OT notes · Orthopaedics

Excision of ganglion (wrist and hand)

Usual anaesthesia
Regional block or general anaesthesia for wrist ganglia; local infiltration for small digital cysts (the cited chapters say only 'adequate anaesthesia')
Position
Supine, arm abducted on a hand table, with an arm tourniquet
Setting
elective

Operative note template for open excision of a ganglion of the wrist or hand (dorsal, volar, flexor sheath or DIP mucous cyst), with a filled example for a dorsal wrist ganglion excised with its stalk under a brachial plexus block.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • recurrence, higher if the stalk and capsular attachment are not removed
  • wrist stiffness, especially loss of palmar flexion after dorsal excision
  • injury to sensory branches of the radial or ulnar nerve with numbness or painful neuroma
  • radial artery injury (volar ganglion)
  • thick or tender scar
  • wound infection
  • the swelling may turn out not to be a ganglion on histopathology

Pre-operative details for this operation

  1. Site and sideDorsal wristVolar wristFlexor tendon sheath (volar retinacular)DIP joint mucous cystPIP jointOthermark the swelling and the side
  2. Size, duration and symptomspain, weakness, cosmetic concern, nerve symptoms
  3. How the diagnosis was confirmedTransilluminationAspiration of jelly-like fluidUltrasoundMRI
  4. Previous aspiration or injectionnumber and dates
  5. Wrist X-rayintraosseous cyst, carpal boss, scapholunate gap, DIP osteophytes
  6. Allen test (volar wrist ganglion)Radial and ulnar arteries patentRadial-dominantNot applicable

Anaesthesia and position

  1. AnaesthesiaBrachial plexus blockGeneralIV regional (Bier block)Local infiltration
  2. Tourniquetsite, exsanguination method, pressure, inflation and deflation times
  3. MagnificationLoupesNoneloupes help around the radial artery

Operative findings

  1. Cystsize, single or multiloculated, contents (clear jelly / blood-tinged)
  2. Origin of stalkScapholunate ligamentRadiocarpal capsuleScaphotrapezial capsuleA1 pulley / flexor sheathDIP joint capsuleOther
  3. Relation to radial artery (volar)free / adherent / encircling
  4. Intra-articular or satellite cystsnumber and site
  5. Scapholunate ligament and cartilage (dorsal)intact / abnormal
  6. Cyst ruptured during dissectionNoYes

Procedure (steps)

  1. Skin preparation, draping, exsanguination and tourniquetantiseptic, Esmarch, pressure, time
  2. Skin incisionTransverse over the cyst (dorsal)Longitudinal or curved (volar)Oblique over sheath (seed ganglion)Transverse or L-shaped over DIP (mucous cyst)length and landmark
  3. Subcutaneous dissectiontenotomy scissors; sensory nerve branches and longitudinal veins protected
  4. Interval usedBetween EPL and EDC (dorsal)Forearm fascia incised, beside FCR (volar)Flexor sheath (seed)Beside extensor tendon (mucous cyst)
  5. Cyst mobilised and stalk tracedto the joint capsule or sheath of origin
  6. Capsule opened (wrist)dorsal: along radius and proximal pole of scaphoid with wrist palmar-flexed
  7. Excisioncyst, stalk and capsular attachment in one piece; size of capsule excised; dorsal: shaved off the scapholunate ligament without cutting into it
  8. Radial artery (volar)Freed from cyst wallSmall piece of cyst wall left on arteryNot involved
  9. Search for residual or satellite cystssurrounding tissue compressed to look for further mucin pockets
  10. Osteophytes excised (mucous cyst)rongeur; extensor insertion and nail matrix protected
  11. Irrigation, tourniquet release and haemostasistourniquet time

Closure, drains and dressing

  1. Joint capsuleLeft openClosedthe hand-surgery texts advise not closing the wrist capsule after ganglion excision
  2. Subcutaneous layersuture and size
  3. SkinSubcuticular absorbable monofilamentSubcuticular non-absorbable monofilament pull-outInterrupted nylonsuture and size; a pull-out suture must be removed at the dressing visit
  4. Dressing and splintBulky dressing, forearm to MP jointsShort-arm volar slab, wrist in slight flexionSimple dressing (digital cyst)
  5. Hand circulation and sensation at end

Specimens and implants

  1. Cyst with stalk sent for HPEYes, in formalinNo (reason)label site and side

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Elevationhand above heart level
  2. Finger movementactive finger movement from the day of surgery
  3. Neurovascular checkcapillary refill and sensation of fingers
  4. Analgesiadrug, dose, frequency
  5. Dressing and suture removal7 to 10 days; state whether there is a suture to remove (pull-out or nylon) or not (absorbable subcuticular)
  6. Wrist movementstart after dressing removal (dorsal) or within 2 weeks (volar); stress palmar flexion after dorsal excision
  7. Hand therapycontinue until full range
  8. HPE reportcheck at follow-up

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Ms. P.D., 26 years, office worker, with a painful 2 x 2 cm swelling on the back of the right wrist for 14 months that recurred after one aspiration.

Case details

Date: 21/07/2026. Elective list. OT 3.

In OT 10:00. Block given 10:10. Tourniquet inflated 10:32. Skin incision 10:35. Tourniquet deflated 11:07. Skin closed 11:15.

Surgeon: Dr A. (3rd-year resident, Orthopaedics). Assistant: Dr B. (1st-year resident). Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: symptomatic right dorsal wrist ganglion, pain on wrist extension and push-ups, recurred after aspiration in January 2026 (clear jelly aspirated).

Transilluminant, non-tender, fixed to deep tissue, mobile under skin, directly over the scapholunate area. X-ray wrist: normal, no scapholunate gap, no intraosseous cyst.

