1. History
2. Benefits of endoscopic CT release
3. The new single portal technique
4. Benefits of single portal

History

One of the most common and successful operations over the last 50 years has been to release pressure over the Median nerve by making an open incision (often 2 -3 inches long) at the base of the palm. Some surgeons place the hand in a plaster for 2 weeks after this surgery, most bandage it, however it is uncomfortable for weeks to months afterwards. Occasionally there may be some permanent numbness at the base of the palm and occasionally soreness over the sides of the palm (pillar pain) for upto 6 months.

The advantages of minimally invasive surgery in Orthopaedics became obvious with the introduction of the arthroscope, at first in the knee, but quickly spread to the other joints such as the shoulder, wrist, elbow, and ankle.

In 1990 the endoscope was being used by orthopaedic surgeons, trained in arthroscopy, in other areas where there was no joint space such as the carpal tunnel (Agee, Chow, Okutsu). After the initial developments the procedure has become very reliable and complications minimised.

Biportal Endoscopic Carpal Tunnel Release

Within a fairly short time a 2 portal technique of Chow became the most popular choice by hand surgeons - there being one 1.5 cm. incision in the wrist where the slotted working cannula (rigid tube) is inserted and a second 1 cm. incision in the palm where the cannula exited. A telescope is use in one end to look at the instrument (knife) working from the other end. The tough compressing band of tissue is divided under direct vision in this manner. The rigid tube tended to stretch the tissues and some patients experienced altered sensation along the side of the ring finger.

Benefits of endoscopic over open surgery

1. However patients reported numerous benefits:
2. only minimal local anaesthetic - no G.A. (and associated nausea) necessary
3. same day surgery
4. tiny incisions - minimal pain
5. normally no tourniquet is needed (again less pain)
6. early use of hand (encourage finger movements immediately)
7. no need for prolonged bandage or splint (only 12 hours for my patients)
8. early return of pinch and grip
9. early return to function - work and sport
10. less "pillar pain"
11. Because of above both hands can be done together

Single Portal Technique

More recently the same procedure can be carried out through a single incision at the wrist crease. A 1 cm. incision is made after some local anaesthetic is infiltrated and a plastic cannular is inserted into the hand about 3 cms. under the carpal ligament. The ligament is cleaned and seen clearly before any cut is made under vision on the T.V. monitor. The end of the ligament is very easily identified as the hooked knife "falls over" its tight edge and the ligament cut by withdrawing the hooked knife while watching all the time as the edges spring apart, ensuring complete release.

Only a small (1.5X1.5cm.) hypafix adhesive tape is applied to the wound to hold the edges together (no stitches are necessary). A firm bandage is applied for 12 hours to stop any bruising and the patient is encouraged to remove this the next morning and start moving their fingers immediately. They can use their hands for daily activities and wash palms when the bandage is removed, keeping Hypafix dressing dry for 2 day after the surgery. There may well be a small blood stain on the hypafix but this is of no concern, if the dressing doesn't remain sticky, replace with another from chemist as it is holding the skin edges together. Return for review at 1 week.

The usual advice that I give is that the hand(s) will be quite tender for approximately 1 week, and to avoid heavy work and tight gripping for 4 weeks. If you keep hurting the hand(s) during this time they will remain tender for longer. Most patients can return to heavy work after 4 weeks. Most patients will lose their tingling and night pain the evening of surgery, but may continue to have some altered sensation (numbness) for a longer period depending on the severity of the condition before the release was undertaken.

Benefits of Single Portal

1. One cut of 1 cm.
2. no palm incision therefore can wash hand that night or next day
3. less pain (? psychological as no cut on emotionally "high" area of hand = palm)
4. no painful lump in palm to rest the golf stick on ( or any other handles!)
5. patients who have had both methods much preferred the Single Portal method

Key Benefits

• Less pain
• Local anaesthetic & day surgery
• Earlier use of hands, shorter recovery