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Name:
10.3171/2024.4.FOCVID244
Description:
10.3171/2024.4.FOCVID244
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/3501013d-89fa-4712-9996-0f3bdd0958f1/videoscrubberimages/Scrubber_514.jpg
Duration:
T00H10M26S
Embed URL:
https://stream.cadmore.media/player/3501013d-89fa-4712-9996-0f3bdd0958f1
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/3501013d-89fa-4712-9996-0f3bdd0958f1/2. 24-4.mp4?sv=2019-02-02&sr=c&sig=NFIOHLur7%2BKd3DS0KG5pP55V2NXL%2FXyygqJs%2FhtY%2Bwc%3D&st=2026-04-03T01%3A53%3A53Z&se=2026-04-03T03%3A58%3A53Z&sp=r
Upload Date:
2024-05-16T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: This video is a step-by-step description of the vagus nerve stimulator implantation technique, providing a general methodology and tips and tricks from an epilepsy surgeon with more than 20 years of experience. Vagus nerve stimulation or VNS is a neuromodulatory treatment that involves chronic intermittent electrical stimulation of the left vagus nerve delivered by a programmable pulse generator. This pulse generator is subcutaneously implanted in the chest wall and connected to a bipolar lead with three helical coils wrapped around the cervical part of the vagus nerve.
SPEAKER: VNS is used mainly for drug-resistant epilepsy, including focal and multifocal epilepsy, drop attacks, and syndromes like Lennox-Gastaut. The ideal candidate for VNS implantation would be a patient suffering from a severe bilateral, nonlesional, drug-resistant epilepsy, where a resective or disconnective surgery would not be adequate. The main objective of this treatment is the reduction in the number and severity of the seizures, thus obtaining a better quality of life.
SPEAKER: The right vagus nerve innervates the sinoatrial node, and its stimulation could cause bradycardia, asystole, and other cardiac side effects. Since the left vagus nerve innervates the atrioventricular node, the stimulator should be placed on the left side, aiming to reduce cardiac side effects. The procedure is performed under general anesthesia with endotracheal ventilatory support. Prophylactic antibiotics are administered 30 minutes before surgery.
SPEAKER: The patient is positioned supine on the operating room table with the head on a donut pillow or a head rest extended and turned approximately 30 degrees to the right. The neck is extended with a shoulder roll in order to ease the passage of the tunneling rod. We have found that the most satisfactory approach in children is to begin by making both incisions in the direction of skin creases, which tends to minimize the amount of widening of the incision and gives a better overall cosmetic result.
SPEAKER: The skin of the left anterolateral neck and chest is prepared and draped in the usual sterile manner for surgery. A 2- to 3-cm transverse skin incision is made in a skin fold of the left side of the neck. The incision is carried out roughly halfway between the mastoid and the clavicle, extending from the midline to the medial border of the sternocleidomastoid muscle.
SPEAKER: The subcutaneous dissection exposes the platysma, which can be divided following the direction of the fibers. The omohyoid and other strap muscles are retracted medially, whereas the sternocleidomastoid is retracted laterally. Below this muscle plane, the dissection turns in a vertical direction, similar to one of the carotid artery and jugular vein. Once the carotid sheath is identified, it is opened sharply between the carotid artery medially and the internal jugular vein laterally.
SPEAKER: The vagus nerve is usually found in between these vessels and is dissected approximately 4 cm, avoiding damage to its vasa nervorum and preserving the perineurium sheath. The nerve is gently retracted superiorly using a vessel loop. A 2.5- to 3-cm long incision following a skin crease line is performed approximately 5 cm below the clavicle and 5 cm medially to the shoulder. A 5-cm-diameter subcutaneous pocket is bluntly dissected 5 cm below the clavicle or just medial to the axilla and superior to the breast.
