Primary Endoscopic Carpal Tunnel Release

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TECHNIQUE STEPS
Preoperative Patient Care
Operative Techniques
E

Preoperative Plan

1

Execute surgical walkthrough

  • describe the steps verbally to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
F

Room Preparation

1

Surgical instrumentation

  • Loupes recommended

2

Room setup and equipment

  • standard operative table and hand table

3

Patient positioning

  • supine position
G

Transverse Incision

1

Identify anatomic landmarks

  • draw out the palmaris longus, flexor carpi radialis and the flexor carpi ulnaris

2

Make incision

  • make a 1 to 2 cm transverse incision in the wrist flexion crease centered over or just ulnar to the palmaris longus
  • if the palmaris longus is not present make the incision half way between the FCR and the FCU
H

Deep Dissection

1

Expose the palmaris longus and retract it radially with a Ragnell retractor

2

Identify and divide the flexor retinaculum

  • create a U shaped flap that is 1 cm wide

3

Retract the flap

  • use a mosquito clamp to retract the flap
I

Prepare Carpal Tunnel

1

Place Hamate finders

  • pass small and large hamate finders down the carpal tunnel to evaluate the space and location of the hamate

2

Ensure proper location of instruments

  • palpate the instruments distal to the TCL at the Kaplan cardinal line
  • if the instruments are palpable proximally then the instruments are not properly placed
  • this could indicate that the insruments are in Guyons canal

3

Separate synovium from the TCL

  • pass the tenosynovial elevator proximally and distally a dozen times along the axis of the fourth ray to dissect the synovium from the undersurface of the TCL
J

Device Insertion

1

Insert the assembled endoscopic device into the carpal tunnel

  • direct the endoscope palmarly.

2

Visual the the undersurface of the TCL

  • TCL has transverse striations

3

Advance the instrument until the distal edge of the TCL is identified

  • the distal edge is identified by a white transverse fiber of the TCL with a yellow amorphous midpalmar fat
  • this fat can contain vessels and nerves
K

Identify Anatomy with Scope

1

Perform a ballotment maneuver with the non dominant hand

  • this is done to distinguish the transition between the midpalmar fat and the distal edge of the TCL

2

Palpate the distal edge of the scope as it emerges into the into the subcutaneous space just distal to the TCL

  • place device in the dominant hand
  • look for a change in the transillumination pattern as the device is moved from underneath the TCL to the transpalmar fat
L

TCL release

1

Divide the TCL

  • elevate the blade of the device while withdrawing device slowly
  • this cuts the TCL from distally to proximally
  • keep the device pressed against the undersurface of the TCL so that no structures come between the TCL and the blade to ensure no other structures are cut
  • only cut the TCL when visualization is excellent
  • repeat this step until the TCL is completely released
  • make sure that there is release from the radial and ulnar flaps from a proximal to distal direction
  • this is ensured by pressing the device against the palmar tissue and being able to seen only one flap at a time
  • also place the device in the trough between the radial and ulnar leaflets
  • visualization of the leaflets should not be possible with the device in this position

2

Divide the antebrachial fascia

  • withdraw the endoscopic device and place hamate finders
  • divide the antebrachial fascia with long tenotomy scissors under direct visualization
N

Wound Closure

1

Irrigation, hemostasis, and drain

  • ensure hemostasis

2

Closure

  • use 3-0 nylon to close skin

3

Dressing and immediate immobilization

  • place in a soft dressing
Postoperative Patient Care
 

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