World Journal of Laparoscopic Surgery

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VOLUME 14 , ISSUE 2 ( May-August, 2021 ) > List of Articles

Original Article

Surgical Aspects of the Possover LION Procedure: An Emerging Procedure for Recovery of Visceral Functions and Locomotion in Paraplegics

Uffe S Løve, Soren B Elmgreen, Axel Forman, Ivan Arsic, Marc Possover, Anette B Jønsson, Helge Kasch

Keywords : Laparoscopy, Neurostimulation, Possover LION procedure, Traumatic spinal cord injury

Citation Information : Løve US, Elmgreen SB, Forman A, Arsic I, Possover M, Jønsson AB, Kasch H. Surgical Aspects of the Possover LION Procedure: An Emerging Procedure for Recovery of Visceral Functions and Locomotion in Paraplegics. World J Lap Surg 2021; 14 (2):75-80.

DOI: 10.5005/jp-journals-10033-1450

License: CC BY-NC 4.0

Published Online: 19-08-2021

Copyright Statement:  Copyright © 2021; The Author(s).


Background: Traumatic spinal cord injury (SCI) may be a devastating life event. Motor and sensory recovery after 6 months post-injury is sparse, despite intensive neurorehabilitation. Long-term disabling consequences may further reduce self-supportiveness and the quality of life. A new surgical intervention, the Possover LION procedure (Laparoscopic Implantation of Neuroprosthesis), may improve long-term perspectives providing the patient with an implantable pulse generator (IPG), and leads to pelvic situated nerves (sciatic and femoral nerves) to regain substantial motor and sensory functions in lower extremities. Objective: To report from the surgical point of view, the experience of implementing an IPG system for direct nerve stimulation of pelvic nerves in a series of chronic traumatic SCI patients. Methods: From two substudies, a feasibility study and a controlled clinical study, data from 21 SCI patients with severe paraplegia who had undergone the Possover LION procedure were obtained. The Possover LION procedure was implemented in a surgical department with skilled surgeons in close collaboration with neurological expertise. The developer of the procedure performed the first operations and afterward provided guidance and collaboration. Results: Twenty patients (F = 3, M = 17, age = 36.9 ± 9.0, ISCNSCI AIS A = 19, AIS B = 1) with lesion between Th3 and L1 had IPG and four leads implanted. One patient had a “frozen pelvis” and could not be operated. During operation, severe bleeding was seen in one patient that could be stopped using on-site applied hemostats, with no need of transfusion. One patient had initial normalization of infection parameters postoperatively, but developed Staphylococcus aureus infection near the IPG, removal of IPG and leads was needed. Clinically significant dislocation of leads was seen in two patients and dislocation/tilting of IPG in one patient. Hardware problems with possible lead breakage were observed in one patient. Conclusion: Posttraumatic SCI patients with paraplegia can be elected for the LION procedure by a specialist team of neurorehabilitation experts (neurologists, PTs), and skilled surgeons in the neuro-pelvic area, with Possover LION expertise. Complication rates for the Possover LION procedure are comparable to or better than those seen with spinal cord stimulation, and the procedure is generally safe. We recommend the monitoring of implanted leads and IPG using CT abdomen.

  1. Lundberg AS, Andersen MK, Kasch H, et al. [Patients with spinal cord injuries experience many sequelae]. Ugeskr Laeger 2015;177(43):V06150476.
  2. Taweel WA, Seyam R. Neurogenic bladder in spinal cord injury patients. Res Rep Urol 2015;7:85–99. DOI: 10.2147/RRU.S29644.
  3. van Middendorp JJ, Hosman AJ, Pouw MH, et al. ASIA impairment scale conversion in traumatic SCI: is it related with the ability to walk? A descriptive comparison with functional ambulation outcome measures in 273 patients. Spinal Cord 2009;47(7):555–560. DOI: 10.1038/sc.2008.162.
  4. Fawcett JW, Curt A, Steeves JD, et al. Guidelines for the conduct of clinical trials for spinal cord injury as developed by the ICCP panel: spontaneous recovery after spinal cord injury and statistical power needed for therapeutic clinical trials. Spinal Cord. 2007;45(3):190–205. DOI: 10.1038/
  5. Elmgreen SB, Krogh S, Løve US, et al. [Neuromodulation in spinal cord injury rehabilitation]. Ugeskr Laeger 2019;181(26).
  6. Possover M. A new technique of laparoscopic implantation of stimulation electrode to the pudendal nerve for treatment of refractory fecal incontinence and/or overactive bladder with urinary incontinence. J Minim Invasive Gynecol 2014;21(5):729. DOI: 10.1016/j.jmig.2014.02.003.
  7. Possover M. A novel implantation technique for pudendal nerve stimulation for treatment of overactive bladder and urgency incontinence. J Minim Invasive Gynecol 2014;21(5):888–892. DOI: 10.1016/j.jmig.2014.03.026.
  8. Possover M. The LION procedure to the pelvic nerves for treatment of urinary and faecal disorders. Surg Technol Int 2014;24:225–230.
  9. Possover M. Recovery of sensory and supraspinal control of leg movement in people with chronic paraplegia: a case series. Arch Phys Med Rehabil 2014;95(4):610–614. DOI: 10.1016/j.apmr.2013.10.030.
  10. Possover M, Schurch B, Henle KP. New strategies of pelvic nerves stimulation for recovery of pelvic visceral functions and locomotion in paraplegics. Neurourol Urodyn 2010;29(8):1433–1438. DOI: 10.1002/nau.20897.
  11. Possover M. The LION procedure to the pelvic nerves for recovery of locomotion in 18 spinal cord injured peoples - a case series. Surg Technol Int 2016;29:19–25.
  12. Angeli CA, Boakye M, Morton RA, et al. Recovery of over-ground walking after chronic motor complete spinal cord injury. N Engl J Med 2018;379(13):1244–1250. DOI: 10.1056/NEJMoa1803588.
  13. Bendersky D, Yampolsky C. Is spinal cord stimulation safe? A review of its complications. World Neurosurg 2014;82(6):1359–1368. DOI: 10.1016/j.wneu.2013.06.012.
  14. Kleiber JC, Marlier B, Bannwarth M, et al. Is spinal cord stimulation safe? A review of 13 years of implantations and complications. Rev Neurol (Paris) 2016;172(11):689–695. DOI: 10.1016/j.neurol.2016.09.003.
  15. Döring M, Richter S, Hindricks G. The diagnosis and treatment of pacemaker-associated infection. Dtsch Arztebl Int 2018;115(26): 445–452. DOI: 10.3238/arztebl.2018.0445.
  16. Eldabe S, Buchser E, Duarte RV. Complications of spinal cord stimulation and peripheral nerve stimulation techniques: a review of the literature. Pain Med 2016;17(2):325–336. DOI: 10.1093/pm/pnv025.
  17. Singh PP, Zeng IS, Srinivasa S, et al. Systematic review and meta-analysis of use of serum C-reactive protein levels to predict anastomotic leak after colorectal surgery. Br J Surg 2014;101(4): 339–346. DOI: 10.1002/bjs.9354.
  18. Blomström-Lundqvist C, Traykov V, Erba PA, et al. European Heart Rhythm Association (EHRA) international consensus document on how to prevent, diagnose, and treat cardiac implantable electronic device infections-endorsed by the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS), the Latin American Heart Rhythm Society (LAHRS), International Society for Cardiovascular Infectious Diseases (ISCVID) and the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). Europace 2020;22(4):515–549. DOI: 10.1093/europace/euz246.
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