R P Onders1, A F DiMarco, A R Ignagni, J T Mortimer. 1. Department of Surgery, University Hospitals of Cleveland and Case Western Reserve University, 11100 Euclid Avenue , Cleveland, OH, 44106, USA. Raymondonders@uhhs.com
Abstract
BACKGROUND: Electrical stimulation of the phrenic nerve motor point of the diaphragm through laparoscopic implantation of a pacing system is an option for high spinal cord-injured patients with chronic respiratory insufficiency. This study assesses the operative learning curve for the initial series of patients. METHOD: A series of six patients underwent laparoscopic placement of a diaphragm pacing system. The operative procedure was divided into the following four steps for analysis and rapid adjustment after each operation: exposure of the diaphragm, mapping of the phrenic nerve motor point, implantation of the pacing electrodes, and final routing of the wires to the external system. RESULTS: The first case required two operations, and the second case was unsuccessful because of a nonfunctioning phrenic nerve that led to a change in the preoperative screening criteria. The operative time decreased from 469 min for the first operation to 165 min for the sixth operation. The significant time decrease can be attributed to changes in the mapping and routing aspects of the operation. Key changes during this series that helped to reduce the operative time include abandonment of a software-dependent mapping technique, development of a grid algorithm for mapping, software improvement to increase the speed of stimulation and mapping, refinement of the mapping probe to maintain adequate suction on the diaphragm, shortening of the electrode lengths, and experience with the implantation of connections to the external electrodes. Presently, all five of the successfully implanted patients can be maintained on prolonged ventilatory support with the device. CONCLUSION: Analysis of every step of this investigational procedure enabled us to make rapid changes in surgical protocol, leading to decreases in operative times and expectant improvements in patient safety and efficacy. In this series, analysis was the key to developing a low-risk cost-effective outpatient diaphragm pacing system.
BACKGROUND: Electrical stimulation of the phrenic nerve motor point of the diaphragm through laparoscopic implantation of a pacing system is an option for high spinal cord-injured patients with chronic respiratory insufficiency. This study assesses the operative learning curve for the initial series of patients. METHOD: A series of six patients underwent laparoscopic placement of a diaphragm pacing system. The operative procedure was divided into the following four steps for analysis and rapid adjustment after each operation: exposure of the diaphragm, mapping of the phrenic nerve motor point, implantation of the pacing electrodes, and final routing of the wires to the external system. RESULTS: The first case required two operations, and the second case was unsuccessful because of a nonfunctioning phrenic nerve that led to a change in the preoperative screening criteria. The operative time decreased from 469 min for the first operation to 165 min for the sixth operation. The significant time decrease can be attributed to changes in the mapping and routing aspects of the operation. Key changes during this series that helped to reduce the operative time include abandonment of a software-dependent mapping technique, development of a grid algorithm for mapping, software improvement to increase the speed of stimulation and mapping, refinement of the mapping probe to maintain adequate suction on the diaphragm, shortening of the electrode lengths, and experience with the implantation of connections to the external electrodes. Presently, all five of the successfully implanted patients can be maintained on prolonged ventilatory support with the device. CONCLUSION: Analysis of every step of this investigational procedure enabled us to make rapid changes in surgical protocol, leading to decreases in operative times and expectant improvements in patient safety and efficacy. In this series, analysis was the key to developing a low-risk cost-effective outpatient diaphragm pacing system.
Authors: Anthony F DiMarco; Raymond P Onders; Krzysztof E Kowalski; Michael E Miller; Sandra Ferek; J Thomas Mortimer Journal: Am J Respir Crit Care Med Date: 2002-12-15 Impact factor: 21.405
Authors: R Onders; M F McGee; J Marks; A Chak; R Schilz; M J Rosen; A Ignagni; A Faulx; M J Elmo; S Schomisch; J Ponsky Journal: Surg Endosc Date: 2006-12-20 Impact factor: 4.584
Authors: Raymond P Onders; Maryjo Elmo; Saeid Khansarinia; Brock Bowman; John Yee; Jeremy Road; Barbara Bass; Brian Dunkin; Páll E Ingvarsson; Margrét Oddsdóttir Journal: Surg Endosc Date: 2008-12-06 Impact factor: 4.584
Authors: Christopher J McDermott; Chin Maguire; Cindy L Cooper; Roger Ackroyd; Wendy O Baird; Simon Baudouin; Andrew Bentley; Stephen Bianchi; Stephen Bourke; Mike J Bradburn; Simon Dixon; John Ealing; Simon Galloway; Dayalan Karat; Nick Maynard; Karen Morrison; Naveed Mustfa; John Stradling; Kevin Talbot; Tim Williams; Pamela J Shaw Journal: BMC Neurol Date: 2012-08-16 Impact factor: 2.474