After induction of adequate anesthesia (regional block when possible, with or without general anesthesia), the authors’ preferred surgical positioning is a beach-chair position with the head elevated approximately 45°. Two blue towels are placed behind the medial border of the scapula between the patient and the bed to ensure that the glenoid and scapula do not rotate anteriorly. The operated arm is placed on the commercially available arm holder. An examination under anesthesia (EUA) is performed to evaluate the pathology and confirm the diagnosis.

After the patient is properly positioned, a complete arthroscopic exam is carried out via the standard posterior viewing portal. The aim of the arthroscopic exam is to identify any coexisting intra-articular pathology, such as the anterior capsulolabral complex, biceps tendon, subscapularis tendon, chondral defects, posterior labral tear, and Hill-Sachs lesions (HSLs). If a posterior labral tear is identified, the authors prefer to perform the arthroscopic posterior labral repair in a lateral decubitus position first before converting the patient into the beach-chair position for the open portion of the surgery. Additional surgical interventions may be required
for the large chondral defects or large HSLs, and these pathologies may be missed without preoperative planning.

A Bankart incision, or an instability-type incision of a deltopectoral approach is used to gain access to the anterior glenoid, which starts from the inferior tip of the coracoid process and extends down to the axillary fold (approximately 5-7 cm). After the deltopectoral interval is identified, the subfascial plane of the deltoid is mobilized. The cephalic vein is identified and retracted laterally. The lateral border of the conjoint tendon is identified, incised, and retracted medially. Incomplete release of adhesions surrounding the conjoint tendon may prevent nerve immobilization and increase the risk of musculocutaneous nerve damage during medial retraction (Figure 35-1). In addition, care is taken to avoid excessive medial retraction to protect the musculocutaneous nerve. Another retractor is placed underneath the deltoid muscle, which is retracted laterally.

The subscapularis (SSc) tendon is then carefully identified by releasing adhesions superiorly and inferiorly with Metzenbaum scissors. Medial adhesions are then cleared with a Cobb elevator. The authors prefer to use the SSc split approach. The SSc split is made using a 15-blade in line with the fibers of the SSc, between the upper two-thirds and lower one-third of SSc, or the ratio between 60% and 40% of the length of the lateral SSc footprint (Figure 35-2). The split should be made medially to the level of the musculotendinous junction and avoid over-medialization of the split because it increases the risk of iatrogenic nerve injury. In revision surgery cases, the authors prefer to convert SSc split into SSc tenotomy for better surgical exposure. A pointed retractor is placed within the SSc split to allow access to the capsule. An inverse L-capsulotomy is then performed using a 15-blade with the apex of the “L” superomedially (Figure 35-3). The medial limb of the capsulotomy is 1 cm in length and at the glenoid neck. The lateral limb of the capsulotomy should be extended laterally to the point where the fibers insert on the humeral head. A stay suture (#2 FiberWire) is placed in the superomedial corner of the capsule to help with capsular retraction and mobilization (Figure 35-4). The glenohumeral joint and glenoid are then fully exposed.