Sorry this is so long But any help is appreciated...

PREOPERATIVE DIAGNOSES: Quadriplegia with ventilator dependence, status post tracheostomy, status post percutaneous gastrostomy.

POSTOPERATIVE DIAGNOSES: Quadriplegia with ventilator dependence, status post tracheostomy, status post percutaneous gastrostomy.

1. Exploratory laparoscopy.
2. Diaphragm mapping with complex neuromuscular stimulation x60 minutes.
3. Insertion of bilateral diaphragms pacers x4 (total of 4 leads).


DEEP VENOUS THROMBOSIS PROPHYLAXIS: Bilateral sequential compression devices.


FINDINGS: The left diaphragm was much more robust in contraction. The right side was much less contractile; however, with 4 lead contraction we were able to generate tidal volumes of 500-600 mL.

Lead L1 on the left side at 25 milliseconds at 200 milliamps generated an interaction with capture in the myocardium with changes in EKG. This lead was turned down and slowly advanced until we were able to stimulate the diaphragm at 25 milliamps at 100 milliseconds, and there was no evidence of interaction with myocardial rhythm. However, the lead was not left at this threshold, but at a much, much lower threshold.

INDICATIONS: A pleasant female who had a tragic accident and suffered a C2-C3 fracture which was treated and was subsequently transferred with quadriplegia and ventilator dependence. At this time, she is being evaluated for insertion of a diaphragmatic pacemaker to wean the patient from the ventilator.

DESCRIPTION OF PROCEDURE: The patient was brought to the operating room after obtaining general informed consent with the patient and the family and placed in the supine position. With the patient awake and alert, a surgical pause was held where the patient's identity, site of surgery, type of surgery were confirmed and compared to the patient's consent form. General anesthesia was induced via the tracheostomy and IV sedation. When she was completely sedated, the lower chest and upper abdomen were scrubbed with chlorhexidine and subsequently prepped and draped in the usual sterile fashion using ChloraPrep. A right internal jugular IV access was obtained. The patient received 1 gram of vancomycin IV prophylactically and had bilateral sequential compression devices placed for deep venous thrombosis prophylaxis. At this time, a second surgical pause was held where the patient's identity, site of surgery, type of surgery were confirmed and compared to the patient's consent form.

A 0.5 cm incision was made in the supraumbilical position. The incision was taken through subcutaneous tissue and fascia using gentle dissection. This area was anesthetized using 0.5% Marcaine with epinephrine. A TrueView trocar was inserted over the camera and the abdomen was entered using gentle blunt dissection. CO2 was insufflated at 10 liters per minute for a pressure of 15 centimeters of water. Once the abdomen was completely insufflated, visualization of the abdomen revealed the patient had a small ligament and the previous gastrotomy which had been proofed was very narrow and did not need to be divided. Two 5-mm trocars were placed in the subcostal position after the area was anesthetized with 0.5% Marcaine. The abdomen was entered. At this time, we began just stimulation of both diaphragms and we noted that we had good stimulation on both sides. Therefore, we proceeded with the remainder of the operation. The falciform ligament was ligated and divided using electrocautery Bovie. A 12 mm trocar was placed in the midline in a subxiphoid fashion. Once all trocars were in, the patient was placed in deep reverse Trendelenburg position. We began stimulation of the diaphragm in earnest. We began on the left side. Contractions were obtained by stimulation of diaphragm and the left sided diaphragm was mapped. Two excellent positions were obtained and these were marked with a marker. Now we began on the right side. The diaphragm was mapped with electrical stimulation and once 2 appropriate spots for the right side were obtained, again these areas were marked. It must be mentioned that the left sided contractions were much stronger than the right side, although we were able to generate good contraction on the right side. Now, the lead inserting mechanism was brought into the field. Two leads were placed on the left side first. Each lead was individually stimulated at the highest level. There was no evidence of interaction with EKG or cardiac rhythm. We obtained excellent contractions of the left sided diaphragm. Now attention was paid to the right side. Similarly to 2 leads were placed using a lead insertion mechanism. Once both leads were placed, again each lead individually and together were stimulated. We had excellent contractions of the right side, as well as no evidence of interaction with the cardiac rhythm. The patient was returned to supine position, the abdomen was desufflated. The 12 mm trocar was removed. The wires were tunneled from the midline incision to the right upper outer quadrant of the abdomen just below the inframammary fold. Once all 4 wires were brought out, a fifth _____ wire was inserted percutaneously. The abdomen was reinsufflated and each wire was stimulated and contraction of the diaphragm was measured and visualized. They all worked and functioned well. There was no evidence of interaction with myocardial rhythm at the lowest level. As we increased the threshold to 25 milliamperes at 200 milliseconds, we noted that there was intermittent interaction and capture of the myocardium by electrical stimulation of the diaphragm with intermittent positives and occasional premature ventricular contractions. Therefore, we individually tested both left and right-sided and we had identified the L1 lead (the most cephalad wire coming out of the skin in the left upper outer quadrant of the abdomen) and we measured the threshold and by slowly increasing the threshold to see if there is any interaction. At 25 milliamperes at 100 milliseconds, there was no evidence of interaction. Therefore, we will cap the highest level of stimulation from that lead at this level in order to insure and prevent any kind of cardiac capture and possible ventricular dysrhythmia. There was no further evidence of bleeding. The abdomen was inspected. The trocars were removed. There was no evidence of bleeding. All incisions were reapproximated in multiple layers using Vicryl and Monocryl. Small amount of Dermabond was applied. The patient was awakened in the operating suite and taken to recovery room in stable condition. All lap pads, instrument and needle counts were correct. There were no complications.


FLUIDS GIVEN: Estimated IV fluid infused was 750 mL of crystalloid.


Thank You,