Gonzalez Stage 2 DBS

Position with bump under the shoulder, oriented longitudinally with one end towards the head and the other towards the feet (not transverse across both shoulders).

Find the leads under the skin, mark a 2 cm up-and-down incision with a slight anterior curve. The chest incisions should be about 4 cm long, centered mid-clavicle, and about 2 finger widths caudal to the clavicle.

JGM usually preps on his own, he starts on the incision and sweeps outwards but does come back to the incision. He seems to like a lot of friction and frequent passing of the scrub over the skin. JGM is definitely a dry rub kind of guy. After the first scrub, he uses lidocaine with epinephrine. Then he does a second scrub.

For draping, minimize use of staples, he does not like staples through the skin when you can avoid it. Be sure to allow plenty of space between the edge of the towels and the incision. Re-mark the incision then apply ioban. A u-drape is used with the base of the drape at the feet and the two ends coming around to cross at the top of the head.

The head incision comes first. Score the skin with the scalpel then use cut to go deeper, coag once you are past the skin. The leads are pulled out from where they are coiled under the skin. The chest incision is made next, going to just above the level of the pectoralis fascia. The pocket is made with an index finger. Go caudally the length of the index finger and sweep the base medial and laterally so that the base is wider than the incision.  

Next, the shunt passer is passed from the cranial incision to the chest incision. You need to be above the galea. JGM likes a double curve to the shunt passer – “like a matador.”

Ask for the leads, which you will pass from the chest to the head. The scrub tech should mark the left lead with a marker. You pass the narrow, uncovered end of the lead up through the shunt passer.