AB87
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I need help with this case. The battery and lead was replaced
Thank you!
Removal of axonics lead and battery and Placement of axonics lead wire, right
Placement of implantable neurostimulator INS, right
Pre-op - Fecal incontinence, OAB
Post op - same as above and migration of axonics lead
Procedure Details:
Lead placed in S3 under fluoroscopy
Findings: removal of battery and lead and placement of the neurostimulator in the right upper buttock in the hollow of the illium.
Details:
After surgical consent was was obtained and reviewed with the patient including risk benefits alternatives the patient expressed desire to proceed with surgery. The patient was then taken to the operating room and placed in the prone position. Pillows were placed in the lower abdomen and hips to level and flatten the sacrum and allow the toes to dangle freely. IV antibiotics were infused prior to incision for infection prophylaxis.
Tape was used to expose the anus.
Preoperative fluorsoscopy was used to visualize the sacral anatomy. The previously placed axonics was identified and no fragmentation was noted. Local anesthesia used to open up the previous pocket site. Battery was grasped and removed. Area of skin dimpling was identified and opened up w/ scalpel. Lead was grasped and twisted around the hemostat and gentle tugged. At this time, it was identified that the lead was noted to uncoil and the electrodes remained in place.
Decision made to place new lead on the right side.
The level of S3 and the medial border of the sacral foramen were identified bilaterally using fluouroscopy in the AP view.
After administration of local anesthesia, foramen needle was placed in the superior medial aspect of S3 such that the needle was parallel to the medial border. A lateral flurosocopic view was obtained. Needle was advanced.
This took multiple attempts to obtain correct placement. J hook was applied and stimulation was obtained for the ideal response.
Once the ideal location was confirmed, a small incision was made at the foramen needle to accommodate the lead wire and tunneling tool. The directional guide was placed through the foramen needle and the needle removed. The introducer was placed over the directional guide and advanced under live fluoroscopy such that the radiopaque marker was placed halfway through the sacral plate. The dilator was removed along with the directional guide using life rule out fluoroscopy the tined lead lead with the curved stylette was placed through the introducer until electrode electrode 3 straddled the anterior surface of the sacrum and ensuring the lead had a gentle downward trajectory. The stimulation clip was then placed in the distal lead and each electrode was tested observing for motor response.
After satisfactory lead positioning was confirmed, the introducer was retracted over the lead under continuous fluoroscopy, deploying the tines into the presacral tissue. Stimulation thresholds were established using the least amount of stimulation required to obtain a motor response.
A tunneling tool with an overlying plastic sheath was inserted from the lead insertion site subcutaneously to the location of the INS pocket site which had been previously marked to be located in the hollow of the ileum.
Previous pocket was used for the new battery. Pocket was opened up slightly more as it was felt to be small using combination of sharp and blunt dissection, maintaining the depth, the tunneling tool was passed from the lead wire insertion site to the lateral pocket. The sharp tip of the tunneling tool was removed and the lead was fed through the sheath, exiting at the pocket site. The sheath was removed. The lead was cleaned and dried and connected to the Axonics battery.
The lead wire was connected to the neurostimulator and secured with a torque wrench. The neurostimulator was placed into the pocket with the lead connection placed superiorly and laterally and the excessive lower lead was coiled and placed behind the neurostimulator. Impedances were confirmed to be within normal limits.
The INS incision was closed with 3-0 Vicryl for the subcutaneous layer the skin was closed with 4-0 Monocryl in a subcuticular fashion. Skin glue was placed over incision. This terminated the procedure.
Thank you!
Removal of axonics lead and battery and Placement of axonics lead wire, right
Placement of implantable neurostimulator INS, right
Pre-op - Fecal incontinence, OAB
Post op - same as above and migration of axonics lead
Procedure Details:
Lead placed in S3 under fluoroscopy
Findings: removal of battery and lead and placement of the neurostimulator in the right upper buttock in the hollow of the illium.
Details:
After surgical consent was was obtained and reviewed with the patient including risk benefits alternatives the patient expressed desire to proceed with surgery. The patient was then taken to the operating room and placed in the prone position. Pillows were placed in the lower abdomen and hips to level and flatten the sacrum and allow the toes to dangle freely. IV antibiotics were infused prior to incision for infection prophylaxis.
Tape was used to expose the anus.
Preoperative fluorsoscopy was used to visualize the sacral anatomy. The previously placed axonics was identified and no fragmentation was noted. Local anesthesia used to open up the previous pocket site. Battery was grasped and removed. Area of skin dimpling was identified and opened up w/ scalpel. Lead was grasped and twisted around the hemostat and gentle tugged. At this time, it was identified that the lead was noted to uncoil and the electrodes remained in place.
Decision made to place new lead on the right side.
The level of S3 and the medial border of the sacral foramen were identified bilaterally using fluouroscopy in the AP view.
After administration of local anesthesia, foramen needle was placed in the superior medial aspect of S3 such that the needle was parallel to the medial border. A lateral flurosocopic view was obtained. Needle was advanced.
This took multiple attempts to obtain correct placement. J hook was applied and stimulation was obtained for the ideal response.
Once the ideal location was confirmed, a small incision was made at the foramen needle to accommodate the lead wire and tunneling tool. The directional guide was placed through the foramen needle and the needle removed. The introducer was placed over the directional guide and advanced under live fluoroscopy such that the radiopaque marker was placed halfway through the sacral plate. The dilator was removed along with the directional guide using life rule out fluoroscopy the tined lead lead with the curved stylette was placed through the introducer until electrode electrode 3 straddled the anterior surface of the sacrum and ensuring the lead had a gentle downward trajectory. The stimulation clip was then placed in the distal lead and each electrode was tested observing for motor response.
After satisfactory lead positioning was confirmed, the introducer was retracted over the lead under continuous fluoroscopy, deploying the tines into the presacral tissue. Stimulation thresholds were established using the least amount of stimulation required to obtain a motor response.
A tunneling tool with an overlying plastic sheath was inserted from the lead insertion site subcutaneously to the location of the INS pocket site which had been previously marked to be located in the hollow of the ileum.
Previous pocket was used for the new battery. Pocket was opened up slightly more as it was felt to be small using combination of sharp and blunt dissection, maintaining the depth, the tunneling tool was passed from the lead wire insertion site to the lateral pocket. The sharp tip of the tunneling tool was removed and the lead was fed through the sheath, exiting at the pocket site. The sheath was removed. The lead was cleaned and dried and connected to the Axonics battery.
The lead wire was connected to the neurostimulator and secured with a torque wrench. The neurostimulator was placed into the pocket with the lead connection placed superiorly and laterally and the excessive lower lead was coiled and placed behind the neurostimulator. Impedances were confirmed to be within normal limits.
The INS incision was closed with 3-0 Vicryl for the subcutaneous layer the skin was closed with 4-0 Monocryl in a subcuticular fashion. Skin glue was placed over incision. This terminated the procedure.