Vagus nerve stimulation in drug-resistant epilepsy: Surgical technique from a tertiary epilepsy center

Background: Drug-resistant epilepsy affects nearly one-third of individuals with epilepsy and is associated with significant morbidity and reduced quality of life. For patients who are not candidates for resective surgery, vagus nerve stimulation (VNS) represents an established neuromodulatory therapy. Despite its widespread use, detailed and standardized technical descriptions of implantation remain limited. This article outlines the surgical technique for VNS implantation developed at a tertiary epilepsy center, emphasizing anatomical landmarks, operative steps, and perioperative considerations to enhance safety and reproducibility. Methods: We provide a step-by-step description of VNS implantation based on institutional practice. The procedure includes patient positioning, identification of cervical landmarks, creation of the subcutaneous generator pocket, cervical dissection with carotid sheath exposure, vagus nerve identification and mobilization, helical electrode placement, lead fixation with strain-relief loop formation, intraoperative impedance testing, and layered wound closure. Technical nuances aimed at minimizing complications and facilitating future revisions are highlighted. Results: The described approach enables consistent vagus nerve identification, secure electrode positioning, and appropriate lead stability while preserving surrounding structures. Standardized incision placement, careful tunnelization, and systematic intraoperative testing contribute to procedural safety and reproducibility. Conclusion: A structured and standardized VNS implantation technique is essential to optimize safety, reduce technical variability, and support the consolidation of epilepsy surgery programs. Detailed reporting of surgical methodology may promote harmonized practice and improve access to neuromodulatory therapies across diverse healthcare settings.