OPERATIVE REPORT

JUSTIFICATION:   The patient is a 32-year-old female, right hand dominant with a previous left carpal tunnel release, cubital tunnel release. The patient has had an increase in symptoms including muscle wasting and constant numbness. The release was done by another physician. A re-release will be performed with a transposition of the nerve.

OPERATIVE NOTE:  The patient was taken to the Operating Suite, placed in the supine position. A tourniquet was applied to the left upper extremity and set at 250 mm Hg. The arm was prepped and draped in the usual sterile fashion. The area in the palm and the elbow were infiltrated with 2% lidocaine and 0.25% Marcaine by me as well as IV sedation. The arm was maximally elevated, exsanguinated and the tourniquet was inflated to its preset pressures.

The first aspect of the procedure was to go ahead and make an incision in the palm. This was extended down to the transverse carpal ligament, which had reformed with scar tissue and an open release of the carpal tunnel was done, both the palm and volar forearm through the limited incision. A synovectomy was also performed due to the heavy reactive synovial tissue encountered. The synovial tissue was submitted to Pathology. The area was irrigated with antibiotic solution. All bleeding was meticulously controlled.  After complete release of the carpal tunnel and transverse carpal ligament release the incision was closed using 4-0 nylon interrupted sutures.

Following this, my attention was then directed at the elbow. The medial epicondyle region, from the previous scar, was then incised carefully removing thick hard scar tissue. After considerable amount of dissection the ulnar nerve was identified and completely released at this time. The nerve appeared hyperemic and compressed. A minor transposition of the nerve and partial submuscular was performed and the area was irrigated with antibiotic solution. The wound was closed using adjacent tissue closure using 5-0 Vicryl for the deep subcutaneous tissue layer and 4-0-nylon closure for the skin.

The patient had incision lines dressed with Xeroform gauge, fluff and 4-inch Kling. The patient had the hand maximally elevated in a stockinette sling. The patient tolerated the procedure well and all sponge counts, needle counts and instrument counts were correct postoperatively. The patient is aware of possible post surgical sequelae, post traumatic complications including but not limited to hypertrophic scar, wound dehiscence, wound infection, retracted scar, contracted scar, nerve compression, nerve injury, tendon injury, further wasting and numbness of the hand and the possible need for further revisional surgery and/or occupation therapy.

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