POSITIONING:

1. The patient is positioned prone on a radiolucent table. Drape in the usual manner for a posterior and posterolateral procedure.

INCISION:

1. Determine the location of the skin incision by placing a spinal needle or probe in the approximate position. Take an x-ray image to verify proper level and trajectory for placement ofthe port. This is the most critical step to minimize the length of the incision and placing the port in proper position for the procedure.

2. The Swivel Standard Port Lumbar 27 requires a skin incision length of approximately 33mm. The Swivel Standard Port Lumbar and Cervical 19 requires a skin incision length of approximately 23mm. The OVOID System requires an approximate incision of 38mm. The fascial incision may be larger. Smaller skin incisions may risk skin edge necrosis. Make a Omm incision through the fascia then insert a Penfield #4 dissector or similar straight dissecting instrument to the level of the bone. Take a second x-ray image to verify the proper level and trajectory of entry. Then the fascial incision should be enlarged for the correct approach angle of the port.

3. If the surgeons prefers using dilation to access the spinal structure, dilate down using our Swivel Port Dilation System.

MUSCLE SPLITTING, SEPARATION AND PORT PLACEMENT:

1. Split paraspinal muscle down to the bony structures using a straight Penfield type dissector or similar instrument using a windshield washer type cutting motion until the spinal bone structure can be palpated. Place a straight Penfield or similar instrument to the correct level of incision and confirm approach and angle with a third x-ray image.

2. Place the handle on the Swivel Port.

3. Insert the closed swivel port with the handle attached into the incision and use the closed swivel port as a handheld retractor to pass the swivel blades through the muscle splitting incision. Confirm location by final x-ray image.

4. Open the Swivel Port, splitting and separating the muscle, by rotating the inner blade clockwise with the rotating ring. If difficult, open the incision another 2mm wider. Good pressure against the paraspinal muscle with the swivel blades is essential for stabilization of the port. Good visualization does not require that the port swivel base collar be flush with the patient's skin.

5. The flexible arm is then secured to the port handle and operating table. The handle may also be removed from the port and placed 180 degrees away from the surgeon and then mounted to the flexible arm allowing more room to work and maximum port stability.

6. For Swivel Standard Ports, select the expander blades that are the optimum length for the case. Make sure the swivel base blades have been fully opened with the rotating ring as noted in the prior section. Insert expander blades into the port until the bottom of the top ring of the expander is flush with the top of the swivel base section, and the blades are aligned rostral-caudal with the patient and 90 degrees relative to the swivel base section. The blades can now be gently expanded in the rostral-caudal exposure using the screwdriver to open the expander blade to the desired width. Caution should be used not to over-extend or force the blades too far in the outward position.

7. The Swivel Port system can be repositioned by loosening the flex arm and reorienting the port as required by the desired approach angle and surgical objectives.

REMOVAL:

1. Loosen screws to bring expanding blades back to a closed position and remove from base. Replace the swivel ring on top of base section and rotate in counter-clockwise direction closing the swivel port. Remove closed port from wound. Close fascial/tissues in standard manner