1. Electrode Placement

2. External Anatomy

a. Identify Anterior Border of Submandibular Gland

b. Isolate Anterior Belly of the Digastric Muscle

c. Identify Posterior Aspect of the Mylohyoid Muscle

d. Control Ranine Vein

3. Hypoglossal Nerve Exposure and Identification

4. Hypoglossal Nerve Branch Identification

a. Secure Stimulation Lead

5. Coupling of Inclusion Nerve Branch

6. Generator Pocket

7. Breathing Sensor Lead

8. Tunnel from Generator to Breathing Sensor Lead

9. Tunnel from Generator to Stimulation Lead

10. Connect Leads to Generator

11. Test System

12. Secure Generator and Check for Hemostasis

Obstructive sleep apnea (OSA) is a common condition with several effective treatment strategies centered around relieving airway obstruction. The gold standard for OSA treatment remains continuous positive airway pressure (CPAP), but other options exist. A recent therapy developed within the past decade utilizes hypoglossal nerve stimulation (HGNS) through a surgically implanted device. As the patient inspires, the device sends an electrical impulse similar to a cardiac pacemaker. The impulse activates targeted branches of the hypoglossal nerve, leading to stimulation of muscles that protrude the tongue and open the airway posteriorly. This mechanism has been shown to reduce airway obstruction by activating these muscles during inspiration. Along with detailing the chronological order of events, this case outlines various complex anatomical structures that are identified in order to safely and effectively implant the hypoglossal nerve stimulator. Please note that an update device and surgical procedure have since been developed, and that this specific video article addresses the original device and surgical technique. The updated procedure is an FDA-approved alternative to this 3-incision technique, where the device is implanted through 2 incisions.

<h4>CHAPTER 1</h4>

<p>So what we're going to do is put the tongue electrodes in.
So these are insulated 18 mm -
so right below the inferior border of the lateral part of
the tongue - about 5 centimeters back.
We're going to pierce through the surface and
then go immediately underneath so you see -
see the electrodes just under the surface.
So that's the first. That's your red - goes in the tongue.
Those are for your
exclusion branches, and then for your inclusion,
you're going to go down to genioglossus.
So we're going to find midline. Just off midline, following
the curve of the mandible, we're going to
insert the electrode into genioglossus.
Prevent them from
being removed iatrogenically
by the attending surgeon.
Put a Tegaderm on the side of the face.
And then placing a bite block
on the contralateral side will aid in
visualization at the end of the case
for tongue protrusion.</p>

<h4>CHAPTER 2</h4>

<p>We're marking out the
normal anatomy, so we're marking out midline
down through to the sternal notch.
We've got the lower border of the mandible
as well as the anterior border
of the submandibular gland, approximately 1 cm or
1 fingerbreadth below the lower border of the mandible.
We have about a 5-cm incision
just above our hyoid. This is where most of the work
will be finding the hypoglossal nerve.
We've also marked out our external jugular vein
as to not to get into that during tunneling.
Further down we've got the inferior border of the clavicle
as well as the deltopectoral groove, approximately 5 cm or
3 fingerbreadths below.
You've got a 5-cm incision, which is where
the generator pouch will be.
And then for lead stent placement for the sensor,
you've got - the sensor will end up inferior to the nipple,
so about 4 cm posterior to that,
put a 5-cm incision along the inferior border of
the pec muscle in an intercostal space - will be our third site.
So one, two, three.</p>

<h4>CHAPTER 3</h4>

<p>Alright, so first we're going to make an incision -
through the skin down to platysma.
Because of the technology - bipolar. Because of the
technology, we are not - we don't use monopolar cautery.
So Adam is going to go through
the platysma.
Which you can see the fibers there.
Bipolar.
Double-pronged skin hooks, please.
We'll cauterize the hemorrhage. Just let me know - on.
Yeah, there's something else.
Skin
Yeah, there we go. Okay.
Bipolar.
Can I have Cowboy hooks, please?
Just finish up the platysma right there.
Knife, please. Yep.
Good.</p>

<p>Alright, so next we're going to find - tonsil and a DeBakey -
we're going to find the anterior border
of the submandibular gland.
DeBakey.
Which you can see is right - right here.
So we're going to free that up.
And come superiorly.
Now I'll take a bipolar. Yeah, just come - make sure...
This way? Yeah, just try to free it up a little bit.
More coming out. Yep.
And we know that we're safe, because we're lateral to
the mylohyoid, so the only thing we can
potentially injure is the marginal mandibular branch of the
facial nerve. So that's really the only
consequence.
Yeah. Let me grab this, and just see if you can clear that up. Yep.
Good.
Okay.
Yep, so that's - see how...
While you've got
the anterior belly digastric here, why don't you
come underneath that and isolate it.</p>

