Updated: 10/4/2016

Surgical Excision of Dorsal Ganglion Cyst

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Questions
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Evidence
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Techniques
1

Preoperative Patient Care

A

Outpatient Evaluation and Management

1

Obtain focused history and performs focused exam

  • concomitant and associated orthopaedic injuries

2

Prescribes and manages nonoperative treatment

  • attempts trial of physical therapy
  • orders appropriate orthosis

3

Makes informed decision to proceed with operative treatment

  • documents failure of nonoperative management
  • describes accepted indications and contraindications for surgical intervention

4

Provides postoperative management and rehabilitation

  • 1 week postoperative visit
  • remove splint
  • diagnose and management of early complications
  • start range of motion exercises
  • start scar massage by 2 weeks
B

Advanced Evaluation and Management

1

Provides post-op management and rehabilitation

  • gradually increase range of motion
C

Preoperative H & P

1

Perform basic medical and orthopaedic history and physical

  • check neurovascular status
  • check range of motion

2

Perform operative consent

  • describe complications of surgery including
  • wound complications
  • neurovascular injury
  • stiffness

Operative Techniques

E

Preoperative Plan

1

Execute surgical walkthrough

  • describe the steps of the procedure verbally prior to the start of the case

2

Description of potential complications and steps to avoid them

F

Room Preparation

1

Surgical Instrumentation

  • loupe magnification

2

Room setup and Equipment

  • standard operating table
  • hand table

3

Patient Positioning

  • patient placed in the supine position with hand on hand table
  • place tourniquet high on the affected extremity
G

Transverse Incision

1

Identify ganglion cyst

  • the cyst is typically dorsal to the scapholunate ligament
  • the scapholunate ligament is typically distal to Lister`s tubercle in the third and fourth compartment interval

2

Mark the transverse incision

  • mark the incision over the scapholunate ligament and entire cyst

3

Make transverse incision

  • be sure to include the scapholunate ligament in the incision
H

Deep Dissection

1

Dissect through subcutaneous tissue

  • use blunt dissection

2

Identify and protect neurovascular stuctures

  • protect and preserve any branches of the dorsal radial and ulnar sensory nerves

3

Incise the extensor retinaculum in a transverse fashion

I

Cyst Visualization

1

Identify the cyst

  • the cyst is usually between the third and fourth extensor compartments

2

Visualize the entire cyst

  • retract the tendons of the second and third compartment radially
  • retract the tendons of the fourth compartment ulnarly
J

Cyst Excision

1

Identify stalk of the cyst

  • incise the dorsal wrist capsule transversely
  • trace the cyst down to the stalk
  • the stalk usually arises from the dorsal aspect of the scapholunate interosseous membrane

2

Excise the cyst at the base of the stalk

3

Send the specimen to pathology

4

Cauterize the site of origin

  • use bipolar cautery
K

Joint Inspection

1

Inspect the joint for any abnormalities

2

Allow the capsular tissues and tendons to return to their anatomic position

  • avoid closure of the capsule to prevent joint stiffness
L

Wound Closure

1

Irrigation and hemostasis

  • copiously irrigate the wound

2

Superficial closure

  • use running subcuticular nonabsorbable monofilament suture

3

Dressing and immediate immobilization

  • dress with antibiotic ointment
  • place a bulky hand dressing and a plaster palmar splint in the neutral position

Postoperative Patient Care

O

Perioperative Inpatient Management

1

Write comprehensive postoperative orders

  • remove splint in one week
  • pain management

2

Discharges patient appropriately

  • write for pain meds
  • schedule follow up appointment in 1 week
R

Complex Patient Care

1

Comprehensive pre-op planning/alternatives.

2

Modify and adjust post-op plan as needed

 

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