Carpal Tunnel Repair and Fasciectomy for Carpal Tunnel Syndrome and Dupuytren’s Disease

CHAPTER 1

Hi, my name is Sudhir Rao and I'm going to describe a surgical procedure that was just recorded. This is a patient who had a Dupuytren's disease affecting his ring and small fingers, and he also had severe symptomatic carpal tunnel syndrome. So this patient opted to have surgical correction. So after a sterile prep and drape, we inflate a tourniquet to 250 millimeters. The first part of the procedure was a carpal tunnel release. I performed this using a two centimeter incision in the thenar crease. Once I incised the skin, I then split the palmar aponeurosis in line with the skin incision. And deep to this you can identify the transverse carpal ligament. The fibers of the transverse carpal ligament run perpendicular to the skin incision. At this point, I used sharp dissection to free the tissue superficial to the transverse carpal ligament. And by elevating the skin incision proximally this dissection can be carried down to the distal forearm. Once I've created a sufficient space superficial to the transverse carpal ligament, I use my self-retaining retractor to place the wound under some tension. This allows me to very gently incise the transverse carpal ligament very small amounts at a time so that once the transverse carpal ligament is completely incised in a small area I can identify the underlying structures, which is usually the synovium covering either the median nerve or the flexor tendons. At this point I stop further incision in the transverse carpal ligament and insert my dissecting scissors, which are usually moistened with saline to prevent adherence to the deep structures. In this manner I can free the deep surface of the transverse carpal ligament. And once this has been accomplished I cut the transverse carpal ligament from distal to proximal. Again, making absolutely certain that this is done under direct vision, and also making sure that the scissor is free from all underlying tendon or the median nerve. By elevating the proximal part of the incision I can visualize into the distal forearm and incise the transverse carpal ligament and the distal forearm fascia under direct vision to free the underlying median nerve. The distal part of the release is performed by placing a Freer elevator to protect the transverse carpal ligament, and then incising the distal portion again under direct vision. Once you see the fat pad surrounding the superficial arch, that is the end of the transverse carpal ligament, and the release is complete. The underlying median nerve is visualized, and almost always there is no need to perform an external neurolysis or any other procedure within the carpal tunnel. But I think it's important to make sure that there is no hypertrophic synovium, which is sometimes seen in patients with inflammatory arthropathy. But in virtually all cases all that is necessary to decompress the carpal tunnel is to incise the transverse carpal ligament from proximal to distal. And again, I emphasize that the release has to be complete and visualized and palpated. Once this is done, I usually never see any large bleeders, and we close the skin in a single layer with the interrupted 4-0 nylon. This completes the carpal tunnel release. The next part of the procedure was a fasciectomy for Dupuytren's disease affecting mostly the small finger, but he did have some contracture of the ring finger as well. Since the small finger deformity was not severe, I chose a zigzag Bruner incision starting in the hypothenar area, extending into the proximal and middle segments of the small finger. It is really important to raise these skin flaps at the subdermal level, and even more important to have extremely sharp knife blades because they dull very easily, and sharp dissection is absolutely necessary to raise skin flaps and prevent buttonholing of the skin flaps. Once the flaps are raised, the next step is to identify the diseased fascia, which in this case was a pretendinous cord extending into the digit. Once this is done, I identify the radial and ulnar neurovascular bundles on either side of the flexor tendon. This is critical because the entire dissection of the diseased fascia is done by keeping the neurovascular bundles under direct vision at all times. So in essence, the fasciectomy is a meticulous dissection of both neurovascular bundles. And as you can see in the course of the procedure, each neurovascular bundle is tagged with a vessel loop and I dissect on either side to free the diseased fascia from the neurovascular bundle. On the ulnar side you can see that there is a lateral and a retrovascular cord surrounding the neurovascular bundle, which requires careful dissection to prevent inadvertent trauma to the artery and nerve. In this case the cord was adherent to the flexor tendon sheath and the collateral ligament of the PIP joint, and therefore a small portion of the flexor sheath and the ulnar collateral ligament had to be excised. Once the cord is completely dissected and both neurovascular bundles have been identified, the entire cord is excised under direct vision. As you see, after excision there was complete correction of the flexion contracture in the digit. The diseased fascia in the ring finger extended from the mid-palm to the base of the digit. I was able to excise that by simply raising the radial flap of the skin incision. Once excision of the diseased fascia is complete, it is critical to release the tourniquet and make sure that all digits are perfused well. You wanna make sure that there are no large arterial bleeders and hemostasis should be done in a meticulous manner. Once I'm convinced that there are no large bleeders, the tourniquet is reinflated and the incision is repaired in the usual manner. I typically place small silicone drains to prevent a postoperative hematoma and I immobilize the digits with a plaster splint in gentle extension. The splint is typically removed in three or four days time, and the patient is allowed to begin self exercise, and this typically will lead to rapid recovery of movement. Stitches are removed in about 10 to 12 days, and thereafter they're allowed to use their hand normally.