SPEAKER: The electrodes are tunneled with a manufacturer-supplied tunneling device, which includes an inner and outer tunneling tube and a bullet tip thread onto the end of the inner tube to optimize the trajectory. The tunnel is slightly curved. We choose to perform the tunneling from the neck incision towards the axillary incision. Once the track is created by the tunneling device, the bullet tip is removed and the shaft is withdrawn from the clear hollow sheath.
SPEAKER: The free end of the electrode is inserted in the sheath and drawn with the sheath from the neck to the chest incision. We have developed a simulator with the purpose of demonstrating the correct placement of the stimulator on the vagus nerve. The stimulator is equipped with three coils, the negative and positive leads, and the anchor or strain reliever. Each electrode is gently grasped one at a time for each pair of string-like attachments in the helices and slightly stretched to facilitate the opening of the cleft between the helical turns.
SPEAKER: The electrode is positioned on the right side, passing underneath the nerve. Once positioned beneath the nerve, the left hand is used to reach the suture at the end of the helix, while the other left hand holds the opposite end of the suture on the right side of the nerve. Subsequently, control tension is applied to open the helices in the direction of the stimulator's rotation, ensuring a precise fit on the nerve.
SPEAKER: The central turn of the spiral should be placed first, followed by the upper and lower turns that wrap around the nerve. The same steps are conducted with the rest of the helices. It is crucial to prevent the helices from being tangled upon themselves before placing the device, as this could significantly impede the electrode insertion. Therefore, it is imperative to stretch each helix and ensure it is correctly positioned before initiating the device placement.
SPEAKER: Another common mistake is attempting to place the helices from the left side of the vagus nerve. Since the system is designed for right-handed surgeons, starting from the left side makes the placement very challenging, if not impossible. This simulator illustrates the difficulty of inserting the helices from the wrong position, contrasting with the ease and simplicity with which the device is placed from the right side of the nerve.
SPEAKER: During this step of the surgery, typically, the nerve is gently retracted upwards with the vessel loop. Each of the electrodes is gently grasped and placed around the nerve. In applying each electrode, the central part of the spiral, must be positioned first. Then the upper and lower turns are wound around the nerve. The tethering inferior anchor is secured around the vagus nerve, and then the positive (middle helical contact) and the negative (upper helical contact) electrodes are positioned.
SPEAKER: To optimize the electrodes' placement, we use a pair of tweezers to grasp the sutures at each end of the helix and pull outward, ensuring a proper stretch. As we explained before, starting with the distal electrode, we place the helix under the vagus nerve and pull its proximal end up to wrap it over the nerve. We repeat this process for the helix's distal end, ensuring the electrode around the vagus nerve.
SPEAKER: These steps are applied to the middle and proximal electrodes. After the electrodes have been positioned on the nerve, it is necessary to make redundant loops so that movements of the neck do not dislodge the electrodes or put strain on the vagus nerve itself. The electrode is then secured by tacking nonabsorbable sutures to silicone holders at the deep cervical fascia. With the pulse generator's setscrew correctly positioned,
SPEAKER: the lead connector is fully inserted into the generator port. The connection is secured by tightening the setscrew clockwise with the torque wrench, seizing rotation upon hearing a click. The excess lead is wrapped around the pulse generator and positioned into the subcutaneous pocket. The generator is sutured into place by stitching through the hole in the header onto the surrounding tissue using nonabsorbable sutures.
SPEAKER: After implantation of the electrodes, the device is checked using the clinician programmer. A successful test result indicates the optimal functionality of both the implanted pulse generator, the lead, and the connections. The lead impedance is tested by a single stimulation impulse less than 1 minute. The wounds are closed in a standard fashion using absorbable sutures.
SPEAKER: The patient is normally discharged one day after surgery. VNS is usually started 2 weeks after implantation with recommended settings of stimulation that must be gradually reached with 0.25 mA increases per week. The complications of VNS therapy are classified as early (related to surgery) and late (related to the device and nerve stimulation).