<p>Make sure you get all the way around it.
Yeah, that's good.
Right through there.
Can I have the blue, please?
So what we're doing is putting a vascular loop around
the anterior belly of the digastric.
Number one - it retracts it out of the way, but number two -
it allows for placement of the lead deep to it
after the sensing lead has been
placed. So next, can I have an Army-Navy, please?
Thank you.</p>

<p>And now that we've got the gland exposed,
the next stop...
is to find the posterior aspect of the mylohyoid.
Tonsil, please.
Yep, good. Perfect.
So...
Can I have bipolar?
So similar to a submandibular gland excision,
we now have the mylohyoid retracted anteriorly.
So if you'll see, we've got a vein of Ranine, and you got the
hypoglossal nerve tracking anteriorly.</p>

<p>So the next step is we need to iden -
is isolate this Ranine vein and ligate it to get it out of the field.
Here you go.
The big one.
Snap.
Snap.
Can - can you - can you shift superiorly?
Yeah, and let's just make sure that the nerve is safe. Kittner, please.
Okay, so the nerve is down. Okay, Metz.
Silk ties, please.
So we're going to tie. You don't want to put any clips near
the electrodes, so all - all of this is done with permanent -
permanent suture.
One more.
Army-Navy, please.
Tonsil.
Good.
Let's get her in.
Kittner.
Help me - and then you reach under that layer. Here, let me...
Army-Navy. Here, let me get a new one under you.
Another Kittner.</p>

<h4>CHAPTER 4</h4>

<p>So Scott, you might be able to hopefully see - start to
see some of the branching
of the nerve.
Tonsil, please.
Just a little branch.
Try to keep your tone in.
So, a bipolar, please.
Hopefully this...
Hopefully you're video recording the little tap dance I'm doing.
Oh my God, I have a Kittner count.
I just have a mental note of all the Kittners I use
during this case. Can I have another Kittner, please?
You can record that. Oh, I will.
So you're starting to appreciate some of the branching patterns.
You got a main trunk, and you're starting to get some...
Do you have the nerve stim?
Alright, here's our most inferior branch.
Okay.
No response.
Good.
This should be an exclusion.
Exclusion, exclusion, inclusion.
Inclusion. Exclusion.
Okay.
Inclusion.
Tonsil. So we're trying to do - generally, the
more inferior branches are the ones
that we are going to include.
Kittner.
Alright, nerve stim.
Alright, we got our main inclusion branch, right here.
Inclusion.
Kittner.
And then the first branch to be excluded
is right here.
Exclusion. Okay.
In. Inclusion.
Out. Exclusion.
Alright. It's a pretty defined -
he's got a big beefy nerve.
Right angle, please.</p>

<h4>CHAPTER 5</h4>

<p>Can we have the...
The...
Coupler.
My English is failing me.
Can I have a tonsil? So what we're doing -
there's an inner...
There's an inner and outer flange,
so we unfurl the outer flange and grab
the outer corner of it.
What we do is we pass this underneath the nerve,
and we grab it with the
right angle that's currently...
Make sure when you free up the fascia around the nerve,
you get a good centimeter
around it to be able to facilitate
the coupler coming through.
Inner has to go around. DeBakey.
Followed by the outer, and that - there's memory to it, so it loops
right around it.
Do you have an angiocath with some saline, please?
Put a little bit of saline around the c - through the
tube just to make sure -
there's no tissue stuck in it.
Alright, so now that tunnel
that was made underneath the digastric - we're now going to
feed - tonsil. We're now going to feed
the lead underneath it.
3-0 silk sutures, please.</p>

<p>DeBakey.
Thank you.
I'll take another one, please.
If you want to tie that one.
Here you go. Yep, so double knot.
This is anchoring
the stim lead down, so you're going to bring one thread around.
Yep. You can tie it down into the groove.
I'm going to do the same thing.
Ray-Tec with some Baci on it, please.
So I don't get the Inspire team upset, I'm going to make sure I leave the
end of it out.</p>

