PREOPERATIVE DIAGNOSES: Moderate obstructive sleep apnea with CPAP
intolerance.
POSTOPERATIVE DIAGNOSES: Moderate obstructive sleep apnea with CPAP
intolerance.
OPERATIONS PERFORMED: 1. Placement of implantable hypoglossal nerve
stimulator with cervical lymphadenectomy
and neuroplasty technique.
2. Insertion of chest wall respiratory sensor.
3. Electronic analysis of implantable nerve
stimulator.
4. Continuous nerve monitoring for two hours
of hypoglossal and marginal mandibular
nerves with intraoperative nerve stimulation.
OPERATIVE PROCEDURE: The patient was brought to the operating room and laid supine on the
operating table. He was identified correctly. After the satisfactory induction of general endotracheal
anesthesia, a shoulder roll was placed and the neck was gently extended. Incisions were marked for
placement of the stimulation cuff for the IPG and for the breathing sensor. The incisions were infiltrated
OPERATIVE REPORT – PAGE 2 of 3
with lidocaine 1% with epinephrine 1:100,000. The marginal mandibular nerve was monitored with the
NIM system and inclusion and exclusion branches of the hypoglossal nerve were monitored as well with
one lead in the floor of mouth to monitor the genioglossus and another laterally on the tongue to monitor
the styloglossus as the exclusion branch. He was prepped and draped in the usual sterile fashion. The
procedure was performed with surgical loupe magnification and a headlight.
We approached the upper cervical incision first. An incision was carried down through the skin and soft
tissue. Cervical lymphadenectomy technique was used to identify and expose the digastric tendon, the
submandibular gland, and the anterior border of the mylohyoid muscle. The digastric was isolated with a
vessel loop and retracted inferiorly. As the mylohyoid was retracted and the submandibular gland was
retracted, this did expose the hypoglossal nerve. The ranine vein was suture ligated. Neuroplasty
technique was then employed. The C1 branch was isolated. The nerve was dissected distally. There
were inclusion and exclusion branches present and a functional break point was identified both visually and
electrically with the NIM system. All inclusion branches using neuroplasty technique were isolated with a
vessel loop. Specific care was taken to ensure that all inclusion branches were captured by the vessel
loop without any exclusion branches present in it. Once this was achieved, the stimulation cuff was
wrapped around the nerve. It sat very well and a thorough lavage of bacitracin irrigation was used. The
wire was wrapped around the digastric and sutured into place in standard fashion. Bacitracin gauze was
then placed. We then approached the chest area. An incision was carried down through skin and soft
tissue. The dissection was carried to the plane just superior to the pectoralis fascia. A small pocket for
placement of the IPG was developed. Bacitracin gauze was placed.
The intercostal space below the breast was palpated. An incision was carried down through skin and soft
tissue. Serratus fibers were identified and mobilized apart. The external intercostals were identified. The
plane between the external and intercostal muscles was developed easily with a malleable retractor. The
breathing sensor was placed. The permanent anchor was sutured down. A catheter passer was used to
bring the breathing sensor wire up into the IPG pocket. Similarly, a catheter passer was then used for
subcutaneous tunneling of the stimulation lead. Both leads were applied to the IPG. There was a good
visual and electrical connection noted.
Device interrogation was performed. An excellent breathing sensor waveform was noted and excellent
electrical stimulation was noted as well. The system was functioning properly at this point. An Omega
loop of breathing sensor wire was left and the movable anchor was sewn into place in standard fashion.
All wounds were re-irrigated with bacitracin irrigation and layered closures of all incisions were performed
with 3-0 Vicryl subcutaneously. Dermabond and Steri-Strips as well as pressure dressings were applied.
The patient tolerated all the above well. He was lightened from anesthesia, extubated in the operating
room and then brought to the recovery room in good condition.