Simulation training for urgent postnatal fetal tracheal balloon removal: Two learning methods

Published:December 27, 2022DOI:



      In fetuses with severe congenital diaphragmatic hernia, fetal endoluminal tracheal occlusion (FETO) with balloon increases survival and reduces morbidity. Balloon removal is often scheduled electively. In urgent cases, in-utero removal is impossible and removal immediately after delivery has to occur, posing risk of death from airway obstruction. Medical staff need training in urgent removal. Ideal training method is unclear; thus, we compared the performance of two groups trained by different methods.


      24 medical students were randomly assigned to two different learning methods for removal: Group 1 (in-person lecture) and Group 2 (online video). Both methods presented the same information: endoscopic instrument set-up, anatomical landmarks for intubation, and balloon removal. All participants were evaluated using the same instruments and high-fidelity simulator, comparing time for instrument set-up and simulate balloon removal (including removal attempts).


      Group 1 took significantly less time for instrument set-up compared to Group 2 [62 (30–92) secs vs 81 (57–108) secs; p < 0.01)]; no difference in time to intubate and locate the balloon [75 (50–173) secs vs 92 (32–232) secs; p 0.42], or number of attempts.


      There was no difference between video training and in-person training with regards to the time taken to locate the FETO balloon in the trachea and to simulate its removal.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      1. Belfort MA, Olutoye OO, Cass DL, Olutoye OA, Cassady CI, Mehollin-Ray AR, et al. Feasibility and Outcomes of Fetoscopic Tracheal Occlusion for Severe Left Diaphragmatic Hernia. Obstet. Gynecol., vol. 129, Lippincott Williams and Wilkins; 2017, p. 20–9. 10.1097/AOG.0000000000001749.

      2. PK C, M R, R M, DH R, S L. Congenital Diaphragmatic hernia - a review. Matern Heal Neonatol Perinatol 2017;3:532–40. 10.1186/S40748-017-0045-1.

        • Britto I.S.W.
        • Sananes N.
        • Olutoye O.O.
        • Cass D.L.
        • Sangi-Haghpeykar H.
        • Lee T.C.
        • et al.
        Standardization of Sonographic Lung-to-Head Ratio Measurements in Isolated Congenital Diaphragmatic Hernia: Impact on the Reproducibility and Efficacy to Predict Outcomes.
        J. Ultrasound Med. 2015; 34: 1721-1727
        • Ruano R.
        • Yoshisaki C.T.
        • Da Silva M.M.
        • Ceccon M.E.J.
        • Grasi M.S.
        • Tannuri U.
        • et al.
        A randomized controlled trial of fetal endoscopic tracheal occlusion versus postnatal management of severe isolated congenital diaphragmatic hernia.
        Ultrasound Obstet. Gynecol. 2012; 39: 20-27
        • Deprest J.A.
        • Nicolaides K.H.
        • Benachi A.
        • Gratacos E.
        • Ryan G.
        • Persico N.
        • et al.
        Randomized Trial of Fetal Surgery for Severe Left Diaphragmatic Hernia.
        N. Engl. J. Med. 2021; 385: 107-118
        • Verla M.A.
        • Style C.C.
        • Olutoye O.O.
        Prenatal intervention for the management of congenital diaphragmatic hernia.
        Pediatr. Surg. Int. 2018; 34: 579-587
        • Jani J.C.
        • Nicolaides K.H.
        • Gratacós E.
        • Valencia C.M.
        • Doné E.
        • Martinez J.-M.
        • et al.
        Severe diaphragmatic hernia treated by fetal endoscopic tracheal occlusion.
        Ultrasound Obstet. Gynecol. 2009; 34: 304-310
        • Jiménez J.A.
        • Eixarch E.
        • DeKoninck P.
        • Bennini J.R.
        • Devlieger R.
        • Peralta C.F.
        • et al.
        Balloon removal after fetoscopic endoluminal tracheal occlusion for congenital diaphragmatic hernia.
        Am. J. Obstet. Gynecol. 2017; 217: 78.e1-78.e11
        • Kurup V.
        • Matei V.
        • Ray J.
        Role of in-situ simulation for training in healthcare: opportunities and challenges.
        Curr. Opin. Anaesthesiol. 2017; 30: 755-760
        • Supramaniam P.R.
        • Mittal M.
        • Davies R.
        • Lim L.N.
        • Arambage K.
        Didactic lectures versus simulation training: a randomised pilot evaluation of its impact on surgical skill.
        Gynecol. Surg. 2018; 15: 1-7
        • Huang J.
        • Tang Y.
        • Tang J.
        • Shi J.
        • Wang H.
        • Xiong T.
        • et al.
        Educational efficacy of high-fidelity simulation in neonatal resuscitation training: A systematic review and meta-analysis.
        BMC Med. Educ. 2019; 19: 1-10
        • Windrim R.
        • Ryan G.
        • Lebouthillier F.
        • Campisi P.
        • Kelly E.N.
        • Baud D.
        • et al.
        Development and use of a high-fidelity simulator for fetal endotracheal balloon occlusion (FETO) insertion and removal.
        Prenat. Diagn. 2014; 34: 180-184
        • Stefanidis D.
        • Acker C.
        • Heniford T.B.
        Proficiency-Based Laparoscopic Simulator Training Leads to Improved Operating Room Skill That Is Resistant to Decay.
        Http://DxDoiOrg/101177/1553350608316683. 2008; 15: 69-73
        • Kory P.D.
        • Eisen L.A.
        • Adachi M.
        • Ribaudo V.A.
        • Rosenthal M.E.
        • Mayo P.H.
        Initial airway management skills of senior residents: simulation training compared with traditional training.
        Chest. 2007; 132: 1927-1931
        • Lee M.O.
        • Brown L.L.
        • Bender J.
        • MacHan J.T.
        • Overly F.L.
        A Medical Simulation-based Educational Intervention for Emergency Medicine Residents in Neonatal Resuscitation.
        Acad. Emerg. Med. 2012; 19: 577-585
        • Kattwinkel J.
        • Perlman J.M.
        • Aziz K.
        • Colby C.
        • Fairchild K.
        • Gallagher J.
        • et al.
        American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.
        Circulation. 2010; 2010: 122
        • Sananès N.
        • Regnard P.
        • Mottet N.
        • Miry C.
        • Fellmann L.
        • Haelewyn L.
        • et al.
        Evaluation of a new balloon for fetal endoscopic tracheal occlusion in the nonhuman primate model.
        Prenat. Diagn. 2019; 39: 403-408
        • Basurto D.
        • Sananès N.
        • Bleeser T.
        • Valenzuela I.
        • De Leon N.
        • Joyeux L.
        • et al.
        Safety and efficacy of smart tracheal occlusion device in diaphragmatic hernia lamb model.
        Ultrasound Obstet. Gynecol. 2021; 57: 105