<h4>CHAPTER 6</h4>

<p>Alright, so that's the first,
so next we're going to make a pocket for the generator.
So this is very similar to a pec flap.
So we're going to make an incision down through skin,
subcutaneous fat, down onto pectoralis
major fascia without going through it.
Same thing - no monopolar cautery. Bipolar, please.
It's otology hot right there.
Yeah. What that means is that
otologists keep their bipolars significantly hotter than the
rest of the world. Come over here.
Yep. Down to pec fascia.
Good. That's good right there - yep, and
a little bit more laterally - medially.
Yep, so with blunt dissection in a
plane just lateral -
just superficial to the pec,
you need to be able to create three
fingerbreadths in order to make the pocket.
So, you can always make it
wider. You don't want to make it too big to prevent migration.
Yep.
So you can see the shiny pec fascia down, and all the sub-q
fat and everything up. That's the pocket.
Ray-tec with saline or Baci. This is one of
the true - you know,
one of the things in head and neck that actually
have to be sterile, so now we're using Ioban.
We're using Baci in our irrigation because
we do not want a device-related infection.</p>

<h4>CHAPTER 7</h4>

<p>So a third is going to be
the place for the sensor.
Incisiones, with a knife-y. Thanks.
Cowboy hooks.
Thank you.
Another one, Adam.
Knife.
Okay, so I can palpate a rib
interspace. DeBakey and a tonsil.
So what we're going to do here is we're gonna
work our way between -
leaflets of the serratus anterior muscle.
Bipole, please.
Bipolar.
Do you have the pedal? On. Yep.
Thank you.
And I want to come...
Right here.
So you can start to see -
the serratus anterior.
Right here.
So again, we're just coming in between.
Yep.
Yep.
It's right - right there.
A little more posterior - right there.
Buzz about right there.
Yeah, good.
So what we're looking for is a change
in the direction of the fibers, so
the serratus anterior looks different than the
intercostals, which we should be able to see shortly.
Yep.
Kittner, please.
Can you see, Scott?
So, you have here the serratus anterior.
And then a little bit deeper you have
a slightly different orientation of the
fibers, right shoulder
to sternum, and they look like -
there's bleeding. Suction, please.
Buzz that right there.
What I'm holding on to? Yep.
You can see the directionality,
and you can see it almost looks like
packing -
like packing tape. So that's the external.
So right on the other side of that...
Is going to be the internal, which goes in a different direction.
Yep.
So do we have the -
ribbon? So we're going to take this malleable.
We're going to measure it to 6 cm.
We're gonna put a nice little bend on it, and what this is doing is
this is going to introduce
between the internal and external
intercostals and is going to make sure
we stay in that -
in this fascial plane between internal and external
oblique fibers -
so that I don't cause a pneumothorax.
Apparently, if I just stay in the direction of the ribs,
which has been told to me more than once, I should be safe.
I still don't believe it, but...
There we go.
Slightly easier that time.
Alright, it should - it's a potential space, so it should
come in rather easily. Tonsil.
So this is the sensor lead, so this has
to go down against the internal.
So you grab it by the little honeycomb part,
and you make sure that these
vertical little nubs are facing up if you forget.
But basically, this goes in; this comes out.
DeBakey.
Hopefully, there isn't a large rush of air when you do this.
I'm kind of not kidding.
Alright, silks - we need four of them.
Yeah, so you have -
similarly to what the -
part in the neck where you have the two
sutures that go around the barrel, but you also have
a couple sutures that
go around the flanges on the side to keep it from migrating.
Can you push that in a little bit?
Nice. Thank you.
Scissors.
Yep.
DeBakey.
Thank you.</p>

<h4>CHAPTER 8</h4>

<p>So, we're going to get a tunneler,
which is up here. And so what Adam's going to do is in the plane
just superficial to the pec fascia,
he's going to connect the two surgical sites.
Yep, good. Yep. So, he's going to remove the central core.
Now I'm going to come this way, sir.
We're going to feed the sensing lead.
Let me just put quite a bit in here.
Go for it. So he's going to gently pull. Yep.
Yep, good.
So, now we've got
what they call this omega-shaped release -
kind of a pressure release valve down here that -
in case there's any tugging or pulling,
there's no - there's limited risk of it coming out.
Silk. So now what we're doing is we're going to secure the
the strain relief
onto the inferior border
of the pec major,
and that is - this lead is mobile. So what you're doing
is by putting the suture around it, you're kind of locking it onto
the cable.
Army-Navy.
Army-Navy.
Scissors.
Stitch.
DeBakey.
Thank you.
Stitch down.</p>

