Ohio State University Wexner Medical Center otolaryngologist Eugene Chio, MD, has implanted more upper airway stimulation devices than anyone in the world. Today, he does it with a two-incision approach he developed to shorten the procedure and healing time. See how Dr. Chio performs this procedure.
Hello, My name is Dr Eugene Choo. I'm asleep surgeon here at the Ohio State University Wexner Medical Center with the Department of Otolaryngology Head Neck Surgery. The video that you'll be watching shortly is a two incision approach for inspired therapy. Inspire therapy is a newer option that's been available for patients who have not been able to tolerate their CPAP for treatment for their obstructive sleep apnea. The two incision approach is a newer technique that we've pioneered here in Ohio State University in the last year, and we've been offering it for patients for the past year or so. The surgical preparation starts with marking of our incisions. Here is shown the chest incision being marked. The chest incision is placed between the ribs and below, the clavicle being shown in the hash marks, and the sub mental incision is made just below the mandible. All the incisions are injected pre operatively with some local anesthetic with up in effort to help with Huma Stasis. And then the patient is then prepped and draped in the usual still fashion. We start the surgery up in the neck incision. At this point, the nerve has been identified and the green probe is being used to stimulate the nerve. The nerve is being shown in our red vessel loop here with branches that air anterior to the vessel loop being our inclusion branches. By stimulating the nerve, you can see the muscle twitch interior lee branches of the nerve. Their post here to the vessel loop should be exclusion branches that we leave out of our cough. The cuff is now brought into the field and placed around the nerve. The images here show a close up view of how the cuff is wrapped around the nerve, with an outer leaflet being pulled underneath the nerve and the cuff being laid on top of the nerve. The outer leaflet is then closed over the entire cuffs of carrying it to the nerve, and the vessel loop is removed. Irrigation is now used to flood the cuff to ensure good contact between our electrical cuff and our nerve itself and the mile Ohio muscles laid back down on top of the nerve. The stimulation lead is now anchored securely to the dye gastric muscle intendant. The chest incision is now made, and what's being shown is the petrol is major muscle. Once we create a subcutaneous pocket, we start to dissect it deep to the peck major muscle spreading parallel with the fibers of the muscle. Once we're beyond the muscle, we typically see a very distinctive yellow fatty layer of tissue that is just deep to the peck major muscle. Once we have this layer identified retractors air used above and below to hold the muscle open and out of the way. The superior tractor is being placed toe hold that upper edge of muscle and the inferior tractor will be placed here to open up that window. And again, that distinct fatty layer is what we want to see now, using some blunt dissection with some kid Nur's, that fat is pushed aside, revealing the external intercostal muscle, which typically has a diagonal pattern running from post cheerier superior thio in fear. Lateral ribs are being palpate ID, and once we identify an inter rib space, the small pocket is created through the muscle. Until we see a fiber change, you can see the fibers running perpendicular now, deep to that upper layer of muscle. Once that plane is identified, the small pocket is created and our sense lead has brought onto the field. The sensor lead is now placed into this pocket and should slide fairly easily into that pocket. The anchor is then secured in several spots with non absorbable future, and the secondary anchor is secured to the surface of the peck major muscle using the same suitor. The upper stimulation lead is now tunneled underneath the skin and connected up to the pulse generator. The sense lead is also attached to the pulse generator, and the entire unit is slipped into the subcutaneous pocket in the upper chest, being secured in two spots using non absorbable future. At this point, the device is now activated and diagnostic testing is done to ensure good interior motion of the tongue. In this video, you can see the tongue pushing up towards the clear drape over the mouth, showing good anterior protrusion with stimulation. This video shows a good respiratory wave form that's being picked up by the respiratory sensor between the intercostal muscles, both incisions, air irrigated and closed and layered fashion, and that completes the surgery. The surgery is typically performed as an outpatient surgery, meaning patients go home the same day. The surgery is done under anesthesia and it takes about 60 to 90 minutes. With the advent of the two incision approach, we found that the operative time is actually about 20 to 25% faster. Recovery takes about a week. There's fewer restrictions after surgery. With the advent of the two incision approach, ideal candidates for this type of surgery need to meet four criteria. The first one is mild. I'm sorry. Moderate to severe obstructive sleep apnea. The patients have to be intolerant of their CPAP b. M. I currently is a criteria. Ideally, a body mass index should be at or below 32. Some insurances are going up to A B m I 35. But of course this will be a case to case basis and the last criteria is something called a dice exam. D i s E, which stands for drug induced sleep endoscopy. This is basically a sedated upper airway endoscopy where we take a look inside your throat when you're asleep. The sedation level of the whole process is very similar to an upper G I endoscopy or colonoscopy. We expect to see, on average a 70 to 80% reduction in their baseline apnea score. Thank you very much for watching today
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