Download - Somsak nerve transfer
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Instructions for Somsak Nerve transfer
N to long head of triceps to anterior division of
the axillary nerveCompiled by Dr S Selvaganesh
Hand Surgery Fellow KTPH
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Cadaveric dissection
First Nerve transfer workshop,KTPH, Singapore
Practical 4
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Incision
• Specimen in prone position
• Make a 10cm longitudinal curvilinear incision on the posterior arm.
• From the level of the quadrilateral space following the posterior order of deltoid and continuing distally along the midpoint of triceps.
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Superficial dissection
• Lift up the skin flaps - look for the upper lateral cutaneous nerve of the arm (ULCNA) – will guide to the posterior division
• This branch can be confirmed by gentle traction, which dimples the skin
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Deep dissection• Split the fascia at the point where the ULCNA pierces - trace this back
to the posterior division of the axillary nerve - loop
• Follow the posterior division deep until the anterior division is identified - trace distally to the deltoid muscle
• (The anatomy in the space may be difficult to define and axillary vessels may cross the nerve branches)
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Upper Lateral Cutaneous Nerve of Arm
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Deep dissection• If ULCNA unidentified, identify the anterior division• Anterior division – passes deep to the posterior border of the deltoid
muscle - 5cm distal to the postero-lateral corner of the acromion• There are usually two main branches and lifting the deltoid using a
retractor placed more proximally facilitates this exposure without risking damage to the nerve branches• Use a rubber surgical loop to tag the anterior and posterior divisions
of the axillary nerve
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Posterior branch
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Deep dissection – between long & lateral heads of triceps
• Identify a fat streak on the triceps• Develop the plane between the long and lateral heads of triceps -
gentle finger dissection• Carefully place a self-retaining retractor in this interval – avoid
damage to the triceps branches• The white tendon of latissimus dorsi – between quadranqular (axillary
nerve) & triangular spaces (RN & Branches)• Tag each nerve with surgical loops
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Recipient Division• Divide the axillary nerve as proximally as possible – gentle loop
surgical traction• Separation of the anterior and posterior divisions by endoneurolysis• (Avoid injury to the axillary artery or vein branches in the
quadrilateral space)• Select a donor muscle branch from triceps long head (Somsak) or
medial head branch
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Donor Division• The posterior cutaneous nerve of the arm lies on top of the main
radial nerve – can confuse• Trace the branch distally to see where the motor branch enters the
muscle & confirm with the faculty• Divide donor distally – external neurolysis using gentle surgical loop
retraction
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Coaptation• Coapt using 9’0 nylon 2 - 3 sutures - use microscope• (May be supported with Tisseel fibrin glue)• Ensure tension free and remain tension free throughout a full passive
range of shoulder motion
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Thank you