<h4>CHAPTER 9</h4>

<p>So, now what Adam's going to do is develop a
subplatysmal plane,
going from -
Why don't you come up here.
yeah, that's good. Thanks, man.
So he's going to develop that plane -
can I have the introducer?
Thank you. Just to make our lives - again, you can kind of see the
external jugular vein,
so we just kind of know where we have to try to avoid.
You just mirror the shape of the patient to -
the introducer, somehow.
Same thing - superficial to pec fascia, over clavicle
in theory - watching me struggle on video.
Trying not to puncture anything.
So, in similar fashion, remove the central core.
I'm just going to feed a healthy portion of this into...
Excellent.
Bleeding.
That's good.
It's not moving.
Ah, hold on.
We got to find a better tunneler.
Seriously.
Rich, please. Or Army-Navy is fine.
Suction. Let's just take a look and make sure we -
where our
red blood cells are coming from.
Bipolar.
Clean those off, please.
Tonsil, please.
DeBakey.
Yep.
Medium, uh...
2-0 tie to Adam.
That's the problem with tunneling.
You got a blunt instrument, but the problem is there is a
branch of the external jugular vein that was
connected to the anterior jugular system that...
Hopefully doing,
you know, the blunt stuff avoids a
lot of bleeding, but sometimes you just can't avoid it.</p>

<h4>CHAPTER 10</h4>

<p>Alright, so Adam is going to clean off the tips of
the electrodes.
Can I have the lap? Again, I just want to be an otologist,
so, similar to my mentors of old, I...
Oh wow. Really clean.
Would you like some new gloves? No.
Would you like a basin? That's right. I'd like a warm towel.
Alright, so next -
can you give us the implant?
So, Adam is going to have the screwdriver,
so he's going to insert it into
the bottom -
can I have a clean Ray-Tec, please? Through the membrane -
and I'm going to get the
sense lead, which says sense lead
on it - again, for head and neck oncologists.
Yep, so we're going to insert, push past...
Yep, and I can see it in the end, so Adam's going to twist and hear 3 clicks.
Okay. He's going to take the screwdriver out.
And I'm going to give it a little tug test and make sure
that's all passed. So then we're going to repeat the process.
So he's going to put the screwdriver in.
Okay.
Same process - insert it all the way in,
putting gentle pressure, twist down three clicks.
Okay. Screwdriver forcibly removed - gentle tug test.
It all looks like it's passed, and all
the insulating bits are where they're supposed to be.
So, now rotating in a
clockwise fashion, getting the wires behind.
Watching me struggle on video - yada, yada, yada.
Into Adam's wonderfully-created chest pouch on top of
the pec fascia.
So now, we're going to see if the whole system works.
Army-Navy. We're good.</p>

<h4>CHAPTER 11</h4>

<p>Yep. Yep, so...
Yep. So similar to what we do with a cochlear implant,
we're going to get the sterile...
Yep, so we're going to put it right over, and we're going to
look to see the green.
Next step is to try to look for inspiration, expiration,
so we're going to look respiratory waveforms.
So, that tells us the electrode is in the right place.
It's not... Right. In the intercostal?
It's in - it's able to sense expansion of the chest.
So we let it go for a few cycles until we get a
pretty picture.
See, there's our pretty picture.
So now, the next step is where we're going to test the actual tongue.
Do you have a Ray-Tec, please?
A moist Ray-Tec, sorry - just so I can clean off the -
the tape, alright.
This is why we use the clear...
What we want to do is see protrusion of the tongue.
Yep, so we're starting at 1.5.
So, we're going to increase the voltage to 2.
It looks like the tongue is straight out of the mouth -
bilateral protrusion - I think if anything, that gauze is hindering it.
Can I remove the gauze? Yeah, go for it.</p>

<h4>CHAPTER 12</h4>

<p>So, there's a hole in the top, so we put two sutures
in a V formation down on the pec fascia to prevent migration,
but there's an air knot in these compared to the other ones.
And you do like a week of antibiotics for these folks?
So technically, you're not sup - you don't
need to, but given that we're near the mouth
and we're mucking around with it,
I just give a - I send them on 3 to 5 days of skin
flora coverage like Keflex just to -
again, just to ward off evil spirits.
Silk. Yeah, there's no -
there's no indication for it, but it makes me sleep better at night,
which in the end, that's all that matters.
Yeah, that's all that matters.
We don't need any more silks. Yeah, we're done.
We need the Vicryls and the chromics.
Okay, can you do a Valsalva, please?
You said you wanted a Valsalva?
Yeah, if you don't mind. Oh, right. Of course, sorry.
Great, thank you.</p>


Watch this full-length, narrated surgical video of the placement of a hypoglossal nerve stimulator in a patient with obstructive sleep apnea.

DOI
Publication Date	2023/08/31
Article ID	246
Production ID	0246
Volume	2023
Issue	246
https://doi.org/10.24296/jomi/246

Hypoglossal Nerve Stimulator

Procedure Outline

Table of Contents