Carpal tunnel syndrome – open carpal roof division

Anatomical orientation through palpation and marking of anatomical landmarks:

• Planning mini-incision with incision line in the extension line of the middle of the 3rd/4th finger ray to the ulnar insertion of the palmaris longus tendon at the aponeurosis (guiding structure)
• Incision in the median palm approximately 2-3 cm long (mini-incision) starting about 1.0 to 1.5 cm distal to the wrist crease
• Sharp dissection of the subcutis under bipolar coagulation of individual veins
• Exposure of the palmar aponeurosis

Tips for Orientation

• Orientation of the carpal tunnel based on palpable pisiform bone and scaphoid tubercle
• Flexor retinaculum begins at the level of the wrist crease
• Orientation of the course of the median nerve between the flexor carpi radialis tendons and the palmaris longus tendon

Transection of palmar aponeurosis with exposure of the flexor retinaculum

• Sharp transection of the palmar aponeurosis in a longitudinal direction
• Exposure of the distal portion of the flexor retinaculum with possible superficial palmar arch (arterial superficial palmar arch)

Transection of the flexor retinaculum with the palmar carpal ligament

• sharp transection of the distal portion of the flexor retinaculum under direct vision
• exposure of the median nerve

Now repositioning of the surgeon to the head of the hand table for better visualization of the proximal carpal canal

• blunt dissection of the median nerve from the carpal roof with careful spreading using scissors above the nerve
• completion of the proximal transection of the flexor retinaculum with scissors
• transection of the palmar carpal ligament with scissors at the ulnar edge of the palmaris longus tendon (guiding structure)

Tips

• tracing the carpal roof with scissors to verify complete transection
• distally, if necessary, exposure of the superficial palmar arch (arterial superficial palmar arch)