C A R P A L T U N N E L R E L E A S E V I A L I M I T E D P A L M A R I N C I S I O N U S I N G R H I N O P L A S T Y I N S T R U M E N T S E r d e m T e z e l , M . D . / B a h a d ır İ m e r , M . D . A y h a n N u m a n o ğ lu , M . D . D e p a r t m e n t o f P la s tic a n d R e c o n s tr u c tiv e S u rg e ry , S c h o o l o f M e d ic in e , M a r m a r a U n iv e rs ity , Is ta n b u l, T u rk e y . A B S T R A C T
O b je c tiv e : C arpal tunnel release via a limited palm ar incision h as been shown to combine the sim plicity and safe ty of the traditional open approach with a reduction of tissue trauma and im proved p o stop erative re co ve ry of the endoscopic technique. A modification of this technique is presented.
M e th o d s: Th e operation begins with a 1.5-2 cm palm ar incision, dissection is performed using a Killian periostal elevator, exposure is provided by a Killian speculum and the transverse carpal ligament is se vere d by angled cartilage sc isso rs. R e s u lt s : Twenty-eight carpal tunnel c a se s were operated using this app roach without any complication.
C o n c lu s io n : T h is technique not only pleased the surgeon by its simplicity and safety but also the patient who m ade a rapid and full recovery.
K e y W o r d s : C arpal tunnel, Decom pression, Limited incision.
IN T R O D U C T IO N
Carpal tunnel decom pression operations have gained new p e rsp e ctive s and techniques in
recent years. S in ce the first release by Sir Ja m e s R. Learmonth in 1930 and popularization by Phalen et al. in 1950, carpal tunnel release operations have been one of the most frequent operations in hand surgery. It gives excellent results both for the patients and the surgeon (1-3). The draw backs of the long incision, such as a
painful and un accep tab le sc a r, tendon
bowstringing and adherence of flexor tendons, have led to (1-3) the u se of end oscop ic procedures in carpal tunnel release. B e ca u se of this, refinem ents in the technique of open surgery have focused on the incision length. Recently,
limited incision tech n iq ue s have been
popularized by se v e ra l authors (1 ,4 -7 ). A modification of this technique is presented.
M E T H O D
Surgery is performed under tourniquet, loup magnification X4, and either regional anesthesia or axillary block is used. A 1.5-2 cm incision is located on a line drawn from the radial side of the ring finger to a point ulnar to the palm aris longus tendon, about 0.5 cm proximal to the distal border of the carpal tunnel as described by Campiglio et. al (7). The wrist is brought to full dorsiflexion. Th e distal edge of the transverse carp al ligam ent is reach ed by longitudinal spreading with s c is s o rs . T h e ligam ent is dissected free from the surrounding structures by blunt dissection using a Killian periostal elevator.
(Accepted 11 August, 2002)
Marmara Medical Journal 2002;15(4):253-255
Correspondence to: Erdem Tezel, M.D, - Department of Plastic and Reconstructive Surgery Marmara University Hospital, Altunizade 81190 Istanbul, Turkey,
e.mail address: erdemtezel@hotmail.com
Erdem Tezel, et al
A Killian nasal speculum with a blade length of 40-50 mm is introduced while its blades are placed on the volar and dorsal asp ects of the transverse carpal ligament (Fig. 1a). Speculum positioning is critical for safety and visibility. The blades of the speculum must be kept in the longitudinal a xis of the fourth m etacarpal throughout the procedure a s em phasized by Abouzahr et. al (4). Th e lower blade has to be kept in direct contact with the transverse carpal ligament to prevent median nerve injury. Opening the speculum c re a te s a rectan g u lar p rism shaped space and the ligament lies between the blades. Through the opening between the blades of the speculum , the ligament is divided from distal to proximal with angled cartilage sc isso rs (Fig. 1 b). This step is performed with great care to avoid damage to the palm ar cutaneous branch of the median nerve. The incision is closed with 2 or 3 stitches after complete release of carpal tunnel has been achieved under direct vision (F ig .2). A soft dressing is applied and the tourniquet is deflated. Patients are encouraged to move their digits in the early postoperative period and they return to daily work within 4-5 days.
RESULTS
This limited incision technique for carpal tunnel release w as used in 28 c a se s , in Ju ly 1998. The
F i g . l ( b ) :T h e tran sve rse carpal ligam ent is severed from distal to proxim al using angled ca rtilag e scissors placed through the o pening b etw een the blades of the speculum .
Fig. 2 : Im m ediate p o stoperative vie w of the incision.
average operation time w a s 25 m inutes. The patients were followed for an averag e of 2 ye a rs and all had full recovery with no com plications.
