Hypoglossal Nerve Stimulator
This transcript has been reviewed and is accurate.
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. Don't look away. Alright, good. 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 - 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 visual - visualization at the end of the case for tongue protrusion.
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 proximally 1 centimeter or 1 finger breath below the lower border of the mandible. We have about a 5 centimeter 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 centimeters or 3 finger breadths below. You've got a 5 centimeter incision which is where the generator pouch will be, and then for lead stent placement for the sensor, you got - the sensor will end up inferior to the nipple, so about 4 centimeters posterior to that, put a 5 centimeter incision along the inferior border of the pec muscle in an intercostal space - will be our third site. So one, two, three.
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 monopole or cautery. Alright, so Adam is going to go through the platysma - which you can see the fibers there. Bipolar. We'll cauterize the hemorrhage. Just let me know - on. Yeah, there's something else. Bipolar. Skin. Yeah, there we go. Okay. Bipolar. Can I have Cowboy hooks, please? Just finish up the platysma right there. Knife, please. Yep. Alright, so next we're going to find - tonsil and a DeBakey - we're going to find the anterior border of the submandibular gland, 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.
Now 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 see if you can clear that up. Yep. Good. Yep, so that's - see how… While you've got - while you've got the anterior belly digastric, why don't you come underneath that and isolate it. 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.
And now that we've got the gland exposed, the next stop is to find the posterior aspect of the mylohyoid. Tonsil, please. So similar to a submandibular gland excision, we now have the mylohyoid retracted anteriorly. So if you'll see, we got a vein of ranine, and you got the hypoglossal nerve tracking anteriorly. So the next step is we need to iden - is isolate this ranine vein and ligate it to get it out of the field.
The big one. Snap. Snap. Can - can you - can you shift superiorly? Yeah, let's just make sure that the nerve is safe. Kittner, please. Okay, good. So the nerve is down. 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 - oh. Let's just go in. Help me - and then you reach under that layer. Let me… Army-Navy. Here, let me get a new one under you. Another Kittner. 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. I'll take this. Hopefully you're video recording all the tap-dancing 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. 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. Kittner. And then the first branch to be excluded is right here. Exclusion. Okay. In - inclusion. Out - alright. It's a pretty defined - he's got a big beefy nerve. Right angle, please.
Can we have the - the - the coupler. My English is failing me. Can I have a tonsil? So what we're doing - there's an inner - can you see, Scott? There's an inner and an outer flange. Can you see that? One second. 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 - inner has to go around. DeBakey. Follow that 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.
DeBakey. Thank you. I'll take another one, please. If you want to tie that one. There you go. Yep, so double knot. This is anchoring the stim lead down, so you're going to bring one thread around. Yep. I'm going to tie it down into the groove. I'm going to do the same thing. Ray-Tec with some Bassey 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. 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 monopole or cautery. Bipolar, please. It's otology hot right there. Yeah, what - what that means is that otologists keep their bipolars sig - significantly hotter than the rest of the world. Come over here. Yep. Yep. Down to prod it from that parotid - 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 - three finger breadths 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. 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 Bassey. This is one of the truth - 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 Bassey in our irrigation because we do not want a device related infection. 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. Okay - knife. Okay, so I can palpate a rib interspace. DeBakey and a tonsil. So what we're going to do here is we're going to find - we're going to work our way between leaflets of the serratus anterior muscle. Bipolar, please. Bipolar. Do you have the pedal on? Yep. Thank you. Come on. Right here. Seeing as it's hard to see the serratus anterior - right here. So again, we're just coming in between. Right - right there. A little more posterior - right there. Just 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 inter - intercostals, which we should be able to see shortly. 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 - you can see the direction - the directionality, and you can see it almost looks like packing - 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 de we have the ribbon? So we're going to take this malleable. We're going to measure it to 6 centimeters and put a nice little bend on it, and what this is doing is this is going to introduce between the internal and external inter - 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 cross the hemothorax. 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. 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. 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. With like a central line or something? 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. DeBakey.
We're going to get a tunneler, which is up here. 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. No, I'm going to come this way - sorry. I'm going to feed the sensing lead. Let me just - let me just put quite a bit in here. Go for it. So he's going to gently pull. Yeah. 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 - 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. Coming in. Scissors. Stitch. DeBakey. Thank you. Stitch down.
So, now what Adam's going to do is develop a sub - subplatysmal plane, going from - yes, good. Thanks, man. She's going to develop a - can I have an introducer? Thank you. Just 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 introduce her 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. You got to find a better tunneler. Seriously. Bridge, please - or Army-Navy is fine. We're tunneling. We got a blunt instrument, but the problem is there is - there is a branch of the external jugular vein that was connected to the anterior jugular system - but hopefully doing, you know, the blunt stuff avoids a lot of bleeding, but sometimes you just can't avoid it. Alright, so Adam is going to clean off the tips of the electrodes, and can I have the lap?
Again, I just want to be an otologist, so similar to my ment - mentors of - of old, I… Would you like some new gloves? No. 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 - yeah, and I can see it in the end, so Adam's going to twist in here three clicks. Okay. he's going to take the screwdriver out, and I'm going to give it a little tug test. Make sure that's all passed.
So then we're going to repeat the process. Who's going to put the screwdriver in? 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. Yep, okay. 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. It's all good. We're good.
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 button. So you if you want to record the - all the screenshots. So we're going to - so your 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 - it's not - in the intercostal or - right. 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 we 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. I'll take the 10-10. 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. Looks like we tie this straight out of the mouth - bilateral protrusion - I think if anything, that gauze is hindering it. Can I have the grasper? Yeah, go for it.
So, there's - 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. Do you do like a week of antibiotics for this? 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 - send them on 3 to 5 days of skin for a coverage like Keflex just to - again, just to ward off evil spirits. So - 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. We don't need any more silks. Yeah, we're done. We need - we need the vicryls and the chromics. Okay. Can you do a valsalva, please? Yeah, if you don't mind. Great, thank you.