- Wound preparation and exploration
- Thorough irrigation and debridement of wound
- Identify and expose the proximal and distal nerve ends
- Trim damaged ends back to healthy fascicles if crushed or frayed
- Mobilise nerve ends gently to allow tension-free approximation
- Microsurgical setup
- Use microscope or surgical loupes (3.5x–5x magnification)
- Keep nerve ends moist at all times (saline-soaked gauze)
- Use microsurgical instruments and 8-0 to 10-0 nylon sutures
- Nerve approximation
- Align the nerve ends epineurially (outer layer) under no tension
- Place epineurial sutures (4–6 interrupted) to bring fascicles into approximation
- Avoid strangulation of nerve tissue or gapping between ends
- If available, fascicular alignment can be attempted for mixed motor/sensory nerves
- Augmentation (optional)
- Fibrin glue or collagen nerve wrap may be used to reinforce coaptation
- Consider vascularised flap or fat graft if overlying soft tissue is thin or scarred
- Closure
- Ensure nerve lies without tension or kinking
- Close deep tissue and skin in layers without compressing the repair
- Splint the limb in position to protect the nerve (e.g., elbow flexion or wrist extension, depending on site)