Endoscopic Carpal Tunnel Release: One-Portal Technique.

Abstract

With the 1-portal technique for endoscopic carpal tunnel release, the incision is less tender and patients have less postoperative need for analgesics, and return to activities of daily living and work seems to be earlier. The literature also confirms an earlier return to work. Surgical time can be shorter as less time is spent in making and closing the incision. The 1-portal technique, as described by Agee et al., is performed with the patient under general anesthesia, supplemented with only a small amount of local anesthesia in the beginning to blunt the pain response during the incision. Then, once the patient is fully anesthetized, the endoscope is inserted, and the carpal ligament is visualized and incised. The incision is closed and the dressing is applied. Another surgical alternative is open carpal tunnel release. Nonsurgical alternatives include corticosteroid injection, splinting, nonsteroidal anti-inflammatory drugs, and ergonomics. The incision is smaller and less painful than the incision utilized during open carpal tunnel release. There is less need for analgesia. Unlike the incision utilized during open carpal tunnel release, the incision in this procedure is not made in a weight-bearing surface of the hand and generally is not firm and tender. Studies also show an earlier return to work with this technique. The endoscopic technique is only for a primary release. Surgical intervention for recurrent carpal tunnel syndrome needs to be performed with the open technique. Because of the need for deep sedation, only patients who are healthy enough for general sedation are candidates for the 1-portal technique. The risk of nerve injury with this technique is higher than with open carpal tunnel release. Generally, the patient will have very rapid resolution of the preoperative paresthesia. The incision typically heals very well; however, when closing the 1.5-cm incision with skin glue and Steri-Strips (3M), there may be cases of delayed wound-healing if the patient is overly physically active in the first 2 weeks after the procedure. Make sure that the endoscope is properly set up and that the patient is supine and the arm is abducted 90° at the shoulder with the hand and forearm fully supinated. Seating of the surgeon and assistant(s) and placement of the monitor are important.Make sure that the patient is fully anesthetized, particularly when the endoscope is being used. If the patient moves during the endoscopic incision of the ligament, other structures (i.e., vessels, nerves, and tendons) could be injured.Difficulty with the insertion of the scope can result in injuries. The carpal ligament must be visualized with the scope prior to any attempts at cutting the ligament. Convert to an open procedure if there are any difficulties with endoscope insertion or visualizing the carpal ligament.