Mini-Open Carpal Tunnel Release

Special Equipment

Basic tray
Hand tray, which contains finer bipolar forceps and self retaining retractors than a basic tray
Sterile, malleable hand holder to maintain hand position with some wrist extension

Operating Room Set-up

Surgeons are seated, facing each other, with the patient’s outstretched arm between them.
Headlight
Loupes
Hand bipolar

Anesthetic Issues

Miscellaneous

A mini-open procedure is generally appropriate for all patients as a first procedure.
Some practitioners choose to perform endoscopic carpal tunnel release in selected, nondiabetic patients.
Reoperative carpal tunnel release requires a more extensive open procedure to safely identify normal nerve above and below the previous incision.
In patients with bilateral disease, one side is performed at a time to ensure the patient has at least one completely functional hand during convalescence.

Positioning

Planning of Sterile Scrub and Prep

Chlorhexidine scrub of hand, wrist, and forearm, followed by alcohol paint, followed by Betadine paint that is allowed to dry
An extremity drape is used to drape hand, wrist, and distal forearm into the field.
Hand is then placed into the sterile malleable hand holder, with the wrist in moderate extension.
A 2-cm incision is marked just distal to the distal wrist crease, in line with the radial aspect of the 4th digit; following a natural wrist crease is not necessary but avoiding injury to the more radially-placed palmar cutaneous and recurrent motor branches is.

Technique

The incision is injected with local anesthetic (four parts lidocaine 0.5% with epinephrine, four parts bupivacaine 0.25%, one part sodium bicarbonate); some practitioners discourage the use of epinephrine in hand surgery; no tourniquet is necessary.
Incise the skin with a no. 15 blade and place a self retaining retractor. Deeper dissection will reveal the palmar fascia; incise this next and place the retractor deeper to keep the subcutaneous fat out of the way; bipolar may be used to shrink some of the more problematic fat away.
Incise the distal portion of the flexor retinaculum with a no. 15 blade until the median nerve is seen; use Metzenbaum scissors to completely divide the ligament proximally and distally.
Have the assistant elevate the skin with a Senn retractor so that all bands of constrictive tissue, including fascia, may be divided for at least 3 to 4 cm proximally and 2 to 3 cm distally beyond the confines of the incision (for a total of 7 to 9 cm of nerve decompression).
Irrigate, obtain hemostasis, and close with 5–0 nylon vertical mattress sutures.

Place a bulky dressing that enables the patient to move and use all of the fingers in the immediate postoperative period.
Encourage patients to use the hand as soon as possible in the postoperative period; however, discourage heavy lifting (carrying groceries, weightlifting, etc.) or excessive force against the incision (push-ups, using hand tools, etc.) for 6 weeks or so postoperatively.
Occupational therapy may begin 4 to 6 weeks postoperatively.