The day before I spoke with Peter Kim, MD, an orthopedic hand surgery specialist in the Boston area, he performed a unilateral endoscopic carpal tunnel release on a friend and colleague, another orthopedic surgeon. The surgery took place on Monday. Dr. Kim`s coworker was seeing patients by that Wednesday and operating again on Thursday - a mere three days after undergoing the minimally invasive surgical procedure. Not long before he operated on that orthopedic surgeon, Dr. Kim performed a bilateral case on a plastic surgeon. [Surgery was performed on a Thursday, she spoke at the podium on Friday and then operated on Monday," he says of the case.
These recoveries are impressive by any standard, but as Dr. Kim points out, impressive is the norm when you`re performing endoscopic carpal tunnel release surgery the right way. [One true advantage of that procedure is an early return to work, particularly if you have bilateral carpal tunnel syndrome," he says, adding that the effectiveness and safety of the endoscopic procedure is noteworthy compared to the gold standard: open carpal tunnel release surgery.
Mischaracterizations and misnomers
Although the endoscopic approach is very popular among both surgeons and patients, it could be even more widespread if there weren`t still lingering misconceptions about its safety, according to Dr. Kim. He says one reason why the uptake of this procedure is a bit lower is that the most-quoted literature is woefully outdated. [The early literature on this that is most quoted is from the 1990s," he says. [There was no question there was a higher nerve injury rate with the endoscopic versus open release, but we understand the surgery way better than we did 20 years ago. Our ability to maneuver around the nerve and be safe is way, way better, and our ability to use the equipment is better as well."
Explanations, expectations and execution
Dr. Kim`s outcomes, rapid recovery times and relentless pursuit of maximum efficiency play a huge role in his ability to maintain a steady flow of patients - many of whom are surgeons themselves - without even marketing his practice.
But he credits a large part of his success to the effectiveness of the approach as well as the dedication of his team to every part of the perioperative process, from setting expectations preoperatively to hammering home the importance of postoperative rehabilitation.
• Selection. Dr. Kim says a crucial point takes place early in the process, when patients must decide how the operation will be done. [The first decision point is trying to pick open versus endoscopic, and I`ll walk patients through the mechanics of the surgery," he says. While Dr. Kim does perform open cases, the majority (around 60%) involve endoscopic carpal tunnel release -approximately 20 surgeries per week compared to around 10 open. The benefits of the endoscopic approach are especially apparent in bilateral cases. [If you have bilateral syndrome, normally I would steer you toward getting it done endoscopically because I do endoscopic bilateral carpal tunnel release with just skin glue - no bandages - so patients can get their hands wet in the shower starting day zero," says Dr. Kim. [This effectively cuts two recovery periods down to one recovery period."
• Education. Once his patients pick a path, it`s all about setting expectations. Dr. Kim provides all the specifics on the dressing, what to expect in terms of pain, the rehab protocol and, of course, when they can go back to work - if they stick to the plan. [What I expect from them is, if you do X as far as the therapy goes, then you can expect Y. If you don`t do X, then you`re going to have a prolonged recovery," he says. [Have those conversations on the front end. I`m forthright so I tell patients, `Surgery is the easy part - the rehab is the most important part. If you stick with the program, I promise you we can get you to where you want to be.`"
• Pain control. Another component of the speedy recoveries Dr. Kim provides is his approach to pain control. For the past five years, he`s maintained a narcotic-free policy for carpal tunnel release cases. [Once in a blue moon someone will call, and the most they`ll need is a Tylenol with codeine," says Dr. Kim. The key to his pain control strategy is to get out in front of the pain by frontloading patients with analgesics and anti-inflammatories. Patients receive monitored anesthesia care (MAC), everybody gets a Toradol IV and, postoperatively, most patients simply receive NSAIDs. Ultimately, the strategy sends patients to rehab right after surgery with little discomfort. [If you preemptively treat patients with anti-inflammatories intraoperatively and immediately post-op, I find their need for narcotics diminishes dramatically," he says.
• Efficiency. Dr. Kim`s endoscopic carpal tunnel cases take, on average, anywhere from six to 11 minutes, skin-to-skin, getting the equipment turned over, up and running and plugged in. An elite, high-volume endoscopic carpal tunnel program comes down to an OR team that has internalized rapid turnover and understands the importance of having everything ready to go. [There`s nothing different about carpal tunnel efficiency from hernia efficiency or cataract efficiency," says Dr. Kim. [A lot of people say, `I don`t like to do an endoscope procedure because it takes too long,` but if you have staff that knows how to do it, the procedure takes no longer than an open release."
`Highest badge of honor`
Elite surgeons like Dr. Kim rely on the results of endoscopic carpal tunnel release procedures to speak for them. As a result, he`s become the type of surgeon who surgeons go to when they need their most vital tools - their hands - repaired. That trust is something he values unequivocally.