DESCRIPTION OF OPERATION: The patient was identified in the holding area. Appropriate surgical limb and site were confirmed, marked and initialed. Axillary block anesthetic was administered.
He was brought to the operating room and placed in the supine position on the operating room table. The right upper limb was prepped and draped in routine fashion. Upper limb exsanguinated with Esmarch bandage and previously placed well-padded pneumatic tourniquet inflated to 250 mmHg.
A 3.5 loupe magnification was used throughout. An incision was made incorporating the thenar crease just radial to the axis of the ring finger ray extending ulnarly across the wrist flexion crease.
Incision was deepened to skin and subcutaneous tissue, palmar aponeurosis down to the transverse carpal ligament. The transverse carpal ligament was sectioned longitudinally from distal to proximal.
Distally, the brachial fascia was divided in the distal forearm. The median nerve was less decompressed. External neurolysis of the median nerve was carried out. It was dissected away from the undersurface of the transverse carpal ligament and dissected away from a high-grade proliferative flexor tenosynovitis. The nerve showed some hyperemia of its vascular markings.
There was no obvious injury to the nerve. No signs of any neuroma or pseudoneuroma. There was some slight hourglassing of the nerve at the level of the transverse carpal ligament, but otherwise the nerve appeared to be normal.
The operating microscope was brought near and the nerve was inspected, but was elected not to proceed with any type of internal neurolysis. Next, attention was directed towards tenosynovectomy. There was a high-grade proliferative tenosynovitis involving the flexor digitorum superficialis and flexor digitorum profundus tendons.
The synovium appeared to infiltrate the tendon, although it dissected and peeled easily off the tendons. It was difficult to determine the extent of the tenosynovium as the synovium blended distally into the lumbrical muscle.
There was high-grade tenosynovitis involving the superficial and deep flexor compartments as well as the radial bursa of the flexor pollicis longus tendon. This extended proximally to the level of the forearm and distally to the level of the lumbrical origin. There were no rice bodies encountered. There was no pus in the Parona space.
Radical tenosynovectomy was carried out of all four superficialis and profundus tendons as well as the flexor pollicis longus tendon. All excised tenosynovium was sent for specimen. Portions were sent for routine pathology and special stains.
Portions were sent for routine cultures as well as AFB and fungal cultures. The tourniquet was now deflated. There was intense reactive hyperemia to the median nerve consistent with compression. Small bleeding points were controlled with bipolar cautery.
The wound was copiously irrigated with saline. Hemostasis appeared adequate. A drain was placed into the carpal canal deep to the median nerve and brought out through a separate stab incision proximally.
The skin wound was then closed in one layer with interrupted 5-0 nylon suture. The wound was dressed with antibiotic ointment and Adaptic. Bulky dressing applied, reinforced with a volar fiberglass splint. Vacutainer tube was applied to the TLS drain with good return of scant amount of blood. The patient tolerated the procedure well, was awakened in the operating room, and transported to the recovery room in stable condition.
