Excision of a Ganglion Cyst from Distal Middle Finger Near Nail Bed

CHAPTER 1

Hi, my name is Sudhir Rao. I'm an orthopaedic surgeon. I'm going to talk about a case that was just recorded. This is a patient with a mucus cyst or a ganglion cyst in the middle finger. This is a fairly common condition. Most people do not need surgery, but some request that the cyst be excised. This patient had pain and recurrent drainage from the cyst. In addition, he also had a deformity of the nail plate. So, I will describe the procedure as recorded in the video. This patient was operated under local anesthesia. I anesthetized the digit with 1% lidocaine, and after we prepped and drape the patient, we applied a tourniquet to the base of the digit. This is important because you don't want bleeding during the surgery. Once the tourniquet is applied, I made a vertical incision directly overlying the visible cyst. And it was really important to dissect at the subdermal level because the cyst is right underneath the skin and the wall of the cyst is adherent to the skin. And more often than not, you'll up rupturing the cyst when you raise your skin flaps. Nevertheless, if you see, I dissected proximal to the cyst, to the level of the distal joint. This way I was able to identify normal tissue and then dissect distally to expose the wall of the cyst. Many of these cysts arise from the distal joint and they have a small pedicle, and it's important to identify this pedicle, and excise the entire mass. In this instance, the cyst was very close to the germinal matrix of the nail, and this caused pressure on the germinal matrix and a resulting deformity of the nail plate. As you see, the entire cyst was excised and this being a very vascular area, it is really important to achieve hemostasis before you close the skin. The skin was repaired with 6-0 absorbable Monocryl sutures. It is necessary to reconstitute the proximal nail fold so it heals adequately, and the nail regenerates in a perfect manner. After surgery, I usually restrict excessive finger movement for about 10 days to allow healing, and after that they have unrestricted use of the hand.

CHAPTER 2

All right, so I'm just going to anesthetize the finger with a lidocaine block. This is 1% lidocaine. You're gonna feel a little poke on your hand, okay? Okay. Okay. One little poke. We doing good? Mm-hm. All right. We'll flip your hand over. This one hurts just a little bit more, okay? Okay. One poke in your palm. So usually I will put about 5 cc on either side of the finger. You have a finger tourniquet, right? Yeah. Okay. Another little poke. That finger should start getting numb in the next five minutes. What we are gonna do is get your hand cleaned up and ready to go. Okay.

CHAPTER 3

So lay your hand down. Just relax and think about something nice.

CHAPTER 4

All right, so this is a ganglion cyst or a mucous cyst near the nail fold. It usually arises from the distal joint of the finger. We're gonna put a tourniquet on the base of the finger. Are you feeling anything. Good. So just relax and enjoy the ride, okay? Just have a med cup. Don't tense your hand, just relax. Thank you. Show me a marking pen.

CHAPTER 5

You put a roll under his hand there. What's that? You wanna put a roll under there so we can...? Yeah, you can. Yeah. So hand me a 15. I need both my pickups. And let's have the double hooks. So this ganglion is very superficial, and as soon as I make the incision, you can see some of that gelatinous stuff coming out. That's the material from the ganglion cyst. We want to try and isolate the cyst itself so the dissection becomes extremely superficial. 15 back.

CHAPTER 6

Steady the finger. Let me have you hold this. So I'm dissecting right beneath the dermis. And right there is the ganglion.

CHAPTER 7

Where it probably has a tail that goes further towards the joint. So that's where I'm dissecting. So unless we remove the whole thing, it can come back. Steve? Yes, sir. Can you have them get some 6-0 Monocryl. We actually may have some here. We got it for the last case.

CHAPTER 8

I do. Yeah. So I'm just gonna remove this whole thing. Now because that ganglion sits right on the nail bed, it often leads to a deformity of the nail. And I don't know if you guys can see that, but there's a hollow depression out there, and that's from that ganglion causing pressure on that nail bed. And the root of the ganglion went right all the way up to the distal joint of the finger. I think we've removed everything.

CHAPTER 9

Now this is a very vascular area so I'm gonna cauterize as much as we can. Let's open that Monocryl. Can you gimme the Monocryl? 6-0? Yep.

CHAPTER 10

You sending this? No. Now the other thing I'm gonna do is the wall of the cyst was extremely thin, so I'm gonna remove a little piece of the skin right there. So when we suture this up, we have healthy tissue, and we will also reconstitute that nail fold the way it's supposed to be. I'll take the 6-0. And we are gonna use very fine absorbable sutures. Go ahead and cut that. 6-0 Monocryl. Go ahead and steady that finger. Do you have a wet sponge? Let's leave a small tail. I usually use 4-0 or 5-0 nylon for closure. But sometimes it helps to use absorbable sutures near the nail so you don't have to remove them at a later time. Steve, do you wanna count? Absolutely. We'll use some two-inch Coban for dressings. Two-inch Coban. Ray-Tecs - one, two, three. Four, five, six, seven, eight, nine, ten. One suture up, two and three. Three sutures correct. Blades one, two. Two blades, count is correct. Looking hard to see with that clear cup. Yeah.

CHAPTER 11

Let me just have the Mayo scissors. Most important part of the operation is to make sure the tourniquet is off the finger.

CHAPTER 12

I usually hold pressure for a couple minutes to make sure it's not bleeding. We are all done. You can relax. That's the ganglion with its pedicle. All right, let's get some Vaseline. Yeah, you have more? We have... Big sticker coming off. Okay. Open that up. Okay. So I'm gonna wrap two fingers together. Okay. Just because it's easier to wrap two than one. Sounds good. But you can unwrap that after 48 hours, and just put a... 48 hours? Okay. Yeah. Okay, cut that off. So after 48 hours you can remove this. Just cover it with a couple Band-Aids. That's all you need. Okay. Go easy on that finger. Don't move it too much. Okay.