Carpal tunnel release via limited palmar incision
te n d e rn e ss, bow stringing and ad hesion of tendons. Th e endoscopic approach overcom es these d raw b acks but it is difficult to operate on the c a s e s m entioned p re vio u sly in which tenolysis, neurolysis or the removal of a sp ace occupying lesion is required. Endoscopic surgery also has som e d raw b acks such a s neurovascular injury, the need for sp e cia l and e xp e n sive equipment, additional surgical training and a prolonged operative setup time. Th e advantages, sim plicity and sa fe ty of the limited incision technique h ave been reported in detail by Abouzahr et al. (4). Th e advantages of the
endoscopic procedures can be achieved by
open su rg ery using short in cisio n s, without having the com plications of endoscopic surgery (5). Th e position of the incision a s described has certain advantages over those in distal wrist c re a s e (4 ). T h e su p e rficia l p alm ar arch is detected im m ediately and the d issectio n is diverted aw ay from this va scu lar structure using a blunt instrument, the Killian periostal elevator, under direct vision. T h is prevents injury to the superficial palm ar arch, palm ar cutaneous and thenar motor b ran ch es of the median nerve and the ulnar nerve and artery.
Limited incisions give limited exposure. Various retractors have been used by various authors to obtain better exposure (6 ,7 ). Abouzahr et al. used a speculum a s a retractor, but they place the blades through a wrist incision and position them palm ar to the carpal ligament, which could lead to superficial palm ar arch injury, a s w as also em phasized by the authors (4). Th is draw back has been solved by changing the localization of the incision from the wrist to the palm ar position a s reported by Cam piglio(7) and S e rra(6 ) et al.
W e have combined Cam piglio’s approach(7)
with A bouzahr’s instrument, the nasal speculum , employing the ad vantag es of both techniques.
The angled cartilage sc isso rs are used to severe the ligament, thus it does not block the surgeon's vision, making the procedure easier and safer. All the instruments used are available in every plastic surgery department, this obviates the need for a special instrument such a s a carpal tunnel tome (5), and lighted retractors or a light source are not required. Carpal tunnel release using a limited palmar incision is a safe and simple procedure and the approach presented here is a reliable modification of this technique.
REFERENCES
1. Hayes C W. Carpal tu n n el syndrom e; In: Aston J, Beasley K W, Thorne C H hi, eds. Grabb & S m ith 's Plastic Surgery. P h iled elp h ia: Lippincott - Raven 199 7 : 91 7-927.
2. Van B eek A L. M a n a g e m e n t o f nerve c o m p ressio n sy n d ro m e s a n d p a in fu l neurom as. In: Mc Carthy JG, May J W, Littler J W, eds. M cC arth y Plastic Surgery. Philedelphia: W .B.Saunders Com pany, 1990: 4 8 2 3 -4 8 3 1 .
3. Eversm ann W W. E ntrapm ent & compression neuropathies: In: Green J L, ed. O perative H an d Surgery. H ew York: C h u rc h ill Livingstone, 1 993: 1 3 4 2 -1 3 4 4 .
4. A bo u zah r M b , Patsis M C, Chiu T W. Carpal tu n n el release using lim ite d direct vision. Plast Reconstr Surg 1 9 9 5 ; 9 5 :5 3 4 -5 3 9 . 5. A ndrew Lee W P, S trickland J W. Safe Carpal
tu n nel release via a lim ited p a lm a r incision. Plast Reconstr Surg 1 9 9 8 ; 1 0 1 :4 1 8 -4 2 1 . 6. Serra J M R, B enito J R, M onner J. Carpal
tu n n e l re le a s e with s h o rt in cision. Plast Reconstr Surg 1 9 9 7 ; 9 9 :1 2 9 -1 3 1 .
7. C am piglio G L, Pajardi G. Carpal tunnel release with short incision. Plast Reconstr Surg 1 9 9 8 ,1 0 1 :1 1 5 1 -1 5 5 3 .
Case Report
A N U N U S U A L C A U S E O F U R I N A R Y R E T E N T I O N : A N I N E T E E N - Y E A R - O L D S U R G I C A L G A U Z E I N T H E B L A D D E R S e lç u k Y ü c e l, M . D . , / K a m il Ç a m , M . D . , / A t ı f A k d a ş , M . D . , L e v e n t T ü r k e r i , M . D . , D e p a r tm e n t o f U ro lo g y , S c h o o l o f M e d ic in e , M a r m a r a U n iv e rs ity , Is ta n b u l, T u rk e y . A B STR A C TIn travesical foreign body is a significant consideration in the asse ssm e n t of lower urinary tract problems. W e present a ca se of foreign body in the urinary bladder with the longest interval in the literature for clinical presentation, about 19 y e a rs following a tra n sv e sica l prostatectomy. It provides an unusual indolent ca u se of urinary retention and stre sse s the consideration of intravesical foreign bodies a s a reason for lower urinary tract sym ptoms.
