this is a video of our approach for the
00:06
endoscopic carpal tunnel release before
00:10
performing this procedure is very
00:12
important to understand how to assemble
00:15
the endoscopic carpal tunnel system we
00:17
and in this case are using the micro air
00:20
system it's important to have an
00:23
appropriate light source and it
00:24
positioned for whether you're right or
00:26
left handed white balancing is critical
00:29
and it's important to make sure that the
00:30
blade does elevate when you engage the
00:34
trigger our approach is the standard
00:37
approach as described in the technique
00:38
where we make a line along the middle of
00:43
the ring finger and that should be the
00:45
path of your blade our second line is a
00:49
Kaplan Cardinal line which will show you
00:50
the distal extent of the of the carpal
00:54
tunnel and approximately the level of
00:56
the superficial palmar arch our incision
01:02
is then based in line with that of the
01:07
ring finger between the FCR and FCU
01:11
tendon and a proximal crease in the
01:14
forearm if you go if you try to make an
01:17
incision at the right at the palm and
01:19
forearm crease it's very difficult to
01:21
enter place the scope so more
01:24
importantly we come back just to the the
01:27
crease proximal to the the distal form
01:30
in Palmer crease skin incision is made
01:34
approximately one to one and a half
01:36
centimeters in length careful dissection
01:39
is performed there is commonly a vein in
01:43
transversing your incision and we tend
01:46
to cauterize this to prevent any
01:49
problems with post-operative bleeding we
01:54
found that using sin retractors is
01:56
helpful in clearing off the fascia in
01:58
this case the palmaris tendon is
02:01
identified and sin retractors or looper
02:04
tractors are used to clear off the
02:06
fascia clear off the tissue above the
02:09
fascist so that it is easily easily
02:12
visualized
02:13
it's important to create a distally
02:16
based facial flap as was just shown and
02:20
we do this with scissors careful to make
02:24
sure that the median nerve which is
02:27
usually which is immediately underneath
02:28
the fashion is not injured
02:33
this is an important for access to the
02:37
carpal tunnel once the facial flap is
02:41
created a small a two-prong hook is
02:45
placed underneath the facial flap and
02:47
then elevated allowing for entry into
02:52
the carpal tunnel your first instrument
02:55
is a synovial reflector and this is
02:57
placed at about approximately a 45
02:59
degree angle in line with the line you
03:02
could recreated along the middle aspect
03:04
of the ring finger and you should clear
03:07
off the synovium and you will feel a
03:09
washboard type feeling when you do do
03:13
this sequential dilators are placed and
03:16
and you should feel the hook of the
03:17
hamate and then the large dilator that
03:20
is equivalent to the camera itself is
03:23
placed and you should be able to feel
03:26
the tip of the die later where your
03:29
thumb is at the intersection of Kaplan's
03:30
cardinal line and the longitudinal line
03:32
along the ring finger you once you've
03:36
done the sequential dilating the camera
03:38
is placed sometimes it's helpful to
03:43
place some sailing along the the scope
03:45
so that it slides in easily this should
03:48
be a very controlled maneuver until you
03:50
can identify the the junction between
03:53
the transverse carpal ligament and the
03:55
superficial
03:58
Palmer fat once you've identified this
04:03
the blade should be raised carefully and
04:05
the distal aspect of the transverse
04:07
carpal ligament should be divided I tend
04:09
to drop the blade and go back and look
04:12
to make sure that I've had an adequate
04:14
release distally it helps to keep your
04:18
thumb along the median nerve and on the
04:21
radial aspect of the of the transverse
04:24
carpal ligament push down on the blade
04:26
so that you can
04:27
keep the median nerve from entering into
04:28
your viewing field once you've confirmed
04:31
that you've divided the ligament
04:33
distally adequately complete the
04:36
resection by slowly bringing the camera
04:39
back with a blade elevated and divide
04:41
the entire transverse carpal ligament
04:42
you can visualize release of this by
04:45
visualizing the two limbs of the
04:46
ligament and identifying the palmaris
04:49
brevis and other a super palmar fascia
04:52
superficial to the transverse carpal
04:54
ligament the median nerve can be seen
04:56
just radial there to the the instrument
05:00
you can confirm your release by using
05:03
the synovial reflector to see that
05:06
you've had adequate release and then
05:08
carefully using scissors you should
05:10
release the the antebrachial fascia
05:14
approximately for several centimeters
05:16
under direct visualization one important
05:21
point is that you should not perform
05:23
this procedure or raise the blade at any
05:26
point unless you can clearly see the
05:30
transverse carpal ligament if there's a
05:33
synovium in the way multiple attempts
05:35
may be necessary or required to release
05:39
to reflect the synovium with several
05:42
passes of the synovial rasp or reflector
05:46
after completion of the procedure a
05:49
simple closure is performed