Atrotech Atrostim PNS Anwenderhandbuch Seite 19

Surgical procedure
- anteriorly through the second intercostal space
(Glenn, Hogan, Phelps 1980)
- through the third intercostal space using an axillary incision
(Glenn,H.,Ph. 1980)
- through a parasternal incision with resection of the
cartilage of the second and partly resection of that of the third rib
(Wetstein 1987)
- through a sternotomy (Thoma et al. 1987).
The anterior approach through the second intercostal space has been used most
frequently (Glenn: PACE 1986). In small children, depending on the local
circumstances, sometimes a lower intercostal space may be used. However, it should
be kept in mind that the distance from the skin to the phrenic nerves increases with
increasing intercostal space numbers in children, too. The axillary approach is more
difficult and should be reserved for special cases only for cosmetic reasons (Glenn,
H, Ph. 1980). The incision of the parasternal approach (Wetstein 1987) may give a
minor cosmetic result compared to that through the second interspace (Wells F.
pers.com. 1988). Additionally, the second and third rib tend to protrude when
disconnected from the sternum, which may cause pressure sores (Markkula H.
pers.com. 1989). The approach by sternotomy certainly differs from all other
approaches in its greater degree of trauma.
2.3 The anterior approach through the second interspace according to Glenn
(Glenn, Hogan, Phelps 1980)
A 15 cm skin incision is made at the second interspace from the lateral border of the
sternum to just beyond the anterior axillary line. The pectoralis muscles are split in
the direction of their fibers and the chest is entered through the second interspace.
The internal mammary artery and vein are divided and the ribs are spread apart. The
pleura is incised laterally as much as is needed for good access. The patient is turned
to the contralateral side, the lung retracted laterally, and the phrenic nerve is
identified as it passes superficially under the pleura. The electrodes should be placed
5-10 cm above the heart. However, in contrast to the unipolar electrode with its large
electrical field between the active and the remote indifferent electrode, the smaller
and only locally appearing electrical field in between the four poles of the Atrotech
electrode allows for a safe short distance to the heart, if necessary. Also, the
four-pole electrode is ideal in cases where a cardiac pacer is used by the patient.
Parallel incisions into the pleura 1.5 cm long are made on both sides of the nerve. A
tunnel is created by blunt preparation behind the nerve. During the following fixation
of the electrode care must be taken not to puncture the caval vein or aorta.
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Atrostim PNS
April 2008