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OPERATION NOTE:
Carpal Tunnel Decompression Left Right wrist(*=delete as appropriate)Date of operation:
Patient name:
Hospital number:
Date of Birth:
Consultant
Surgeon: Supervision: Independent/Unscrubbed/ScrubbedGrade: FY2/CT1/CT2 StR/SpR Fellow Consultant
Assistant: Grade: FY2/CT1/CT2 StR/SpR Fellow Consultant
Anaesthetist: _Grade: FY2/CT1/CT2 StR/SpR Fellow Consultant
Indication: Carpal Tunnel Syndrome. Confirmed by Nerve Conduction Study Clinical Assessment . Severity: Severe Moderate Mild
Background: Patient consented, understanding the risks of recurrence, bleeding, infection, nerve damage, further surgery, complex regional pain syndrome and anaesthetic.
Setup: WHO safety checklist performed .Prepped with Betadine/Chlorhexidine* and draped
Anaesthetic: Local: Block: General Anaesthetic
Antibiotics: Not routinely required At induction __mg_
Equipment: Tourniquet: Tourniquet pressure: _ mmHg Tourniquet time:_ _mins
Inflated after e Exsanguination Elevation
Position: Supine with arm board
Approach: Incision from the intersection of Kaplan’s cardinal line and the radial border of the fourth ray, ending at the wrist crease
Findings: Median nerve compression: Severe Moderate Mild
Procedure: Dissection down to transverse carpal ligament under direct t vision.
Carpal tunnel release completed under direct vision. Distally confirmed with presence of fat and proximally complete release seen proximally.
Washout.
Haemostasis.
Closure: Nylon 3-0 Monocryl 3-0 for skin. Jelonet. Opsite dressing, crepe & Bandage.
Post-op: Routine obs. Elevate. Home when safe.
Reduce bulky dressing in 48hours. Keep clean and dry for two weeks.
Follow-up with GP in 10-14 days for wound review and removal of sutures.
Follow-up in clinic in six weeks
Signed: ______________________
