.  Today, minimally invasive techniques are primarily used in gynecology, urology, thoracic, and cardiac surgery.  ISE looks ahead to an exciting year filled with surgical milestones. 

#  #  #

ISE is a 501(c)(3) public charity, whose mission is to create lasting solutions for complex healthcare problems related to emerging technologies, with the ultimate goal to improve patient care and outcomes. ISE utilizes a systems-based approach (collective impact model) to bring together key stakeholders from a variety of sectors to identify issues, set clearly defined goals, facilitate collaboration, determine and fill gaps, and better inform health care consumers. ISE is embarking on a series of transformational projects with respect to the role and standards of surgical technologies, with the first and current focus on Robotic Surgery.  As part of this project, ISE continues to manage and develop the Robotic Training Network (RTN) through participation with hospitals across the country, and research-focused engagement with the Fundamentals of Robotics Surgery (FRS). 

Doctors at The Fetal Institute, Miami are conducting a clinical trial on the fetoscopic repair of open spina bifida

Doctors at The Fetal Institute, Miami are conducting a clinical trial on the fetoscopic repair of open spina bifida

Open spina bifida (OSB), a birth defect that occurs in approximately 1 in 1,500 births in the United States, results from failure of the spine to close at some point along its length during fetal development. The defect leads to injury and loss of spinal cord tissue at and below the defect. Research showed that antenatal treatment of OSB via open fetal surgery, which requires opening the maternal abdomen and uterus, can improve the outcome of babies affected with OSB. However, the mother is at risk for rupture of the uterus (uterine rupture) and requires delivery by cesarean section for the affected pregnancy and for any subsequent pregnancy.

Doctors at The Fetal Institute, Miami and the USFetus, in collaboration with colleagues in Brazil, have developed a minimally-invasive (fetoscopic) technique to treat fetuses with OSB, which does not require opening the uterus. This allows the mother to deliver vaginally and avoid the risk of uterine rupture. The doctors are currently conducting a clinical trial to validate this new fetoscopic technique. For further information, please click here.

We’re honored to have Dr. Kontopoulos on The TTTS Foundation’s Medical Advisory Board

We're honored to have Dr. Kontopoulos on the TTTS Foundation's Medical Advisory Board

I respect and share the mission of The TTTS Foundation of providing babies and mothers in need with the best possible options for treatment.

Their website serves as the first point of information for families seeking treatment for TTTS, including TAPS, SIUGR and TRAP.

The TTTS Foundation does amazing work! I have admired over the years how much they have helped families in need and how effectively they have helped spread awareness. I share in the passion of The TTTS Foundation in helping families affected by these conditions.

I am truly honored and very pleased to be a member of the Medical Advisory Board of The TTTS Foundation and help to fulfill their mission.

Dr. Eftichia V. Kontopoulos
TTTS Foundation
Medical Advisory Board

Kontopulos and Quintero at the Society of Maternal Fetal Medicine Meeting 2020

Kontopulos and Quintero at the Society of Maternal Fetal Medicine Meeting 2020

The mission at The Fetal Institute is to provide the utmost care to patients with complicated twin pregnancies, which is perfectly in line with that of The TTTS Foundation.

The Fetal Institute shares the passion of The TTTS Foundation in helping families affected by these conditions by providing state-of-the-art counseling and treatment.

For more information about TTTS, including TAPS, SIUGR and TRAP, please go to

The Fetal Institute Miami helps create history in the care of Twin-to-Twin Transfusion Syndrome in Mexico

The Fetal Institute Miami helps create history in the care of Twin-to-Twin Transfusion Syndrome in Mexico

In collaboration with The Fetal Institute Miami, the National Institute of Perinatology in Mexico (INPer) successfully performed a Fetal Laser Photocoagulation Surgery. The goal is to create the first public National Center for Fetal and Perinatal Surgery in Mexico

Dr. Ruben Quintero from The Fetal Institute Miami and the specialists from the National Institute of Perinatology, “Isidro Espinosa de Los Reyes” (INPer), successfully performed a fetal laser photocoagulation surgery. The procedure was carried out in a patient with a twin pregnancy of 20 weeks’ gestation.

This intervention allowed correcting an alteration known as Twin-Twin Transfusion Syndrome (TTTS), a specific and unique complication of multiple gestations with a single placenta that causes both fetuses to pass blood to each other in an unbalanced way through placenta vascular communications, which puts the lives of both fetuses at risk.

On January 29, 2021 the intervention was carried out by a team of specialists from The Fetal Institute Miami and Maternal-Fetal Medicine Specialists from INPer. In Mexico, there are approximately 32,000 twin births; of these, 30% are monochorionic (development of twins with a single placenta), of which up to 20%, about 1,800 pregnancies, will develop TTTS.