K e y W o r d s : Bladder, Foreign body, C a se report
IN T R O D U C T IO N
Intravesical foreign body is an important concept in the a sse s sm e n t of low er urinary tract symptoms and a challenge to the urologist in both diagnosis and m anagem ent. Two main ca u se s of intravesical foreign bodies are se lf
bladder w as reported a s 9 y e a rs (1). In our c a se , the interval for clinical presentation w a s about 19 ye ars following a tran sve sical prostatectom y. The com m onest sym ptom s are chronic irritative complaints and hem aturia (2, 3). H ow ever, the current c a se presented a much more indolent course with urinary retention at the nineteenth year of tran svesical prostatectomy.
The current c a se provides an unusual ca u se of urinary retention and sug g ests the consideration of intravesical foreign bodies a s a reason for lower urinary tract sym ptom s.
CASE R E P O R T
An 83-year-old gentlem an presented with a history of urinary retention a sso c ia te d with multiple urethral catheterizations for a year. His past m edical history re ve ale d tra n sv e sic a l prostatectomy at the age of 64. His physical exam ination revealed a m oderately enlarged prostate with a hard nodule. P S A level w a s 4 .9 7 ng/ml. Ultrasonography dem onstrated a 6x4x4
An unusual cause of urinary retention
ultrasonographic exam ination revealed a 5-cm hypoechoic m a ss in the liver and ultrasound guided biopsy of this m a ss exhibited a malignant epithelial tumor. P S A staining of the pathological sp ecim ens w a s negative. Tran srectal ultrasound (T R U S ) guided prostate biopsy disclosed benign prostatic h y p e rp la sia . R e p e a t T R U S guided biopsy of the pelvic m a ss showed foreign body reaction with m ultinuclear giant cells. Further sy ste m ic investigation for the origin of the m alignancy w as unrevealing. Consequently, he w as diagnosed a s having m etastatic anaplastic carcinom a of unknown origin. A cystoscopy w as performed due to lower urinary tract sym ptoms. Endoscopy show ed normal findings except a 4x2x2cm surgical g auze which w a s easily freed and taken out by an alligator forceps protruding through the right bladder wall. However, residual threads of the g auze w ere still emerging through the bladder wall. Th e app earance of the surgical gauze w a s surprisingly very fresh. Transurethral deep resection of the right bladder wall and deep biopsies around this location w ere performed. Th e patient recovered from surgery well and pathological evaluation revealed chronic cystitis with no findings of m alignancy. After removal of the urinary ca th e te r, he voided effectively. Palliative radiotherapy to the right acetabulum w as applied.
D IS C U S S IO N
Intravesical foreign body is an important concern in the evaluation of lower urinary tract problems. Two main c a u se s of intravesical foreign bodies are self-introduction and iatrogenic. Reports of tran svesical migration of surgical m aterials and
transurethral insertion of foreign bodies for masturbative purposes and curiosity or due to mental disorders are not uncommon (1). In the
literature, the longest time for clinical
presentation of a foreign body in the urinary bladder w as reported a s 9 ye ars (1). In our case, the interval for clinical presentation w as about 19 years, following a transvesical prostatectomy. Also, it w as interesting to se e the surgical gauze had no degeneration or calcification in the acidic environment of the urinary bladder. Although the com m onest sym ptom s w ere chronic irritative
com plaints and hem aturia, acute urinary
retention w as reported similarly due to surgical g auze left during the inguinal hernia repair performed two w eeks before (2). Our ca se w as unique a s having a much more indolent course with urinary retention at the nineteenth year of transvesical prostatectomy.
The present c a se postulates an exceptional ca u se of infravesical obstruction and em phasises the importance of intravesical foreign bodies related to the previous surgery a s a reason for lower urinary tract sym ptom s even after two decad es of the operation.
REFERENCES
1. Eckford SD, Persad RA, Brewster SE, Gingell JC. In tra v e s ic a l Foreign b od ies: fiv e -y e a r review. Br J Urol 1 9 9 2 ; 6 9 : 4 1 -4 5 .
2. L epp an iem i At\. Intravesical foreign body afte r inguinal herniorrhaphy. Scand J Urol Nephrol
1 9 9 1 ; 2 5 : 8 7 -8 8 .
3. Schw artz BE, S to ller ML. The vesical calculus. Urol Clin North Am 2 0 0 0 ; 2 7 : 3 3 3 -3 4 6 .
