To date, this report represents the largest series of patients undergoing the 1-stage transanal Soave pullthrough. This approach is safe, permits early feeding, causes minimal pain, facilitates early discharge, and presents a low rate of complications.

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CONTRIBUTIONWhat are the novel findings of this work? For fetal surgery of spina bifida aperta (SBA), the learning curve (LC) is significant regardless of the approach, and the number of cases operated on is correlated with outcome. Competency is reached after 35 consecutive cases for standard hysterotomy and is predicted to be achieved after ≥ 57 cases for mini-hysterotomy and after ≥ 56 for percutaneous two-layer fetoscopy. What are the clinical implications of this work?Standard hysterotomy for closure of fetal SBA has the shortest LC and remains the gold-standard technique, with regards to safety and efficacy. Mini-hysterotomy and percutaneous fetoscopy have a longer LC. Percutaneous fetoscopy requires advanced endoscopic dissection and suturing skills and adequate preliminary training. ABSTRACTObjective The Management of Myelomeningocele Study (MOMS) trial demonstrated the safety and efficacy of open fetal surgery for spina bifida aperta (SBA). Recently developed alternative techniques may reduce maternal risks without compromising the fetal neuroprotective effects. The aim of this systematic review was to assess the learning curve (LC) of different fetal SBA closure techniques. Methods MEDLINE, Web of Science, EMBASE, Scopus and Cochrane databases and the gray literature were searched to identify relevant articles on fetal surgery for SBA, without language restriction, published between January 1980 and October 2018. Identified studies were reviewed systematically and those reporting all consecutive procedures and with postnatal follow-up ≥ 12 months were selected. Studies were included only Learning curves of fetal surgery for spina bifida Conclusiones El número de casos operados está correlacionado con el resultado del cierre de la EBA fetal, y el número de casos operados necesarios para alcanzar la competencia estuvo entre 35 para la histerotomía estándar y ≥56-57 para las operaciones con mínima agresividad. Las observaciones realizadas proporcionan información importante para las instituciones que buscan establecer un nuevo centro fetal, desarrollar una nueva técnica de cirugía fetal o entrenar a su equipo, e informar a los médicos que remiten a especialistas a los posibles pacientes y a terceros.

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