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- For gluteal insertion, place the patient on their side, rolled slightly anterior leaving enough space to place the disposable trocar kit on the table behind the patient.
- For anterior insertion (inguinal or peri-umbilical fatty tissue) have the patient move away from the insertion side of the table, leaving 8 inches for the disposable trocar kit.
- Place the normal saline (or lidocaine + bicarb) bottle(s) to the side of the trocar kit and swab the tops of the bottles with the alcohol wipe.
- Remove the trocar kt from the plastic wrapper
- Open the trocar kit, turning/folding back the paper edges maintaining an ‘inner’ sterile field. (see video)
- Open the pellets and drop them gently into a corner of the tray.
- Sterile gloves will be located at the top of the kit.
- Using sterile technique, draw up the local anesthetic (or sterile saline) – see below for details.
- Sterilize the skin using the chlorascrub swab stick (or betadine) – apply in a concentric circle(s) with the center of the sterile field at the site of the incision.
- Gluteal insertion: Upper mid-gluteal area, below the waistline, above the gluteal crease (women)
- Inguinal insertion: 1-2 cm medial to the anterior to the iliac spine below the swimsuit line (see image below)
- Abdominal insertion: Peri-umbilical fatty tissue, either away from the umbilicus or towards the umbilicus (any medial, lateral, or inferior). Make sure the pellets do not end up where the patient wears her ‘pants’/belt line
- Place the fenestrated drape with the opening over the sterile field.
- Anesthetize the subcutaneous tract (~5-7 cm in length and at least 1 cm deep) and skin wheal with 6 ml of local anesthesia.
- Make sure there is a visible skin wheal.
- Using a #11 blade (held like a pencil), make a small 5-7 mm skin incision approximately 5-7 mm in depth. You must get through the subcuticular tissue the entire length of the incision or there will be resistance. The skin incision should be transverse on the body (Langer’s lines).
- At a 45-degree angle, guide the sterile cannula with the sharp trocar approximately 4 cm distal into the subcutaneous tissue (medial to lateral). The tract should be at least 8-10 mm in depth. The depth depends on the amount of subcutaneous fatty tissue.
- Do not place the pellets directly under the skin, they may cause discomfort.
- Remove the sharp trocar.
- Place the pellets into the cannula well using the sterile forceps.
- Insert the blunt trocar into the cannula and advance the pellets beyond the tip of the cannula – holding the cannula securely in place.
- Remove the cannula/blunt trocar and apply pressure using the sterile gauze pad.
- Clean the skin using the alcohol wipe while continuing to hold pressure on the incision.
- Apply the skin tapes (Steri-strips®) over the incision.
- Have the patient hold pressure with the gauze pads.
- Dispose of the sharp trocar, needle, and scalpel in the appropriate container.
- Apply the tegaderm dressing and have the patient hold pressure for 3-5 minutes. (Up to 10 minutes if on anti-coagulant or aspirin/anti-inflammatory therapy)
Tips for drawing up local anesthetic without an assistant
- Sterile gloves will be located at the top of the insertion tray.
- Glove your dominant hand: Pick up one of the gloves by the cuff and place it on your dominant hand.
- Using your ‘gloved’ hand, pick up the sterile 10-cc syringe, remove the cap with your non-dominant (un-gloved) hand, and draw up the saline or lidocaine, holding thebottle with your un-gloved hand – make sure you swab the top of the bottle with an alcohol wipe prior to gloving.
- Glove your non-dominant hand and proceed.