SPEAKER: In our pediatric VNS practice, we initially perform the neck incision as low as possible, anticipating the need for future device revisions. Our primary goal during revisions is to remove the entire device. However, if complete removal proves unfeasible, we carefully cut the electrode as close to the nerve as possible and we then implant a new electrode proximally on the vagus nerve.
SPEAKER: This approach is designed to ensure minimal impact while maintaining effective treatment for our pediatric patients. Thank you very much.
Segment:0 .
[MUSIC PLAYING]
SPEAKER: This video is a step-by-step description of the vagus nerve stimulator implantation technique, providing a general methodology and tips and tricks from an epilepsy surgeon with more than 20 years of experience. Vagus nerve stimulation or VNS is a neuromodulatory treatment that involves chronic intermittent electrical stimulation of the left vagus nerve delivered by a programmable pulse generator. This pulse generator is subcutaneously implanted in the chest wall and connected to a bipolar lead with three helical coils wrapped around the cervical part of the vagus nerve.
SPEAKER: VNS is used mainly for drug-resistant epilepsy, including focal and multifocal epilepsy, drop attacks, and syndromes like Lennox-Gastaut. The ideal candidate for VNS implantation would be a patient suffering from a severe bilateral, nonlesional, drug-resistant epilepsy, where a resective or disconnective surgery would not be adequate. The main objective of this treatment is the reduction in the number and severity of the seizures, thus obtaining a better quality of life.
SPEAKER: The right vagus nerve innervates the sinoatrial node, and its stimulation could cause bradycardia, asystole, and other cardiac side effects. Since the left vagus nerve innervates the atrioventricular node, the stimulator should be placed on the left side, aiming to reduce cardiac side effects. The procedure is performed under general anesthesia with endotracheal ventilatory support. Prophylactic antibiotics are administered 30 minutes before surgery.
SPEAKER: The patient is positioned supine on the operating room table with the head on a donut pillow or a head rest extended and turned approximately 30 degrees to the right. The neck is extended with a shoulder roll in order to ease the passage of the tunneling rod. We have found that the most satisfactory approach in children is to begin by making both incisions in the direction of skin creases, which tends to minimize the amount of widening of the incision and gives a better overall cosmetic result.
SPEAKER: The skin of the left anterolateral neck and chest is prepared and draped in the usual sterile manner for surgery. A 2- to 3-cm transverse skin incision is made in a skin fold of the left side of the neck. The incision is carried out roughly halfway between the mastoid and the clavicle, extending from the midline to the medial border of the sternocleidomastoid muscle.
SPEAKER: The subcutaneous dissection exposes the platysma, which can be divided following the direction of the fibers. The omohyoid and other strap muscles are retracted medially, whereas the sternocleidomastoid is retracted laterally. Below this muscle plane, the dissection turns in a vertical direction, similar to one of the carotid artery and jugular vein. Once the carotid sheath is identified, it is opened sharply between the carotid artery medially and the internal jugular vein laterally.
SPEAKER: The vagus nerve is usually found in between these vessels and is dissected approximately 4 cm, avoiding damage to its vasa nervorum and preserving the perineurium sheath. The nerve is gently retracted superiorly using a vessel loop. A 2.5- to 3-cm long incision following a skin crease line is performed approximately 5 cm below the clavicle and 5 cm medially to the shoulder. A 5-cm-diameter subcutaneous pocket is bluntly dissected 5 cm below the clavicle or just medial to the axilla and superior to the breast.
SPEAKER: The electrodes are tunneled with a manufacturer-supplied tunneling device, which includes an inner and outer tunneling tube and a bullet tip thread onto the end of the inner tube to optimize the trajectory. The tunnel is slightly curved. We choose to perform the tunneling from the neck incision towards the axillary incision. Once the track is created by the tunneling device, the bullet tip is removed and the shaft is withdrawn from the clear hollow sheath.
