In-Utero Myelomeningocele Repair: Historical Evolution, Technical Refinements, and Global Impact of the Vanderbilt Experience.

Abstract

Myelomeningocele (MMC) is a severe neural tube defect resulting from incomplete closure of the spinal column during early embryogenesis, often leading to lifelong neurological, urological, and orthopedic impairments. The "two-hit hypothesis" describes both the primary embryologic malformation and progressive in-utero neural injury as contributors to clinical severity. While postnatal repair prevents further exposure of neural tissue, it does not reverse the intrauterine damage already sustained. This manuscript provides a comprehensive review of the historical evolution, surgical techniques, and institutional experience of in-utero MMC repair, with particular emphasis on the pioneering role of Vanderbilt University Medical Center. Key operative advancements-such as the use of bipedicled fasciocutaneous flaps, refined hysterotomy techniques, and multidisciplinary coordination-are discussed alongside postoperative maternal-fetal management and long-term outcomes. The manuscript also examines comparative outcomes between open and fetoscopic approaches, highlighting the challenges, safety profiles, and global expansion of fetal MMC programs. Detailing both historical context and modern innovations, this work aims to underscore the important reconstructive challenges presented by in-utero repair of MMC, and the critical role played by plastic surgery in optimizing fetal MMC repair and advancing care for this complex condition.