DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right carpal tunnel syndrome.
POSTOPERATIVE DIAGNOSIS: Right carpal tunnel syndrome.
PROCEDURE PERFORMED: Right carpal tunnel release.
SURGEON: John Doe, MD
ANESTHESIA: Local with sedation.
ESTIMATED BLOOD LOSS: Minimal.
DESCRIPTION OF OPERATION: The patient was placed in supine position on the OR table. After adequate IV sedation, the right palm was anesthetized with 0.5% Marcaine. A tourniquet was placed over Webril cast padding on her right forearm, and the hand and wrist were prepped and draped in the standard fashion. The hand was exsanguinated, and the tourniquet inflated to 280 mmHg.
A 1.5 cm incision was made in the right palm in line with the ring finger ray just distal to the distal flexion crease of the wrist. It was taken down through the subcutaneous tissue and through the palmar aponeurosis in line with the skin incision. The transverse carpal ligament was identified deep and was also divided in line with the incision. Distally, we were able to see the fat pad and proximally the incision taken proximal to the flexion crease of the wrist. No significant abnormality was in the carpal tunnel itself, and the nerve appeared to be in good condition.
The wound was then irrigated out well, the tourniquet released, hemostasis obtained, and the wound closed with interrupted 5-0 nylon. Adaptic, dry sterile fluff dressing was applied. The patient tolerated the procedure well and was transferred to the recovery room in satisfactory condition.
Carpal Tunnel Release Sample Report #2
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right carpal tunnel syndrome.
POSTOPERATIVE DIAGNOSIS: Right carpal tunnel syndrome.
PROCEDURE PERFORMED: Right carpal tunnel release.
SURGEON: John Doe, MD
ANESTHESIA: MAC plus local.
ESTIMATED BLOOD LOSS: 10 mL.
DRAINS: None.
SPECIMENS: None.
COMPLICATIONS: None.
CONDITION: The patient stable to recovery.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed supine on the operating room table. MAC anesthesia was initiated, and local anesthetic was given in the region of skin overlying the palmar aspect of the transverse carpal ligament and carpal tunnel. The right hand was prepped and draped in sterile fashion.
An incision was made in line with the radial border of the fourth digit on the palmar skin overlying the transverse carpal ligament. Dissection was carried down through the skin and subcutaneous tissues into the palmar fascia. A small amount of palmaris brevis was encountered. The transverse carpal ligament was encountered and then divided in its entirety using a combination of 15 blade scalpel and tenotomy scissors.
After this had been done, the wound was irrigated with normal saline. The tourniquet was released. Hemostasis was obtained. The wound was then closed with 4-0 nylon in an interrupted horizontal mattress fashion. A standard sterile dressing was placed, and the patient was transported to recovery in stable condition.
Carpal Tunnel Release Sample Report #3
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left carpal tunnel syndrome.
POSTOPERATIVE DIAGNOSIS: Left carpal tunnel syndrome.
PROCEDURE PERFORMED: Left carpal tunnel release.
SURGEON: John Doe, MD
ANESTHESIA: MAC sedation with local anesthetic.
CONSENT: The risks and benefits of the procedure were discussed at length with the patient, who agreed to proceed.
DESCRIPTION OF PROCEDURE: The patient was brought into the operating room, where she was lightly sedated. The left hand was prepped and draped in the usual sterile fashion with a limb stocking dressing. The palmar crease was marked for a linear incision, and the site was then infiltrated with 1% lidocaine with Neo-Synephrine.
The skin was then incised with a #15 blade. Under the fat pad, the flexor retinaculum was identified. The ligament was then identified medially and was shaved with the #15 blade. The median nerve was identified. The ligament was cut with tenotomy scissors. This was extended distally until the last band was freed and passage of a Penfield 4 dissector was met without resistance. This was then extended proximally as well in the same fashion. After confirming adequate proximal release of the Penfield 4 dissector as well, hemostasis was maintained with bipolar cautery.
The skin was then closed with a 4-0 nylon suture in a simple running fashion. The wound was dressed with Telfa and flexible bandage dressing. A gauze wad was placed in the palm and the arm wrapped in Ace bandage. The patient was given instructions. She verbalized understanding of all these instructions. No complications were encountered.
Carpal Tunnel Release Sample Report #4
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left carpal tunnel syndrome.
POSTOPERATIVE DIAGNOSIS: Left carpal tunnel syndrome.
PROCEDURE PERFORMED: Left carpal tunnel release.
SURGEON: John Doe, MD
ANESTHESIA: MAC and local.
COMPLICATIONS: None.
ESTIMATED BLOOD LOSS: Minimal.
DESCRIPTION OF PROCEDURE: The patient was brought to the OR and laid supine on the OR stable. After MAC anesthesia was induced and 8 mL of Marcaine was injected into the carpal tunnel region as a local anesthetic, the tourniquet was placed on her left forearm, and the left upper extremity was prepped and draped in the usual sterile fashion. Next, Esmarch bandage was used to exsanguinate the left hand and wrist, and the tourniquet was inflated to 275 mmHg.
Next, approximately 1.5 cm incision was made just distal to the wrist flexion crease in line with the radial border of the fourth digit. Dissection was carried down to the palmar fat down to the level of the fascia. The fascia was incised longitudinally in line with the skin incision. The transverse carpal ligament was then visualized and incised using 15 blade releasing the contents of the carpal tunnel. The transverse carpal ligament was then incised distally until fat was visualized. Proximally, dissecting scissors were used to release the transverse ligament proximally up into the antebrachial fascia. Good release of the carpal tunnel was obtained.
Next, the wound was sterilely irrigated with normal saline, and the tourniquet was deflated. The skin was closed with 5-0 nylon suture in a horizontal mattress fashion. Sterile dressings were applied. The patient was then transferred back onto a stretcher and taken to the PACU for recovery.
