How To: Anatomic-Based Technique for Sensing Lead Placement in Hypoglossal Stimulator Implantation

Descriptive photo and video documentation of a revised surgical technique. This study was considered exempt from human studies research by the Mass General Brigham IRB.

The Inspire Medical Systems, Inc. (Maple Grove, Minn., USA) implantation device was used. The incision is planned more lateral to the standard incision as the nipple line as a midline for the incision, which serves as an external landmark for the boney cartilaginous (BC) junction of the rib (Fig. 1). The incision is then made through skin, carried through the subcutaneous fat and pectoralis muscles directly to the anterior rib surface (as opposed to the standard technique, in which the intermuscular plane is identified midway between the ribs by separating the adipose tissue overlying the intercostals and dissecting to find the junctional boundaries, depicted in Fig. 2). Soft tissue can be cleared over the rib, leaving the periosteum and perichondrium intact. Just superior to the BC junction of the rib, where the internal and external intercostal muscle fibers intersect, a pocket is made with a blunt dissector (Fig. 3) between the internal and external intercostal muscles. During this maneuver, the superior aspect of the rib can be continually palpated so as not to dive deep into the pleural space. The sensing lead is implanted close to the junction, using the malleable as a guide, and placed from medial to lateral (Fig. 4) rather than in a fashion that starts from superior to inferior before turning medial to lateral, which feels more likely to injure deeper structures. The remainder of the procedure is carried out in a standard fashion as previously described or as recommended by Inspire.

RESULTS

The change in technique, using reliable anatomy in young children with DS, results in successful and safe implantation and is especially helpful in those who are relatively obese.