title: Minimally invasive trans-mediastinal endoscopic approach to insert phrenic stimulation electrodes in the human diaphragm: a preliminary description in cadavers.
abstract: OBJECTIVE
  Diaphragm pacing by phrenic nerve (PN) stimulation is currently used for patients with central respiratory paralysis to be weaned from mechanical ventilation. Electrodes are inserted either through bilateral thoracotomy or through four ports laparoscopy. The aim of this experimental work is to demonstrate the feasibility of trans-mediastinal bilateral implantation of PN electrodes using a flexible gastroscope introduced through a cervical incision in human cadavers.
  
  
  METHODS
  Ten refrigerated and non-embalmed cadavers were used. The gastroscope was introduced through a cervical incision into the latero-tracheal space and then subsequently into both pleura by opening the mediastinal pleura. After identification of the PN, electrodes were introduced through an intercostal space to the desired diaphragmatic location using a long, pliable needle with the electrode loaded in its lumen.
  
  
  RESULTS
  Results are described for each hemi-diaphragm not for an anatomic subject. Mediastinal exploration and introduction of the video gastroscope into the pleural cavities proved easy in all subjects. Pleural adherences were present in five hemi-diaphragms. The central tendon of both hemi-diaphragms could be identified unambiguously in all the subjects. Identification of the entry point of the phrenic nerve into the diaphragm was straightforward in 10 hemi-diaphragms. In the remaining 10, this proved more difficult because of mediastinal fat or lung parenchyma. Introduction of the electrode-holding needles through the intercostal space and their insertion close to the phrenic nerve entry point was also easy. Withdrawal of the needle from the diaphragm and 'capture' of the hook were successful on the first attempt in 14 hemi-diaphragms, but failed in six others in whom a second attempt was necessary.
  
  
  CONCLUSIONS
  Trans-mediastinal implantation of PN stimulation electrodes is possible using a flexible endoscope. This application of endoscopic surgery could allow a minimally invasive placement of PN electrodes in patients with central respiratory paralysis, for example, at the time of tracheostomy.
authors.affiliation: Department of Thoracic Surgery, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, 4 Rue de Chine, 75020 Paris, France. jalal.assouad@tnn.aphp.fr
authors.forename: Jalal
authors.initials: J
authors.lastname: Assouad
authors.forename: Hicham
authors.initials: H
authors.lastname: Masmoudi
authors.forename: Camille
authors.initials: C
authors.lastname: Steltzlen
authors.forename: Dominique
authors.initials: D
authors.lastname: Grunenwald
authors.forename: Vincent
authors.initials: V
authors.lastname: Delmas
authors.forename: Thomas
authors.initials: T
authors.lastname: Similowski
mesh_terms: D000369:Aged, 80 and over; D002102:Cadaver; D003964:Diaphragm / Q000294:innervation* / Q000503:physiopathology; D004599:Electric Stimulation Therapy / Q000295:instrumentation / Q000379:methods; D005240:Feasibility Studies; D005773:Gastroscopy / Q000379:methods; D006801:Humans; D058542:Implantable Neurostimulators; D008481:Mediastinoscopy / Q000379:methods; D008482:Mediastinum / Q000601:surgery*; D019060:Minimally Invasive Surgical Procedures / Q000295:instrumentation / Q000379:methods; D010791:Phrenic Nerve / Q000503:physiopathology*; D012133:Respiratory Paralysis / Q000628:therapy; D020775:Thoracic Surgery, Video-Assisted / Q000295:instrumentation / Q000379:methods; D015300:Ventilator Weaning / Q000379:methods