DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Left ulnar neuropathy at the elbow.
2. Left ulnar neuropathy at the wrist.
POSTOPERATIVE DIAGNOSES:
1. Left ulnar neuropathy at the elbow.
2. Left ulnar neuropathy at the wrist.
OPERATION PERFORMED:
1. Left submuscular ulnar nerve transposition.
2. Left ulnar tunnel release.
SURGEON: John Doe, MD
ANESTHESIA: Laryngeal mask airway.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
COUNTS: Instrument count was correct.
TOURNIQUET TIME: Seventy minutes.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed supine on the operating table. After an adequate level of general laryngeal mask airway anesthetic had been obtained and a preoperative dose of 1 gram of Ancef had been given, the left upper extremity was sterilely prepped and draped in the usual fashion. The extremity was elevated, exsanguinated, and the tourniquet insufflated to 275 mmHg.
The landmarks were palpated. An approximately 10-12 cm incision was made just posterior to the medial condyle in an L-shaped fashion using a 15 blade. The dissection was carried down through the subcutaneous tissues using pickups and tenotomy scissors. Great care was taken in the dissection through the proximal forearm portion of the L-shaped incision while dissecting the soft tissues down to the level of the flexor forearm fascia to ensure that the medial antebrachial cutaneous nerve was not cut, and it was not.
Just proximal to the medial epicondyle, in the upper arm portion of the wound, the ulnar nerve was identified and dissected free from the medial epicondyle proximally for at least 8 cm using Army-Navy retractors to gain access to the upper arm. The dissection of the ulnar nerve was then continued around the medial epicondyle by releasing the flexor forearm fascia that was over the nerve until it again dove down deep into the flexor muscles. At this point, the nerve was completely identified and had been unroofed.
Attention was then directed toward the submuscular ulnar nerve transposition. The skin and subcutaneous tissue was then released off the fascia overlying the medial epicondyle and folded anteriorly into a flap. Proximally, the intermuscular septum was released and resected with minimal difficulty. A step-cut was then made approximately a centimeter off of the medial epicondyle through the fascia of the flexor bundle. This dissection proximally was carried down until the brachialis muscle could be identified. The muscle was then completely released from the more superior aspect of the flexor attachment to the more inferior portion of the attachment near where the nerve was traversing.
Any bundles of fascia that might impinge on the nerve were completely released until there was a good submuscular tunnel that had been created for the nerve. The nerve was then gently released from its bed preserving its vasculature, and it was transposed into the muscular bed that had been created by the submuscular dissection. Once it was passed in this area, it was gently irrigated. There were no tension points either proximally or distally on the nerve as it first entered and then exited the submuscular tunnel. The flexor forearm mass was then reattached to its fascial insertion point using interrupted inverted #2 FiberWire sutures. Once it had been completely repaired, the nerve was checked and found to not be compressed at any point along its course.
Attention was then directed towards the left ulnar volar wrist. A Bruner-style incision was made over the ulnar portion of the flexor crease of the wrist. The dissection was carried down to the subcutaneous tissue. Proximal to the wrist flexor crease, the ulnar artery and ulnar nerve were identified with gentle dissection. We then unroofed the fascia of Guyon’s canal, extending into the palm of the hand, by releasing the fascia using tenotomy scissors for the entire length of the Guyon’s canal. After this had been done with the tenotomy scissors, the nerve was inspected and found to be intact, as was the ulnar artery.
At that point, all incisions were washed out and closed in layers with 5-0 nylon for the skin and the wrist and 2-0 Vicryl inverted interrupted sutures for the subcutaneous tissue of the elbow and 5-0 nylon for the skin. All incisions were injected with 0.25% plain Marcaine. A sterile dressing and posterior splint was applied. The patient was extubated and taken to the recovery room in stable condition. The patient will be discharged home on p.o. pain medicine and follow up in 10 days.