Consent: general, procedure-specific and anaesthesia consent taken in Hindi from the patient. Recurrence, stiffness, numbness and scar explained.

Right wrist marked. WHO checklist sign in and time out done.

No antibiotic prophylaxis: clean hand procedure with no implant.

Anaesthesia and position

Supraclavicular brachial plexus block by anaesthetist. Supine, right arm on hand table.

Parts painted with povidone-iodine and draped. Limb exsanguinated with Esmarch bandage and arm tourniquet inflated to 250 mmHg at 10:32.

Procedure

3 cm transverse incision over the cyst, in a skin crease over the proximal carpal row.

Subcutaneous dissection with tenotomy scissors. Superficial radial nerve branches kept in the skin flaps. Longitudinal veins preserved.

Cyst found between EPL (retracted radially) and EDC (retracted ulnarly). Cyst 2 x 1.5 cm, single, thin-walled, clear jelly. Mobilised all round with blunt and sharp dissection.

Stalk traced to the dorsal capsule. Wrist palmar-flexed. Capsule opened along the dorsal rim of the radius and the proximal pole of the scaphoid and turned distally.

Stalk attached to the dorsal part of the scapholunate ligament. One small intracapsular cyst seen next to it. Capsule incised around the stalk, leaving the rest of the capsule.

Cyst, stalk, intracapsular cyst and about 1 cm of attached capsule excised in one piece, shaved tangentially off the scapholunate ligament. A fine mucin duct in the ligament fibres was divided. Scapholunate ligament not cut into and intact. Articular cartilage normal.

Surrounding tissue compressed: no further mucin pockets. Wound irrigated with saline.

Tourniquet released at 11:07 (tourniquet time 35 minutes). Haemostasis with bipolar cautery.

Closure

Joint capsule left open.

Subcutaneous tissue closed with polyglactin 910 (Vicryl) 3-0. Skin closed with subcuticular poliglecaprone (Monocryl) 3-0, absorbable, no suture to remove.

Bulky dressing from upper forearm to MP joints with a volar slab holding the wrist in slight flexion. Fingers pink, capillary refill brisk.

Specimens and implants

Cyst with stalk and capsular attachment sent for HPE in formalin, labelled 'right dorsal wrist ganglion'.

No implants.

End of procedure

Estimated blood loss: about 10 ml.

Swab, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications.

Patient shifted to recovery in stable condition. Pulse 76/min, BP 112/70 mmHg.

Post-op orders

Keep right hand elevated on a pillow and in an arm sling when walking.

Active finger movements from today.

Check finger circulation and sensation hourly till the block wears off.

Oral analgesic as per unit protocol.

Dressing and slab removal on day 10 in OPD, then start wrist movement, especially bending the wrist forward. Physiotherapy till full range.

Follow up HPE report at the day 10 visit.

Discharge when the block has worn off. Instructions explained in Hindi.

Signature

Dr A., JR-3, Orthopaedics. Reg. no. ________. 21/07/2026, 11:30.

Must document for this operation

  • The origin of the stalk and that it was excised with its capsular attachment. Incomplete excision of the stalk is the main cause of recurrence, and the note is the only proof it was removed.
  • The state of the scapholunate ligament after dorsal excision. If the patient later has wrist pain or instability, the next surgeon needs to know whether the ligament was left intact.
  • The relation of a volar ganglion to the radial artery and what was done. If part of the cyst wall was left on the artery, a later swelling at that site may be residual cyst, not a new one.
  • That the specimen was sent for histopathology (HPE), with site and side. Malignant soft tissue tumours are often misdiagnosed as ganglions, and only the report settles it.
  • Whether the capsule was closed and the wrist position in the splint. These decide the rehabilitation plan and explain any later loss of wrist flexion.
  • Tourniquet pressure and time. Needed if the patient has nerve symptoms afterwards, and it is one of the items most often missing in orthopaedic note audits.

Common mistakes in these notes

  • Writing 'ganglion excised' without the site of origin of the stalk.
  • Not recording whether the cyst ruptured during dissection.
  • Not recording the radial artery relation for a volar ganglion.
  • Leaving out whether the specimen went for HPE.
  • Leaving out tourniquet time and the splint position.

Indian practice and paperwork

  • If the excised cyst is not sent for HPE, it goes in the yellow bag as human anatomical waste. Discarded formalin from specimen jars is yellow (f) chemical waste. (Bio-Medical Waste Management Rules 2016, CPCB guidelines)
  • In a Lucknow two-cycle audit, an RCS-based op-note proforma raised documented parameters in orthopaedic notes from 35.8 percent to 90.2 percent. (Aslam MA et al., Cureus 2025;17(5):e84632)
  • Consent must be in a language the patient understands and cover risks, benefits, alternatives and who will operate. (NABH Hospital Standards 5th ed., PRE.4(c))
  • NABH expects the operative note to be written before the patient is moved out of recovery. (NABH 5th ed., COP.14(e))

Sources

  • Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, Cohen MS, eds. Green's Operative Hand Surgery. 7th ed. Elsevier; 2017, Ch 59 Bone and soft tissue tumors: Ganglions and mucous cysts (dorsal, volar, volar retinacular, mucous cyst, PIP ganglia), pp. 1997-2009.
  • Saghieh S, Weinstein SL, Hoballah JJ, eds. Operative Dictations in Orthopedic Surgery. Springer; 2013, Ch 92 Volar ganglion excision (Mollano AV); Ch 93 Dorsal ganglion excision (Saghieh S), pp. 331-334.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Clean orthopaedic procedures of the hand, knee or foot without implants: no prophylaxis recommended (strength C). academic.oup.com/ajhp/article/70/3/195/5112717

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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