CHAPTER 2

Gonna squeeze the fingers. All right. Let's inflate please. Inflating to 250 at 12:22. So this patient has Dupuytren's disease and carpal tunnel syndrome. We will do the carpal tunnel release first, then address the Dupuytren's contracture.

CHAPTER 3

So I usually make the incision right in the thenar crease. And my first incision is just down to the subcutaneous plane. And I use this to spread the tissues apart. Knife please.

CHAPTER 4

The second incision goes through the palmar aponeurosis. You can see the longitudinal fibers. And once you split that you can see the flexor retinaculum which runs transversely.

CHAPTER 5

Then I readjust my self retainer. All right, hold that down please. So you can see the transverse carpal ligament. So now I dissect superficial to it, down to the distal forearm. Is a clear plane of separation. I don't have to force myself. And then I enlarge that space a little bit. All right, now. And then... I have a clear shot of the entire transverse carpal ligament. Now sometimes you can see the origin of the thenar muscles right there. So I simply incise that gently and dissect that away. Take that off.

CHAPTER 6

I'm gonna readjust my retractor. Take it as deep as possible. All right. I'm gonna adjust my light. So I have a view of the entire transverse carpal ligament from its distal end all the way down into the forearm. And now I start to incise very gently. So I don't want to go too deep. I just used the tip of this number 15 blade.

CHAPTER 7

As as soon as I get through you can see a tiny opening right there. And that's your median nerve. You really don't want to go any deeper. So now I create plane of separation. I'll have a wet sponge please. It helps to have a moist instrument so you don't get stuck. And now you just... Gently lift up your retractor. You can see all the way down. You can actually feel the tip of your instrument in the distal forearm so you know you're well beyond the transverse carpal ligament. And all this can be done under direct vision, but you can also feel the tip right there. If you're in the distal forearm, you've done your release completely. And you can also see it and feel it.

CHAPTER 8

So I've done my proximal release. Now, I release the distal part. Knife, please. I use a Freer elevator and simply incise. Let's have a Senn. And once you see the fat, which surrounds the neurovascular structures, the superficial transverse arch, once you see that fat pad, that's the end of your distal release. And that structure out there is a median nerve. You really don't have to do anything to the nerve. Those are the two edges of the transverse carpal ligament that we released. So the carpal tunnel is wide open. We've done the release, and now we sew up and close the incision.

CHAPTER 9

All right.

CHAPTER 10

All right, so now we're gonna do a fasciectomy in the ring and small fingers. This is not a very bad contracture, so I usually take zigzag incisions. But if it is a severe contracture it'll be a straight incision followed by Z-plasties. So when you make these incisions just go down to the dermis and no more. All right.

