title: Online signal processing of internal anal sphincter activity during pelvic autonomic nerve stimulation: a new method to improve the reliability of intra-operative neuromonitoring signals.
abstract: OBJECTIVE
  Intra-operative neuromonitoring is increasingly applied in several surgical disciplines and has been introduced to facilitate pelvic autonomic nerve preservation. Nevertheless, it has been considered a questionable tool for the minimization of risk, as the results are variable and might be misleading. The aim of the present experimental study was to develop an intra-operative neuromonitoring system with improved reliability for monitoring pelvic autonomic nerve function.
  
  
  METHODS
  Fifteen pigs underwent low anterior rectal resection with pelvic autonomic nerve preservation. Intra-operative neuromonitoring was performed under autonomic nerve stimulation with observation of electromyographic signals of the internal anal sphincter and bladder manometry. As the internal anal sphincter frequency spectrum during stimulation was found to be mainly in the range of 5-20 Hz, intra-operative neuromonitoring signals were postoperatively processed by implementation of matching band pass filters.
  
  
  RESULTS
  In 10 preliminary experiments, signal processing was performed offline in the postoperative analysis. Of 163 stimulations intra-operatively assessed by the surgeon as positive responses, 135 (83%) were confirmed after signal processing. In the following five consecutive experiments intra-operative online signal processing was realized and demonstrated reliable intra-operative neuromonitoring signals of internal anal sphincter activity with significant increase during pelvic autonomic nerve stimulation [0.5 μV (interquartile range = 0.3-0.7) vs 4.8 μV (interquartile range = 2.5-7.5); P < 0.001].
  
  
  CONCLUSIONS
  Online signal processing of internal anal sphincter activity aids reliable identification of pelvic autonomic nerves with potential for improvement of intra-operative neuromonitoring in pelvic surgery.
authors.affiliation: Department of General and Abdominal Surgery, University Medicine of the Johannes Gutenberg-University, Mainz, Germany.
authors.forename: D W
authors.initials: DW
authors.lastname: Kauff
authors.forename: K P
authors.initials: KP
authors.lastname: Koch
authors.forename: K H
authors.initials: KH
authors.lastname: Somerlik
authors.forename: A
authors.initials: A
authors.lastname: Heimann
authors.forename: K P
authors.initials: KP
authors.lastname: Hoffmann
authors.forename: H
authors.initials: H
authors.lastname: Lang
authors.forename: W
authors.initials: W
authors.lastname: Kneist
mesh_terms: D001003:Anal Canal / Q000294:innervation / Q000502:physiology*; D000818:Animals; D017776:Autonomic Pathways / Q000502:physiology*; D004558:Electric Stimulation; D004576:Electromyography; D008297:Male; D008365:Manometry; D016343:Monitoring, Intraoperative / Q000379:methods*; D059351:Organ Sparing Treatments; D012007:Rectum / Q000601:surgery; D015203:Reproducibility of Results; D012815:Signal Processing, Computer-Assisted; D013552:Swine; D001743:Urinary Bladder / Q000294:innervation / Q000502:physiology*