Surgical Table. The patient should be supine for the procedure. Any flat table is adequate, with the rolling stretcher often used for convenience to avoid moving the patient.

Once the patient is in the operating room, anesthesia should be administered.

Place a tourniquet on the proximal forearm of the operative extremity. The average tourniquet size is generally 18 inches, but will vary depending on body habitus.

Make sure to hook the tourniquet lines to the tourniquet prior to prepping and draping.

Now that the patient is under anesthesia, as a team, turn the bed 90 degrees so that the operative extremity is facing away from the anesthesiologist.

Prep and drape the operative extremity.

Apply local anesthesia (marcaine and/or lidocaine) to the skin and subcutaneous tissues overlying the carpal tunnel. Some local anesthesia can be placed within the carpal tunnel, but be careful not to inject into the nerve itself.

Primary surgeon position. The primary surgeon should sit on the axillary side for left operative extremities and the opposite side for right operative extremities. ²

Create a “bump” using a surgical towel to place under the wrist and hand.

Placement of incision. There are several techniques for incision placement.

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  Option 1 (▶Fig. 3.1). Flex the ring finger down to the palm. The point at which the ring finger makes contact should be marked with a pen. A line is then extended proximally, ending just distal to the distal wrist crease.

  
  
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  Option 2 (▶Fig. 3.2). Draw Kaplan’s cardinal line over the palm. Draw a second line starting at the radial border of the ring finger moving proximally. The intersection of the two lines is the distal extent of the incision. The incision should end just distal to the distal wrist crease.

Exsanguinate the arm and inflate the tourniquet.

With the bump placed under the wrist and hand and the fingers and thumb held down by your assistant, incise the skin down to the palmar fascia with a 15-blade scalpel.

Use small skin rake retractors on the radial and ulnar aspects of the skin incision to expose the palmar fascia (▶Fig. 3.3).

With the retractors in place, incise the palmer fascia for the full length of the incision.

Once the palmer fascia is completely incised, place the skin retractors deep to the palmer fascia to expose the transverse carpal ligament (▶Fig. 3.4).

The transverse carpal ligament fibers are oriented transversely and are distinct from the longitudinal palmar fascia fibers.

Occasionally, a palmaris brevis muscle is encountered over the volar surface of the transverse carpal ligament. In this case, gently sweep the muscle fibers radially with the 15-blade scalpel to expose the ligament.