Surgical Information

Thoracic Approach & Cervical Approach

Introduction Of The Thoracic & The Cervical Approach

A surgical procedure is necessary to implant the electrode under the phrenic nerve and the receiver just under the surface of the skin. This procedure can be done Cervically (via the neck) or Thoracically (via the chest). For bilateral stimulation (stimulation of both phrenic nerves) two antennas, two electrodes and two receivers are needed. For unilateral stimulation (stimulation of only one phrenic nerve) one antenna, one electrode and one receiver are needed.

The procedure averages 2-4 hours in length, and the patient is typically discharged from the hospital 1-2 days later. Some procedures can be performed on an outpatient basis.

The decision as to which approach is appropriate is determined by the surgeon performing the procedure.

Thoracic Implantation

Thoracic Approach

The thoracic approach involves a small (5-7 cm) incision made between a pair of ribs so that the phrenic nerve can be isolated alongside the heart. The surgeon places the electrode under or near the phrenic nerve and sutures it in place. The receiver is then placed just under the skin, usually from within the same incision. The thoracic approach can be performed in a minimally invasive manner by using VATS (video-assisted thoracic surgery) techniques. Since a small camera is used to provide visualization of the operative site, the incision can be significantly smaller.

VATS involves the use of multiple small (5-10 mm) incisions instead of one primary incision. Through these incisions, a camera and specially designed instruments are used to visualize the nerve and place the electrode. Thoracoscopic procedures can be performed with standard endoscopic instruments or by use of a surgical robot.

This approach is commonly chosen for the youngest pediatric patients since the anatomy of the neck is not sufficiently developed in these cases. It is also a common approach for patients who are suspected of having nerve damage so that the stimulation can occur below the presumed injury.

The thoracoscopic surgical technique is unique in that the camera allows for direct visualization of the diaphragm while under stimulation.

Cervical Approach

The cervical approach is also considered minimally invasive and can be performed under local or general anesthesia.

It uses a small (3-5 cm) incision made in the area where the neck meets the torso. The phrenic nerve is isolated where it is most superficial, the scalenus anticus muscle. The surgeon places the electrode under the phrenic nerve and sutures it in place. The receiver is then placed just under the skin in a subcutaneous pocket.

This approach is commonly chosen for older pediatric patients and adult patients who are known to have good phrenic nerve conduction.

Cervical Implantation

Examples Of Surgical Procedures

VATS Placement of Diaphragm Pacing Electrode

Diaphragm Evaluation

Intraoperative Testing

The primary purpose of intraoperative testing is to confirm stimulation of the phrenic nerve. Intraoperatively, diaphragm function can be confirmed via a number of methods including: visual observation of chest wall, palpation of the costal margin, observation of CO2 changes as measured by anesthesia equipment, and rarely, fluoroscopy.

The primary purpose of intraoperative testing is to confirm stimulation of the phrenic nerve. Additionally, preliminary threshold and amplitude settings can be assessed. These numbers can provide a baseline from which pacing can be established once healing is complete.

Dr. Headley With Our Success Patient Chuck.

Find A Physician

Avery Biomedical Devices works with physicians and medical centers throughout the United States for the implementation of the Avery Diaphragm Pacemaker. To find a physician or medical center near you, please contact us and we will be happy to connect you to a physician or medical center that is familiar with the device and may further assist you and your specific needs.