The Procedure

Minimally-invasive surgery consisted of making an incision in the skin of the mother to insert a cannula into the uterine cavity, where a camera and the laser fiber were introduced.

Through the camera, a direct view of the placenta is obtained through an endoscope. After identifying the vascular communications, they are coagulated with laser, eliminating all vascular connections between the fetuses and dividing the single placenta into two independent placental territories.

More collaborations

In order to offer specialized and high-quality care that patients and their babies require, INPer has the project of creating the first public National Center for High-Specialty Perinatal Surgery with the support of The Fetal Institute Miami, directed by the renowned specialists in fetal surgery Dr. Rubén Quintero and Dr. Eftichia Kontopoulos.

The collaboration between both institutes aims to train and expand INPer’s fetal medicine specialists’ skills, weighing ethics and humanism values, becoming the first public hospital in Mexico to treat pathologies during pregnancy with minimally-invasive techniques.

Quintero Staging for TTTS

Quintero Staging for TTTS

The Quintero’s TTTS staging system has basically been adopted all over the world it is a very practical way of assessing patients with twin twin transfusion syndrome it has very clearly defined parameters that anyone can follow and it has withstood the test of time. I published this in 1998 and many years later it still holds and allows us to evaluate and tell patients how severe their particular condition is.

The Quintero staging system allows both the colleagues and the patients to know how severe their particular TTTS case is. People have asked me how did you come up with this classification system? What I realized when I started evaluating patients with twin twin transfusion syndrome is that not all the cases presented in the same way. I decided to analyze what was the difference in the different presentations. For example, we will get a phone call from a colleague saying, “hi I have a patient has a mild case of TTTS” or “I have a patient with a severe case of TTTS” so we didn’t know what that meant. By noting that they don’t present in the same fashion, I basically came up with a classification that helps us say how severe is the disease for each particular case and the staging system that I proposed as five stages:

Stage 1

In the first stage an ultrasound you can still see the bladder of the donor twin they all have regardless of the stage the discordant in amniotic fluid volume one more than eight centimeters deep and the other less than two centimeters deep regardless with days but in stage 1 you can still see the bladder of the donor twin.

Stage 2

In stage 2, after an hour of observation and ultrasound you cannot see the bladder of the donor twin, though a stage 2 patient is more severely affected than a stage 1 patient.

Stage 3

In stage 3, the blood flow studies of either twin are very abnormal. When we say very abnormal that means that they are not above a certain percentile or some other norm that you can look on a table, not they are either present or absent the blood flow studies the anomalies in the blood flow studies. So in stage 3 either the umbilical artery shows no blood flow at the end of the cardiac cycle, is called absent end diastolic velocity also revered as a AEDD or the umbilical vein shows bumpy positive flow or the ductus venosus which is a vessel that runs through the liver of the fetus those either no flow or backwards flow in a segment of the cardiac cycle we’re supposed to always show polar flow.

Either twin can have any of these abnormal Doppler studies so you can have stage 3 donor for stage 3 recipient for stage 3 donor recipient.

Stage 4

In stage 4 the babies have gone into heart failure one or both that is shown on ultrasound with fluid that accumulates that extravasation different parts of the body the level of the scalp at the level of the chest at the level of the belly so there is fluid accumulation and the baby that means the baby went into heart failure

Stage 5

In stage 5 one or both babies have passed away.

Now the staging system has several features that are very important to note they may not be apparent when you first read the staging system but they have a purpose. First of all I call this stage not type. This suggests or implies that babies can have different degrees of severity meaning it’s the same condition but one one patient can be more severely affected than another or less affected than the other.

Because of that, the Quintero staging system also uses Roman numerals that also implies that the higher the Roman numeral the more severe the disease. The third aspect that is characteristic of the system is that all the parameters that we evaluate are either present or absent and that makes it very practical to use. In virtually every ultrasound lab in the world they have the Quintero staging system and it’s very easy to follow because either the bladder is visible or not visible or the Doppler are abnormal or they’re not abnormal, or there’s hydrops or there’s no hydrops. This is very easy and very practical.

The importance of the staging system is not only that they didn’t establish a common language among physicians but also that it helps us evaluate the prognosis when either nothing is done or when symptomatic treatment is offered. Symptomatic treatment is when you simply take off fluid from the sac of the recipient. The more advanced the Quintero state stage was for that particular patient the worse the prognosis you know for that patient. It always works. This is the origin and the importance of the Quintero staging system.