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TECHNIQUE STEPS
Preoperative Patient Care
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

Nerve Exposure

1

Make the incision over the injured nerve

2

Bluntly dissect to the injured nerve

3

Expose both ends of the injured nerve

H

Nerve Mobilization

1

Mobilize the nerve

  • mobilize nerve ends for about 1 to 2 cm at either end
  • avoid any unnecessary stripping of the mesoneurium over long distances

2

Identify and preserve vital structures

  • preserve the common sheath of the neurovascular bundles
  • this maintains nerve vascularity and minimizes the tension on the nerve repair
I

Epineural Repair

1

Expose the fascicles

  • expose the nerve fascicles until they are clean and pouting

2

Identify the epineurium

  • identify the epineurium circumferentially by resection or pushing back at the mesoneurium
  • correct alignment of the nerve ends is critical

3

Correctly align the epineurium

  • line up the blood vessels and other external markings in the epineurium
  • match the fascicular bundles into two bundles

4

Select the appropriate suture

  • suture needs to be monofilament on an atraumatic needle to minimize the trauma to the nerve ends
  • suture size in the arm is usually 8-0 is used in the arm, 9-0 in the fingers
  • repair with larger suture does not add strength to the repair

5

Place the initial sutures

  • place 2 simple sutures 180 degrees from one another
  • avoid penetrating fascicle with the needle
  • leave one tail of each suture long to stabilize the nerve during the repair
J

Anterior Repair

1

Place additional sutures

  • place three or four additional sutures on the anterior face of the repair as needed
  • this is done to approximate the epineurium and prevent fascicular extrusion

2

Remove excess tension on the nerve

  • flex the limb to further to relax the nerve
K

Posterior Repair

1

Expose the posterior face of the nerve

  • turn the nerve over
  • expose the posterior wall by using the suture tails

2

Stabilize the nerve

  • weigh each suture down using a vascular clip

3

Perform the posterior wall repair

  • complete the posterior wall repair with three or four simple epineurial sutures
  • cut the long tails short

4

re-evaluate the nerve

  • examine the nerve to ensure that the epineural seal is complete
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

  • immobilize the extremity
  • place the elbow in 90 degrees of flexion
  • avoid wrist flexion greater than 20 degrees
Postoperative Patient Care
 

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