Endoscopic Carpal Tunnel Release

Dr. Woloszyn and the Hand Treatment Center are experts in the minimally invasive endoscopic treatment for carpal tunnel syndrome. (Brown Procedure)  Performed as an ambulatory surgery procedure in just a few minutes. Anesthesia is similar to sedation that would be required for a colonoscopy or a tooth extraction. Postoperatively most patients don’t even require any pain medication other than Tylenol or Motrin. Some patients report that the night of surgery is the best night’s sleep they have had in a long time especially if they have been waking at night with radiating pain and numbness as a result of their pinched median nerve causing carpal tunnel syndrome.


Surgeons view of a left Endoscopic Carpal Tunnel Release procedure. Incisions are marked out indicating the proximal and distal portals. The dotted line is the Palmaris Longus (PL) Tendon, if present.






The proximal portal incision is marked out as a one cm. transverse incision just ulnar to the PL tendon within one to two cm’s of the distal wrist crease. A distal portal incision is marked at 3 and 4 cm’s distal to the distal wrist crease in line with the 3rd web space.




The extremity is exsanguinated with an Esmarch bandage and a tourniquet is inflated so the procedure can be done in a bloodless field.






A transverse incision is made at the proximal portal extending just through the dermis.






Soft tissues are spread longitudinally to preserve small superficial draining veins and sensory nerve fibers.






Soft tissues bluntly dissected down to the level of the volar forearm fascia.






The volar forearm fascia is entered in a transverse direction.







An elevator is used to clean the synovium from the undersurface of the volar forearm fascia and transverse carpal ligament.






The distal edge of the ligament is determined by feeling the elevator enter a more superficial plane and the distal end of the ligament. A mental note of  the location of the distal end of the ligament is made in reference to the two marking made earlier.





The obturator cannula assembly is inserted into the carpal tunnel through the proximal portal parallel to the ligament and advanced to the distal edge of the ligament and the predetermined marking.






Similar to the synovial elevator the tip of the obturator is palpated with the non dominant hand as the obturator enters a more superficial plane at the end of the transverse carpal ligament.






The skin is tented up with the tip of the obturator at the end of the ligament and a small vertical incision is made creating the distal portal.






The obturator is removed leaving the cannula in place with the open side up against the undersurface of the transverse carpal ligament.






A 4mm 30′ endoscope is inserted through the distal portal and a Q-tip inserted proximally to clean the end of the scope. The undersurface of the ligament is inspected to make certain that transverse orientation of the fibers is noted and that nothing obscures our vision of the entire length of the transverse carpal ligament.




The hook blade is inserted into the proximal portal and advanced to the distal edge of the ligament and the ligament is then divided from a distal to proximal direction under direct vision of the endoscope. The ligament is visualized as it is divided and widely separated any additional restricting fibers are released as well.




Lateral view showing how the hook blade is stabilized against the obturator as it is used to divide the ligament.






The proximal portal is inspected to make certain the full length was divided.






The soft tissues are elevated off of  the volar forearm fascia proximally, isolating it from the superficial and deeper structures and divided proximally under direct vision to prevent a secondary site of compression.





Marcaine 0.5% is infiltrated froximally for post-operative analgesia and the wounds closed with 5-0 nylon or dermabond and steri-strips.






Pressure is maintained on the wounds and the tourniquet is deflated. Xeroform gauze and a dry sterile dressing is applied, secured with a cling or Kerlix and a volar forearm splint applied keeping the wrist in neutral position and secured with an ace bandage.