Single tunneling technique

This technique uses a single tunneling path for placing the driveline in the abdomen. ◘ Figure 28.2a, b gives a schematic view on the driveline course.

In one approach, the cable is placed in a U shape facing caudal from the pump toward the umbilicus, following the U bend again cranial toward the exit site at the midclavicular line below the right or left subcostal margin. This surgical technique uses a U-shaped tunneling device. Some surgeons prefer a custom-made device bent into a U shape [7].

A second single tunneling approach uses a short tunneling track very lateral to the right or left exit site, which is again at the midclavicular line below the subcostal margin. The driveline is formed with a loop near the midline using the surgical pump implantation field to increase the intracorporeal part of the cable and act as a strain relief. The loop is fixed with a suture to the peritoneum. The driveline may exit in every abdominal quadrant, although the variables in DLES decisions mentioned in the previous section should be considered [7].

Doubled tunneling technique

This technique uses a tunneling path, which is set up in two to three steps. In ◘ Fig. 28.3a–c, respectively, the tunneling incisions and the driveline course can be seen; ◘ Fig. 28.4 gives an view of the intraoperative tunneling procedure.

In the two-step approach, the driveline is placed in a big C shape. The first tunneling step places the driveline with a long-curved course beneath the fascia of the abdominal muscles, transition the fascia through a small incision near the anterior axillary line, and 3 cm caudal of the subcostal line. The final DLES will be near the midline in the direction of the left lateral abdominal wall through a second small skin incision. Due to the design of the HeartMate II pump and its cable, this technique suits this pump type very well [3].

In the three-step approach, the driveline forms a long C-shape course with a more lateral exit site. Initially, the driveline is tunneled from the pump pocket through a small incision, approximately 5 cm medial of the anterolateral thoracotomy above the rectus abdominis muscle. Then the driveline is placed in the sheath of the musculus rectus abdominis and exits the muscle’s fascia through a second small incision, which is placed caudal, median in umbilical direction. The third section of driveline course leads subcutaneously to the left or right upper abdominal quadrant [4, 6].

The standard tunneling device recommended by the pump manufacturer should ideally be used for this tunneling technique.

In case of the implantation of an HVAD (HeartWare Inc.), the cable may be placed around the pump before it finds its way through the fasciae. This is not necessary with the St. Jude Medical, Inc. devices HMII and HMIII, Berlin Heart’s INCOR, or ReliantHeart’s HeartAssist5.