Performance of a Flexible Versus Rigid Fetoscope in the Simulated Management of Twin‐to‐Twin Transfusion Syndrome

Objective To assess the feasibility and operative performance of a flexible fetoscope (FF) compared with a rigid fetoscope (RF) in the simulated management of twin‐to‐twin transfusion syndrome (TTTS) with anterior placentation. Method A randomized, non‐blinded crossover trial was conducted during a national training session for fetal surgeons. Twenty participants each performed a simulated Solomonization procedure using both the FF and RF in a high‐fidelity TTTS simulator. The FF consisted of a single‐use flexible video‐endoscope inserted into a 10 Fr, 230‐mm stainless steel cannula. Outcomes included the visualization of the recipient cord insertion, the completeness of Solomonization, operative time, tangential vessel approach, and spatial analysis of the Solomonization path to quantify equatorial deviation and its direction relative to the intertwin membrane. Results No statistically significant differences were observed between the FF and RF in recipient cord insertion visualization (80% vs. 40%, p = 0.17), complete Solomonization (95% vs. 70%, p = 0.58) and total procedure duration (11.30 ± 3.09 vs. 9.00 ± 2.36 min; p = 0.08). The overall vessel approach angle was slightly more perpendicular with the FF (median 3.5[IQR 3.0–4.7]) than with the RF (3.0[2.2–3.7]; p = 0.08). Spatial analysis revealed a larger equatorial deviation area with the FF (31.1 ± 10.3 vs. 17.8 ± 7.1 cm 2 ; p = 0.01) and a more anterior trajectory (signed deviation 15.6 ± 10.2 vs. −15.0 ± 17.0 cm 2 ; p < 0.01). Conclusion Flexible fetoscopy appears feasible in the setting of anterior placentation in simulated TTTS surgery, supporting its potential clinical value and the need for dedicated training before clinical translation.