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Arthroscopy of the shoulder is a minimally invasive surgical technique by which inside of the joint can be visualised using an external light source and video camera. Images or movies can be recorded to confirm the diagnosis or to show the steps undertaken during the interventional procedures. In real life space in the shoulder joint is a potential space and in order to pass a telescope and move it around safely, the joint needs to be ‘inflated’ with fluid (sterile saline) under pressure. This is done using a special pump which can maintain a constant internal pressure. The joint is accessed through small ‘stab’ incision placed in areas which are known to be ‘safe-corridor’ to pass instruments without damaging any vital structures inside the body.
Although shoulder joint is big, it is not an easy joint to access and the skills needed to do this safely is acquired over a period of time. Such skills includes ‘triangulation’ skill and psychomotor skills to appreciate how small movements 20 to 30 cm away from the area visualised is translating into action. As a trainee registrar one is taught to do these over a period of time starting with simple and ‘easier’ joint to scope and then move over to shoulder joint. I did my first shoulder arthroscopy was in 1998 with the consultant scrubbed and guiding me.
Majority of the shoulder scopes are done under full general anaesthetic. In the 1500+ arthroscopy of shoulder that I have done so far, only very few (in single digit number) were done under local anaesthetics/nerve blocks. I perform
the shoulder arthroscopy with the patient lying on the unaffected side so that the joint with the problem is in on the top.(lateral position). The arm is held steady with a simple traction device and about 4lb to 6lb traction is applied. The area is completely sealed off to create a sterile field. Even now, I find marking the skin with bone land marks to be very useful as it is vital to have reference points should the shoulder swell during operation due to fluid extravastion. So do not be surprised if you see my artwork on the skin!. It will wash-off anyway.
Now a days it is uncommon to do diagnostic arthroscopy. Usually there is a working diagnosis and I go in with a plan. I will take your permission to address any pathology that I see and consider relevant to your symptoms. Now and then we do get a surprise findings which was not picked up by the investigations and this may have to be addressed. If you have expressed explicitly that the timescale for recovery should not change due to work commitment, and if by doing any additional procedures this can be affected, then I will not proceed with the extra step. Very rarely, I may encounter a problem that cannot be addressed by arthroscopic technique and in that situation, the arthroscopy will turn into a ‘diagnostic one. It is not easy to convert arthroscopic procedure to an open procedure as the tissues would have swollen. I have shown an example of healed scar at 6 weeks after shoulder stabilisation operation. A link to normal shoulder joint seen during arthroscope is also provided.
Healed portals from the arthroscopy at 6 weeks. One in the back and two in the front of the shoulder.
| Ultrasound scans |
| MRI scans |
| A S D + D C E |
| Impingment syndrome - Picture |