Step 1: Disinfect and prep site according the hospital protocol.
Step 2: Select a MILA long "length adjustable" E-tube. The long lengths are necessary to manipulate with the tunneler. These tubes are Item Number: E1430; E1450; E1830; and all can be cut for desired final length.
Step 3: The size 14Fr or 18Fr is printed on the side of the tunneler. The shorter; non-etched end; enters the mouth first to "tent" the side of the neck to palpate and incise. The longer; dark etched end; is pushed into the feeding tube for pulling through the incision.
Step 4: Remove the hub and skirt from the tube by unscrewing the skirt and pulling the Y adapter and skirt off. Retain the pieces to reinstall later.
Step 5: Trim 3-4cm off the end of the tube where it was stretched by the adapter. This is necessary so that the tube will fit tightly and not slip off the tunneler when being pulled through.
Step 6: Measure the length and mark the E-Tube.
Step 7: Insert E-Tube into mouth and advance until distal tip is positioned in caudal esophagus.
Step 8: Advance short end tip of the tunneler in cranial esophagus; adjacent to E-Tube; palpate exit site and incise and dissect to create access.
Step 9: Push tunneler partially through exit site. OPTIONAL: Grab the tip of the tunneler with a forcep to stabilize it.
Step 10: Connect proximal end of E-Tube to the long etched end of the tunneler.
Step 11: Pull the tunneler and E-Tube through exit site. Remove the tunneler.
Step 12: Confirm placement with a radiograph; fluorography; or endoscopy. Adjust if needed.
Step 13: Suture and bandage according to hospital protocol.
Step 14: Cut the tube to desired length; and replace the skirt and Y adapter.
Stiff low profile tip allows catheter to navigate into the anal sac orifice.
Instructions for Use:
The balloon catheter is placed into the anal sac through the anal sac orifice and inflated with 2-3 cc of saline to distend the anal sac making identification and palpation of the gland simple. The protruding catheter allows the surgeon to place gentle traction on the gland during dissection. A 360° degree skin incision is made around the protruding catheter. Metzenbaum scissors are used to dissect to the level of the anal sac wall. Identification of the wall is made by the grayish to blackish color of the wall in comparison to the red color of external anal sphincter muscle fibers being dissected off of the wall. As the dissection progresses constant traction is placed on the catheter to accentuate and retract the sac. Dissection is continued until the sac is completely free from its surrounding tissue. Any injured fibers of the external anal sphincter muscle are sutured with 3-0 Maxon and the skin closed using a subcuticular suture.