Atrotech Atrostim PNS Anwenderhandbuch Seite 39

Surgical procedure for pediatric patients
2 APPROACH TO THE PHRENIC NERVE
In children, the approach to the nerve in the neck is very difficult and not
recommended. With the thoracic approach the possible risks of a thoracotomy,
hemo- and pneumothorax, are present. Therefore the surgeon should be familiar with
the basic rules of pediatric thoracic surgery.
2.1 Approach in the thorax
Four different methods have been described to approach the phrenic nerve above the
heart inside the thorax:
- 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.
2.2 The anterior approach through the second interspace according to Glenn
(Glenn, Hogan, Phelps 1980)
A 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
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Atrostim PNS
April 2008