SPEAKER: The free end of the electrode is inserted in the sheath and drawn with the sheath from the neck to the chest incision. We have developed a simulator with the purpose of demonstrating the correct placement of the stimulator on the vagus nerve. The stimulator is equipped with three coils, the negative and positive leads, and the anchor or strain reliever. Each electrode is gently grasped one at a time for each pair of string-like attachments in the helices and slightly stretched to facilitate the opening of the cleft between the helical turns.
SPEAKER: The electrode is positioned on the right side, passing underneath the nerve. Once positioned beneath the nerve, the left hand is used to reach the suture at the end of the helix, while the other left hand holds the opposite end of the suture on the right side of the nerve. Subsequently, control tension is applied to open the helices in the direction of the stimulator's rotation, ensuring a precise fit on the nerve.
SPEAKER: The central turn of the spiral should be placed first, followed by the upper and lower turns that wrap around the nerve. The same steps are conducted with the rest of the helices. It is crucial to prevent the helices from being tangled upon themselves before placing the device, as this could significantly impede the electrode insertion. Therefore, it is imperative to stretch each helix and ensure it is correctly positioned before initiating the device placement.
SPEAKER: Another common mistake is attempting to place the helices from the left side of the vagus nerve. Since the system is designed for right-handed surgeons, starting from the left side makes the placement very challenging, if not impossible. This simulator illustrates the difficulty of inserting the helices from the wrong position, contrasting with the ease and simplicity with which the device is placed from the right side of the nerve.
SPEAKER: During this step of the surgery, typically, the nerve is gently retracted upwards with the vessel loop. Each of the electrodes is gently grasped and placed around the nerve. In applying each electrode, the central part of the spiral, must be positioned first. Then the upper and lower turns are wound around the nerve. The tethering inferior anchor is secured around the vagus nerve, and then the positive (middle helical contact) and the negative (upper helical contact) electrodes are positioned.
SPEAKER: To optimize the electrodes' placement, we use a pair of tweezers to grasp the sutures at each end of the helix and pull outward, ensuring a proper stretch. As we explained before, starting with the distal electrode, we place the helix under the vagus nerve and pull its proximal end up to wrap it over the nerve. We repeat this process for the helix's distal end, ensuring the electrode around the vagus nerve.
SPEAKER: These steps are applied to the middle and proximal electrodes. After the electrodes have been positioned on the nerve, it is necessary to make redundant loops so that movements of the neck do not dislodge the electrodes or put strain on the vagus nerve itself. The electrode is then secured by tacking nonabsorbable sutures to silicone holders at the deep cervical fascia. With the pulse generator's setscrew correctly positioned,
SPEAKER: the lead connector is fully inserted into the generator port. The connection is secured by tightening the setscrew clockwise with the torque wrench, seizing rotation upon hearing a click. The excess lead is wrapped around the pulse generator and positioned into the subcutaneous pocket. The generator is sutured into place by stitching through the hole in the header onto the surrounding tissue using nonabsorbable sutures.
SPEAKER: After implantation of the electrodes, the device is checked using the clinician programmer. A successful test result indicates the optimal functionality of both the implanted pulse generator, the lead, and the connections. The lead impedance is tested by a single stimulation impulse less than 1 minute. The wounds are closed in a standard fashion using absorbable sutures.
SPEAKER: The patient is normally discharged one day after surgery. VNS is usually started 2 weeks after implantation with recommended settings of stimulation that must be gradually reached with 0.25 mA increases per week. The complications of VNS therapy are classified as early (related to surgery) and late (related to the device and nerve stimulation).
SPEAKER: In our pediatric VNS practice, we initially perform the neck incision as low as possible, anticipating the need for future device revisions. Our primary goal during revisions is to remove the entire device. However, if complete removal proves unfeasible, we carefully cut the electrode as close to the nerve as possible and we then implant a new electrode proximally on the vagus nerve.
SPEAKER: This approach is designed to ensure minimal impact while maintaining effective treatment for our pediatric patients. Thank you very much.
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