DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Carpal tunnel syndrome.
POSTOPERATIVE DIAGNOSIS:
Carpal tunnel syndrome.
OPERATION PERFORMED:
Left carpal tunnel release.
SURGEON: John Doe, MD
ANESTHESIA: IV sedation with local anesthetic.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
DISPOSITION: Stable to recovery room.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and administered IV sedation. Next, we administered local anesthetic via a subcutaneous injection at the base of the palm along the radial border of the ray of the ring finger. Once adequate anesthesia had been obtained, the left upper extremity was prepped and draped in standard sterile surgical fashion. The left upper extremity was exsanguinated with an Esmarch bandage and upper arm tourniquet was raised to 250 mmHg.
A 3.5 cm longitudinal incision was utilized at the radial border of the ray of the ring finger extending from the distal volar wrist crease towards the mid palm. A knife was used for the skin and subcutaneous tissue. Blunt dissection was then utilized through the soft tissues down to the superficial palmar fascia. Blunt retractors were inserted to carefully protect the cutaneous nerves and soft tissues. The superficial palmar fascia was divided allowing access to the transverse carpal ligament. This was then incised longitudinally up to its distal margin near the mid palm. Blunt dissection was then utilized with tenotomy scissors to develop a plane superficial deep to distal volar forearm fascia. This was then divided approximately 1.5 cm into the distal forearm.
The contents of the carpal canal were then examined. The edges of the transverse carpal ligament were noted to be widely separated with no remaining areas of compression. The median nerve was somewhat flattened and pale. However, there was no hourglass deformity. There was no evidence of any acute injury to the median nerve. The thenar motor branch was intact. There were no anatomic abnormalities.
Hemostasis was attained with a bipolar cautery. The skin was closed with nylon interrupted sutures. Sterile dressing, bacitracin, Adaptic, and gauze were applied. The tourniquet was let down prior to the application of any circumferential dressing. The digits were pink and viable at the end of the case. The patient tolerated the procedure very well. There were no complications.
Ortho Operative Sample Reports
DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Left carpal tunnel syndrome.
2. Flexor stenosing tenosynovitis, left ring finger.
POSTOPERATIVE DIAGNOSES:
1. Left carpal tunnel syndrome.
2. Flexor stenosing tenosynovitis, left ring finger.
OPERATION PERFORMED:
1. Left carpal tunnel release.
2. Release of left ring finger flexor tendon sheath.
DESCRIPTION OF OPERATION: The patient was brought to the operating room where Bier block was placed by the anesthesia department. The left upper extremity was prepped and draped in the usual manner for hand surgery.
Under tourniquet contraction and loupe magnification, a longitudinal incision was placed in the base of the palm in line with the ring finger axis. Subcutaneous tissue was bluntly divided. The palmar fascia was split. The transverse carpal ligament was exposed. The entire transverse carpal ligament was incised from its distal edge up to its proximal edge, staying on the ulnar aspect. The median nerve was released of adhesion to the overlying transverse carpal ligament. The various branches were traced distally and found to pass unimpinged through the fat pad toward the superficial palmar arch. The subcutaneous tissue overlying the distal volar forearm fascia was bluntly divided. Lifting the skin, the distal fascia was divided under direct visualization. The median nerve demonstrated flattening. The epineurium was soft, and epineural neurolysis was not felt to be needed. The wound was irrigated. Skin edges were infiltrated with 0.25% Marcaine without epinephrine. The skin was closed with nylon suture.
A longitudinal incision was placed overlying the ring finger A1 pulley area. The subcutaneous tissue was bluntly divided. The flexor tendon sheath was exposed. The entire A1 was released. Dissection was performed. The patient had no proximal constrictions. The release was carried distally toward the MP flexion crease. The wound was irrigated. The skin was closed with nylon suture. The surgical area was infiltrated with 0.25% Marcaine without epinephrine.
The wounds were sterilely dressed, and a bulky compression dressing was applied. The operative course was uneventful. She had no complications. The patient tolerated the procedure well and was brought to recovery in good condition.
