DATE: @TD@ PATIENT NAME: @NAME@ PREOPERATIVE DIAGNOSIS:  1. Moderate /Severe obstructive sleep apnea with positive airway pressure intolerance (ICD-10 G47.33). 2. Adult BMI *** (ICD-10 Z68.***). POSTOPERATIVE DIAGNOSIS: Same as above. OPERATION: Right 12th cranial nerve (hypoglossal) stimulation implant with placement of chest wall respiratory sensor (CPT 64582) SURGEON: William Morrel, MD  ASSISTANT SURGEON: *** No qualified resident was available to assist with the procedure. ANESTHESIA: General INDICATIONS FOR PROCEDURE: This is a @AGE@ patient with a history of moderate to severe obstructive sleep apnea with an associated BMI of ***. This patient is intolerant and unable to achieve benefit from positive pressure therapy. Patient has passed the clinical, polysomnographic, and endoscopic screening criteria and presents today for the implant. FINDINGS:  Successful placement of right hypoglossal nerve stimulator. DESCRIPTION OF PROCEDURE: This patient’s obstructive sleep apnea diagnosis (G47.33) is associated with a BMI diagnosis of (Z68.***). The patient was brought to the Operating Room and was anesthetized via general endotracheal anesthesia without complication. A shoulder roll was placed and the patient was prepped and draped in usual sterile fashion with the head turned to the left. Prior to prepping and draping, electrodes were placed in the genioglossus and hyoglossus muscle and connected to the NIM box for intraoperative nerve monitoring. A surgical time-out was performed to confirm the correct patient, procedure, and laterality. A modified sub-mandibular incision was made in the right upper neck approximately 2 cm below the mandible. Dissection was carried down through the subcutaneous tissue and platysma. The anterior/inferior border of the submandibular gland was identified as well as the digastric tendon. The submandibular gland and the overlying fascia with the marginal mandibular nerve were retracted posteriorly. The digastric tendon was retracted inferiorly. Dissection continued down into the digastric triangle and the posterior border of the mylohyoid muscle was freed up and retracted anteriorly. With balanced retraction, the hypoglossal nerve was identified in its usual fashion and was dissected up towards the floor of the mouth. The superior/posterior branches innervating the hyoglossus muscle were identified using the NIM stimulator and anatomical cues. The cuff electrode for the hypoglossal nerve stimulator was placed distally to these branches innervating genioglossus, transverse, and vertical muscles. The stimulation lead was anchored to the digastric tendon using two 3.0 silk sutures and lead body slack between the cuff and the anchor gently tucked deep to the submandibular gland. A second 5 cm incision was made in the right upper chest over the second intercostal space, approximately 2 cm lateral to the sternal margin. Dissection was carried down through the skin and subcutaneous tissue to the fascia of the pectoralis muscle. An inferior pocket for the generator was created deep to the subcutaneous layer and superficial to the fascia of the pectoralis muscle. The pectoralis major fascia was dissected directly over the second intercostal space with subsequent blunt dissection through the muscle. The pectoralis minor was then retracted to expose the fatty layer just superficial to the external intercostals. The fatty layer was carefully swept away to expose the external intercostal muscles. A throw-down base knot was placed to the fascia of the external intercostals just lateral to the anterior external membrane using 3.0 silk suture. A fasciotomy through the external intercostals was performed approximately 5 mm lateral to the suture knot and the respiratory sense lead was advanced with the sensor facing the pleura into the interfascial plane between the external and internal intercostals. The primary anchor was sutured into place with 3.0 silk on the external intercostals. The secondary anchor was sutured with 3.0 silk to the pectoralis major allowing adequate slack between the anchors. The stimulation lead was then tunneled in a subplatysmal plane with blunt dissection under direct visualization and brought out into the chest pocket where both the stimulation lead and the respiratory sensing lead were connected to the implantable pulse generator, using the two person, three-handed approach. The implantable pulse generator was placed in the subclavicular pocket ensuring lead body was deep to the generator and secured with use of air knots to the pectoralis fascia using 2.0 silk sutures. Diagnostic evaluation confirmed good placement of the stimulation cuff as demonstrated by activation of the genioglossus and transverse and vertical muscles, resulting in unhindered, stiffened tongue protrusion, confirmed visually. Diagnostic evaluation also confirmed good respiratory sensor placement as demonstrated by a sensing waveform with good rise and fall associated with patient respirations. All the wounds were thoroughly irrigated and closed in three layers with deep 3-0 Vicryl, dermal 4-0 Vicryl, and a 5-0 fast-absorbing suture on the skin. Mastisol and Steri-Strips were applied followed by pressure dressings. The patient was then awakened, extubated, and transferred to Recovery Room in stable condition. I was present for and performed the entire procedure. ESTIMATED BLOOD LOSS: *** mL   COMPLICATIONS: None SPECIMENS: None DISPOSITION: The patient was transferred to the recovery room in stable condition.