DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Dry gangrene, right second and third toe.
2. Nonhealing left medial calf wound.
POSTOPERATIVE DIAGNOSES:
1. Dry gangrene, right second and third toe.
2. Nonhealing left medial calf wound.
OPERATIONS PERFORMED:
1. Open ray amputation, right second toe.
2. Open ray amputation, right third toe.
3. Full-thickness and soft tissue debridement of the left medial calf wound.
SURGEON: John Doe, MD
ANESTHESIA: General by trach collar.
INDICATION FOR OPERATION: The patient is a (XX)-year-old renal failure patient on dialysis, who presented to the office with gangrene of his second toe with extension into his third toe. The patient was evaluated for arterial disease and was found to have some evidence of arterial disease but was thought to have adequate perfusion to heal primary toe amputation, based upon laser Dopplers. The patient was also found to have a nonhealing medial left calf wound. Initially, we were requested to do a biopsy of this, however, it was felt that partial biopsy of the eschar wound would result in a large nonhealing wound, and it was discussed with patient’s primary nephrologist, as to whether or not to proceed with a biopsy or a full-thickness debridement. It was agreed that he should have the debridement done.
DESCRIPTION OF OPERATION: The patient was brought into the operating room and placed on the operating table in the supine position. After adequate induction of anesthesia, the right foot and left calf were prepped and draped in a sterile fashion.
The procedure was begun by making a fishmouth incision around the base of the right second and third toes to encompass the entire area of gangrenous changes. The medial incision was made between the first and second toe and the lateral between the third and fourth toe. This teardrop-shaped incision was continued down through the subcutaneous tissue to the bone. A bone cutter was used to divide the proximal phalanx of both the second and third toes. A rongeur was then used to remove the proximal portion of both proximal phalanx and to remove the distal head of the second and third metatarsal. Sharp dissection was then used to remove remaining necrotic tissue. There was no significant plantar or proximal extension. The wound was made hemostatic with limited electrocautery and several 3-0 chromic sutures. The wound was then packed with saline-soaked gauze and dressed with a sterile dressing.
Attention was directed to the left calf. A #10 blade knife was used to make incisions around the border of the necrotic eschar wound. The subcutaneous tissue was incised deep to the necrotic tissue, and there was noted to be healthy tissue in the subcutaneous fat. The entire wound was debrided. Several bleeding points were controlled with 3-0 chromic sutures. A saline dressing was applied, and clean sterile dry dressing was applied. The total size of the wound was 7.5 cm by 7.5 cm. The patient was then extubated and transferred to the recovery room in stable condition, having tolerated the procedure well.
