Name: Endoscopic Carpal Tunnel Release Using the NanoScopic™ Release System
Uploaded: 2022-10-10T00:00:00Z
Channel: Arthrex
Description: Mollie Manley, MD (Akron, OH), introduces the NanoScopic™ release system.

<p>Mollie Manley, MD (Akron, OH), introduces the NanoScopic™ release system.</p>

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VID1-003504-en-US | A | Endoscopic Carpal Tunnel Release Using the NanoScopic™ Release System

Mollie O. Manley

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A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

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Endoscopic Carpal Tunnel Release Using the NanoScopic™ Release System

This is a fully disposable endoscopic carpal tunnel release kit. In this one set, there are three items. There's a Centerline release handpiece, there's the dilator, as well as the elevator, as well as the 180 millimeter nano needle scope. This then plugs into the NanoScope console, and this whole system produces no heat, which means no fogging without having a tower. It decreases your footprint, which means you can be in a much smaller room and even a procedure room. This also decreases the setup time, since there's not multiple trays to open with not having multiple trays to depend on for the surgery. This can be unlimited, so this will not be the rate limiting factor in how many surgeries you can do in a day. So put the device together. You have the Centerline handpiece and the nano needle. So you place the nano needle into the end of the Centerline handpiece and you'll feel it click in. The striations on here would be facing up or north, but you can move this 360 degrees around to have different looks of the camera. And so this is the view with the blade to release the carpal tunnel, as well as the handpiece attached to the nano needle for setup. You have the person prone with their arm extended. If you have a patient with a very large hand, then you can take two blue towels and have them rolled under the wrist, because you want to make sure that you can get their wrist extended. For standard patients, one rolled blue towel is satisfactory. It is important to have the wrist extended so you can get into the carpal tunnel. I first start out by drawing out my landmarks. What you want to find is the piece of form. So I'll make a small dot there. The hook of a hamate. Because you do want to hug that in here. And you can look for their creases. So to make this as cosmetically pleasing as possible, I try to use and find their natural creases. Sometimes the natural creases here, sometimes it's closer to the palm. I always stay in the crease to again make it cosmetically pleasing, but you can do what you would like for this technique. You do want to stay on the hook of the hamate. You can make your incision slightly more radial, but you do need to make sure you hug that hook to watch out for any aberrant branches. So I would draw up my incision. I then take a scalpel and you can make this smaller or larger depending on when you're first starting out. I would make it a little bit bigger and then use dissecting scissors to dissect down to the antebrachial fascia. After making the incision, we then dissect through the soft tissue. I take a regional or a small retractor of some point and place one radially. Then I place one ulnar. The ulnar one is very important because the ulnar neurovascular bundle, it's much more superficial than you think. And you do want to make sure you protect this, especially if you do decide to hug the handmade more with your incision. So then I go down to the brachial fascia. After finding the brachial fascia, which you can slightly see by this white tissue deep in the wound there. I make a u-type flap. And so what that means is that with the striations like this, you could just take one slit and insert the Centerline like that. But I choose to make a flap like this. So that way you can peel this up. And then this protects all the soft tissue from kind of getting in your way when you're doing the release. So then I take my knife and I make my u-type flap. Then I make the cuts on the side. After I have that flap, all of this fat here, that's pooching out. That's kind of in my way. I can kind of pull that back so that I have a nice pathway to the canal. So I take a two pronged skin hook of some sort. And then now I have a great view of the nerve as well as the canal, so we can take our dilator and help dilate up that canal. And you can really kind of push on the hamade. I always like to hold the retractor on the ulnar side, so that I make sure my ulnar vascular bundle is protected, but then I can use my index finger to kind of feel how far I'm going. And then you use the elevator. Once you go up, you kind of put it in and really rock your hand down, and you can actually feel the striations. And what you're doing is getting the synovium off the undersurface. So at this point, I've prepared the canal and I'm ready for the center line. So the center line has this nice synovial elevator as well as this tip. So I want to take that tip, go right under it. And this is a very important step. If you don't kind of go under it and start it more perpendicular to it and then bring your hand down, you can trap tissue and that can be hard to see. So this is kind of the big part of the learning curve. So you really want to take it like almost perpendicular and drop your hand almost parallel to the hand and elevate and go in. So when you first start doing this, a lot of people want to hold this almost like a pencil. And that's really not helpful because if you're holding it like a pencil, then you can't get your hand down because your hand is in the way. After you place this under that fashion, you can kind of feel that. And again, we made this beautiful flap that helps guide us in. You can feel the striations with the end piece. Now that I'm in and I know where I'm at because my index finger here. So I can feel that I'm kind of at the end of the carpal tunnel. You can deploy your knife. And again, with this system, if you felt like it, you can kind of look different ways around if you want to without actually changing where the handpiece is. But we want to look north. So that's what we're going to do. So you can take your handpiece. And I like to pull back and you can cut a little bit. And then I can see okay did I get far enough. And if not you can get a little bit farther and you can easily see the end of it there. And then I continue to continue to release. And you can put some downward pressure on your hand just to make sure it goes all the way through. I always do multiple passes to make sure we got the entire view. And so when I go in another time I'm looking for this edge. So on the screen you can see that edge right there. And I think there's a piece there left. So I would go in and grab that. And you can really kind of lever your hand up to get that last little bit. And then once you push all the way through, I can actually feel the camera almost midway up the palm. And obviously you want to be careful because of the arch, but I definitely see that there's no fascia, I don't feel any fascia. And so you want to make sure it's all released. The other thing I like to do is after I see that that's released, I actually then push the camera kind of in further and rotate so that one of the flaps then are in my field of view, and I can kind of see that that's entirely free on both sides. Once that release is done, what I do from there is I take all my retractors out. I then use my assistant to hold the skin on the proximal portion, and from here I can then release the antebrachial fascia, and so you can easily see this in view. I do not push my scissors. I want to see the entire way, and I can see the fascia and release it at the end of that release. I'm confident that I've released not only the carpal tunnel, but this brachial fascia as well. So from there I rinse this and I close this. I typically use A40 prolene where I'll make a knot on one end. Then I run it and make the second knot. And basically you just snip the one knot and pull it. I have people actually start using their hand the day of surgery. They can lift anything up to a gallon of milk, encourage them to be active. And most people actually, if they have a desk job, go back to work within a day or two.

Endoscopic Carpal Tunnel Release Using the NanoScopic™ Release System

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