Characterization of the human diaphragm muscle with respect to the phrenic nerve motor points for diaphragmatic pacing.

Diaphragm pacing from laparoscopically placed electrodes is an alternative to conventional phrenic pacers that use electrodes placed in direct contact with the nerve in the neck or chest. The challenge with the laparoscopic approach is determining where to implant the electrodes, as the phrenic nerves are not visible from the abdomen. The objective of this study was to locate the phrenic nerve "motor points" in the human diaphragm muscle from an abdominal perspective. Twenty-five cadavers were examined by excising the diaphragm muscle and assessing for the thickness of the muscle, the motor point area, and the accessibility of the motor point from the abdominal approach. The data indicate the average thickness of the muscle in the motor point region was 3.0 mm for the left and 2.9 mm for the right hemidiaphragm. The average motor point area was 73 mm2 for the left and 58.7 mm2 for the right hemidiaphragm. The motor points were accessible from an abdominal approach, but the motor point on the right hemidiaphragm was located on the central tendon in many cases (12 of 25). Thus, although the nerves branch prior to entry into the muscle on the right side, several well-placed electrodes could still activate the entire nerve. In this study, we have characterized the human diaphragm muscle in the motor point region and found that it is feasible to place laparoscopically intramuscular electrodes in the motor point region. This is the foundation for the laparoscopically placed diaphragm pacing device that has been utilized in a small series of patients.