Carpal Tunnel Release Procedure

This is the video short form for carpal tunnel release. And here's the table of contents for the various aspects of our how to do our carpal tunnel release. My incision is very ulnar to the thenar crease. It's long and it's ulnar to the thenar crease. And it's ulnar to the thenar crease for several reasons. One is I wanna be way away from the palmyrocutaneous branch of the median nerve.

I want any healing to be way away from the median nerve itself. And by coming ulnar, I achieve both of those goals. And also in many patients, if not most patients, there's a small cutaneous branch coming off the ulnar nerve and it's large enough to protect through this ulnar incision.

It's about two and a half to three and a half centimeters distal to the wrist crease. This incision also lets me see the V between the hypothenar and thenar muscles. And that cues me as to where the termination of the carpal ligament releases. This is a thin woman. I don't need to go above the wrist on her. But on some patients that are obese or have very thick hands knowing about the distal marker for the V and being able to extend the incision above the wrist is also very helpful.

Now it's about in here where you would see that cutaneous nerve branch coming off the ulnar nerve. And I'm not seeing it in this patient, but I'm looking for it. I'll frequently open up Guyan's canal, not necessarily because I think I need to open up Guyan's canal, but because it lets me see the V for the hypothenar and thenar. Of course, when you do a carpal tunnel release by just doing that, you are also decompressing Guyan's canal. So now I'll start to look for the V. And I see the thenar muscles running in the direction

of the thenar muscles, the hypothenar muscles in the opposite direction. And that junction between the two is the V. So there's thenar fascia. And then over here, hypothenar fascia and muscle and right between the two of them is this one spot where the hypothenar and thenar fascia meets that's the termination of that carpal release. I've marked it there with that ink dot. So now I'll start proxily. It doesn't really matter if you start proxily or distly, but I usually start proxily and I go very slow. I slow down the speed of the surgery now

and just scratch through the carpal ligament, going very slowly. And I'm on the extreme ulnar side of the ligament. I have not had any problem with a subluxation or bow stringing of tendons. And I'm very ulnar to the median nerve.

Way away from the parmicutaneous branches, you can see. And this allows the healing relating to that division of the flexor retinaculum to be way away from the median nerve. Now I'm coming to the end, that V. And I get rid of my knife and I use my tenotomy so I can pick up and slowly just get fascia. You can see that bright yellow fat, which means you're at the end of the release. And the median nerve is way over there. It's interesting that even though I'm way ulnar

to the median nerve, it's very close to the median nerve. So if you're making your incision right on top of the median nerve, I believe you're gonna scar down to it. Now I then move to the very end of the table. And I'm releasing the antebrakeal fascia and or proximal portion of the ligament. I'm the only one that can see this. So I position those CEN retractors or small down curve retractors myself. And then I tug on that proximal divided end of the flexor retinaculum. I pull it towards myself.

So I pull it towards myself. I make sure that the wrist is slightly flexed, not dorsiflexed. And I'm cutting that ligament and antebrakeal fascia on the ulnar side. So I'm sort of veering away from the median nerve. And I'm going very slowly here. No pushing, no blind pushing. And when you get to the end of that ligament, and you can see I've got that wrist slightly flexed, so I'm moving the nerve down. I'm cutting on top of the tendon right now. And when I get to the very end,

everything is under direct vision. And I'm the only one that can see as I'm doing this. So I make sure I like where the retraction is. When you're done cutting that ligament, there's an abrupt drop off. So it's not a little slow drop off. You are done when you get to the end of that thick antebrakeal fascia. And everything is under complete observation. Median nerve is way over there, so way away from the overlying cut on the flexor retinoculum.