CHAPTER 11

Littlers. Double hooks. 15 blade. See, our plane of dissection is just deep to the dermis, but you wanna make sure you don't buttonhole the skin. As you dissect you can see all that white tissue, that's the contracted fascia. Okay, and I keep looking all the time to make sure I haven't gone through the skin. Get me a fresh blade, please. Okay, let's go up here. Okay, come up here. Yeah, come up. So I'm going extremely slow because I don't want to damage the skin, but at the same time, I don't know where the neurovascular bundle is, which we will identify shortly. But I'm just raising the skin flaps right now so we have a decent exposure. We can switch to the medium hooks now.

CHAPTER 12

And we start looking for our neurovascular bundle. Show me a marking pen, please. And once I find it, just go put a mark on that nerve and artery. Show me a vessel loop please. Right angle hemostat. So we're gonna tag that so we know where to look for it. Come close by, please. So you want to keep that nerve under vision at all times. Because we have no idea where it goes. I need my Steven scissors as well. Let's find the nerve on this side. Okay, that's the second neurovascular bundle. Artery and nerve. You can see it goes right through that tissue. You can see that much clearer right there. So we'll take a second vessel loop and a mosquito. Yeah, because you really don't want to traumatize these. Okay. You have my Steven scissors? So you can still see the artery and nerve is still intact. So we are safe there. Let me move you a little further down. Have we put a bipolar up? Mm-hm. Okay. So I think we're pretty good on the radial side. Now we have to... This one is a little bit more challenging. Yeah, I'll take a knife. Keep pulling on that.

CHAPTER 13

So you can see the nerve going right there. There's some tissue here which I'll excise, but she has what we would consider a classic retrovascular cord which goes behind the artery and nerve, but we'll get rid of the main tissue. There you go. So we still have one neurovascular bundle. The other one is still wrapped a little bit with the fibrous tissue, but we'll get to that as well. You can still see the nerve right there. Now I've gotten behind it and will excise... I'll take a knife. Pull on your... And I've seen this diseased fascia attached directly to the collateral ligaments and the flexor sheath. And it's only... Take that off please. After you excise everything that you can get full correction. And I think we are there. Yep, that's the joint. That's the collateral ligament. And that tissue was attached directly to it. Take that off, please. Take the retractors off. We've taken out all that tissue, and you can see now that finger is pretty straight. Still have some tissue here to remove, and we'll go ahead and get that taken out. Yeah.

CHAPTER 14

Pull on this side. I still have to be very careful because all the nerves are right beneath that fascia. Pull on that. Knife to me. Here you go. So those are the... The blueish red ones are the arteries right there. Those are the lumbrical muscles. Those are the flexor tendons. And those are the two neurovascular bundles to the small finger.

CHAPTER 15

Take that out. There's a little bit of tissue there. We'll get that out. A knife please. I'm gonna release the tourniquet. There you go.

CHAPTER 16

So this now is probably the most important part of the procedure where we let the tourniquet down. Go ahead, please. And you wanna make sure... Deflating tourniquet, 12:58, 35 minutes. That these fingers regain circulation and that we haven't cut any arteries. The finger pinks up and we'll just make sure we don't have any big bleeders there. All right, let's get our double hooks.

CHAPTER 17

Actually, let's start up at the top and move down. I need Ray-Tecs. Okay, let's move down there. Come down here. There's something there, so retract that. Just relax a little bit. Gentle on that one. The Ray-Tecs please. I'm sorry? Ray-Tecs. Can you come out?

CHAPTER 18

All right, we don't have any major bleeders. We're gonna reinflate and close the incision. Yeah, we do not want straight incisions, straight scars, across the flexor crease because they always contract. I'll take a wet sponge please. This will be a plaster splint. Okay. What's our tourniquet time? Tourniquet's up. You have another suture? Yes. So that is a fasciectomy. And I think we managed to get them straight, both the fingers.

CHAPTER 19

All right, let's clean him up. That's with? Without. Okay. Did he have a block? He did. We'll take some vessel loops. Here, you can have that back.

CHAPTER 20

These are little drains that I put in so they don't develop a hematoma. We can cut that. Dressings. Cast padding. So we'll get that around these two fingers. All right, let the tourniquet down please. You can cut the drapes off.