DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Right carpal tunnel syndrome.
2. Right cubital tunnel syndrome.
3. Right long finger stenosing tenosynovitis.
4. Right hand Dupuytren’s contracture.
POSTOPERATIVE DIAGNOSES:
1. Right carpal tunnel syndrome.
2. Right cubital tunnel syndrome.
3. Right long finger stenosing tenosynovitis.
4. Right hand Dupuytren’s contracture.
OPERATION PERFORMED:
1. Right mini open carpal tunnel release.
2. Right endoscopically-assisted mini open in situ ulnar nerve decompression.
3. Right long finger trigger finger release.
4. Right long finger subtotal fasciectomy.
SURGEON: John Doe, MD
ANESTHESIA: General.
TOURNIQUET TIME: 25 minutes.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: The operative sites were marked, and she was transported to the operating room where the anesthesia service administered anesthetic and placed a laryngeal mask airway. The right upper extremity was then prepped and draped in the usual sterile fashion from the tips of the fingers to the axilla. A sterile tourniquet was applied, but not inflated, until we performed the cubital tunnel procedure. We injected 1% lidocaine with epinephrine at the wrist from Kaplan’s cardinal line distally to approximately 3 cm proximal to the volar wrist crease, as well as at the level of the distal palmar crease of the long finger.
We performed the carpal tunnel release through an approximately 2.5 cm length curvilinear incision following Langer’s lines in the axis of the long-ring webspace. We started approximately at Kaplan’s cardinal line distally and ended approximately 2 cm distal to the volar wrist crease. Dissection was sharp through skin with a 15 blade, followed by blunt dissection with Littler scissors to the level of the palmar aponeurosis. A hemostat bluntly dissected deep to the palmar aponeurosis, which allowed placement of a Senn retractor. This exposed the transverse fibers of the transverse carpal ligament, and a second Senn was placed at the distal extent of the carpal canal in order to protect and retract the ulnar neurovascular bundle and superficial palmar arch. With a hemostat, we bluntly dissected deep to the transverse fibers of the transverse carpal ligament. This freed adhesions between the transverse carpal ligament and the subligamentous tissue, and the ligament was then divided under direct inspection from distal to proximal with a 15 blade, being careful to stay as far ulnar as possible and yet radial to the hook of the hamate. At the most proximal extent of the carpal canal, Metzenbaum scissors was used to bluntly dissect superficial and deep to the remaining intact fibers of the transverse carpal ligament, and then the same Metzenbaum scissors was used to engage and push cut the remaining intact fibers of the transverse carpal ligament with the contiguous volar forearm fascia, with the tips of the scissors only slightly open. The median nerve was inspected and noted to be flat and hyperemic in the area of the carpal canal. The transverse carpal ligament was highly mineralized. The wound was copiously irrigated, and the skin was reapproximated with 5-0 nylon locking horizontal mattress suture.
We then made a Bruner incision at the level of the distal palmar crease and extending proximally. We sharply elevated the skin off of the cord and nodule beneath the skin. We identified several bands of connective tissue that were diving both radial and ulnar to the first annular pulley. The Dupuytren’s connective tissue was excised en bloc from the long finger axis, including the extensions that were diving deep. The Dupuytren’s connective tissue was sent as a single permanent pathology specimen, dimensions approximately 1.6 to 2 cm in length x 1 cm in width x 0.5 cm in depth. Next, we turned our attention to performing the first annular pulley release, which was completed easily under direct inspection within our Bruner incision. Finally, we performed a traction tenolysis, freeing the FDS and FDP from each other, and this wound was also copiously irrigated and the skin was reapproximated with 5-0 nylon locking horizontal mattress suture.
Next, we turned our attention to the elbow. We exsanguinated the upper extremity and inflated the tourniquet at 250 mmHg. We made an approximately 2.5 cm length curvilinear incision posteromedial and distal to the medial epicondyle. Dissection was sharp through skin, blunt through subcutaneous tissue, to the medial epicondyle. We then used curved Mayo scissors to bluntly dissect along the fascia. We identified the ulnar nerve just distal to the cubital tunnel, and using the nerve guide created a plane between fascia and muscle and the nerve. We divided the proximal edge of fascia with bipolar electrocautery at the volar forearm fascia. We then replaced the nerve guide to maintain space between the fascia and the muscle, and using the Integra push knife divided the antebrachial fascia for a length of approximately 8 cm. Under direct inspection, we evaluated the ulnar nerve, found Osborne’s fascia to be abutting the nerve, and using the nerve guide, we again created a plane between the nerve and this constricting tissue. We used the push knife again to divide this overlying fascial band, and the nerve was then freely mobile distal to the medial epicondyle.
We turned our attention to the brachial fascia and the ulnar nerve proximal to the medial epicondyle and similarly dissected with a curved Mayo. We placed the Integra trocar cannula and soft tissue retractor. We used the camera and push knife in order to ensure that no neurovascular structures were at risk. We then divided this tissue. We completed division of the brachial fascia over the nerve for a distance of approximately 10 to 12 cm. The nerve itself was inspected and noted to be of normal caliber proximal to the medial epicondyle.
We then turned our attention to dividing the cubital tunnel behind the medial epicondyle and did this under direct inspection with Littler scissors, being careful to protect the nerve. The elbow was flexed and extended, and there was no evidence of subluxation of the ulnar nerve. The wound was copiously irrigated. Tourniquet was deflated. Hemostasis was obtained with direct pressure proximally and distally, and bipolar electrocautery for subcutaneous bleeders. A soft compressive dressing was applied at the elbow, including Xeroform, 4 x 4s, 4 inch Webril and 4 inch Ace wrap. At the wrist and hand, a soft compressive dressing was applied, including Xeroform, 4 x 4, 2 inch Conform, 2 inch Webril, and a 3 x 12 inch splint to maintain full extension of the long, ring and small fingers while at rest and sleeping, and this was secured with an Ace wrap.
The patient was instructed to remove the splint during the day but to reapply it for resting and napping and sleeping. All of her questions were answered. She will be discharged home with p.o. pain medication, antibiotic, and instructed to follow up with therapy.
