DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Necrotizing soft tissue infection of the abdominal wall.
POSTOPERATIVE DIAGNOSIS: Necrotizing soft tissue infection of the abdominal wall.
OPERATION PERFORMED:
1. Irrigation and debridement of abdominal wall.
2. Reopening of recent laparotomy.
3. Placement of temporary abdominal closure.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: General via endotracheal tube.
ESTIMATED BLOOD LOSS: Less than 50 mL.
DRAINS: JP drains x2.
SPECIMENS: None.
TUBES: Endotracheal tube and Foley.
POSTOPERATIVE CONDITION: Critical, in the surgical intensive care unit.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old Hispanic male who sustained a gunshot wound several days ago. This has been followed by a necrotizing soft tissue infection of his abdominal wound. He underwent exploratory laparotomy and debridement twice in the last 48 hours, and he now presents for repeat debridement of the ongoing necrotizing soft tissue infection.
DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed on the operating table in the supine position. He had previously been intubated in the SICU. General anesthesia was induced. His previous dressings were removed, and the wound was prepped with Betadine and draped in the standard sterile fashion. A time-out was held, and the patient’s planned procedure and the consent form were confirmed with all present.
We began by examining the anterior abdominal wall. We removed the multiple Kerlix that had previously been placed in the subcutaneous tissue and discarded these. These were stained somewhat with purulent-looking material. We explored the wound, exploring underneath each of the flaps. The previous retention sutures that had been placed were cut and removed. We found small pockets of pus in the inferior portion of the inferior-most flap. These were suctioned and removed.
We noted a portion of his external oblique muscle just inferior to the crosswise portion of the laparotomy, lateral to the Vicryl mesh, that appeared to be nonviable. This was sharply debrided back to viable tissue and removed. Likewise, subcutaneous fat in the superior portion of the wound also appeared nonviable, and this was sharply debrided and removed. We also checked the fascia for separation of the subcutaneous tissue from the fascia and all of the flaps around, and in general, we noted that there was no additional separation that had occurred. In short, it appeared that the necrotizing soft tissue infection had been adequately debrided yesterday and only a relatively small amount of additional debridement was needed today. We checked the wound completely for hemoptysis.
We then turned our attention to the abdomen. The temporary plastic sheeting was removed from the abdomen. An inflammatory exudate was present over the anterior abdominal wall contents. Finger sweep was used to break up these forming adhesions. We explored especially the right lower quadrant looking for evidence of leak from the ileocolic anastomosis. No feculent material or succuss was seen or returned in this area.
We also then explored the underside of each of the fascia laterally, on either side superiorly and inferiorly in the wound, looking for evidence of fasciitis on the underside of the anterior abdominal wall fascia and found none. A piece of transplant base and slush liner was then brought up on the field and was cut to size and was placed underlying the fascia in all four quadrants and underlying the Vicryl mesh that was in the right lower quadrant. This was done to keep the small bowel and colon from adhering to the anterior abdominal wall fascia.
Once this was in place, each of the pockets of the wound was then tucked with Kerlix. Large flaps of skin were then brought together in a temporary retention fashion with #2 nylon sutures just to temporarily close the skin. Two Jackson-Pratt drains were used to overlie the Kerlix, and this was covered with a sterile towel. An Ioban then covered the entire dressing. The Ioban was reinforced at any leaking points with Tegaderm. The drains were placed to suction to create a vacuum effect. This appeared to control the wound well. The patient was then transferred to the bed and returned to the intensive care unit in critical condition under the care of anesthesia and surgical staff.
