DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Necrotic right forefoot.
POSTOPERATIVE DIAGNOSIS: Necrotic right forefoot.
OPERATION PERFORMED: Debridement of right foot amputation site.
SURGEON: John Doe, MD
ANESTHESIA: MAC.
ESTIMATED BLOOD LOSS: Less than 50 mL.
FLUIDS: Administered during the case, 750 mL of crystalloid.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old Asian female who is status post a right knee replacement. The patient had injury to the popliteal nerve and subsequently underwent a right fem-pop bypass. The patient developed necrotic forefoot and was unable to be revascularized. She underwent transmetatarsal amputation. The wound subsequently has developed additional areas of necrosis at the amputation site along with osteomyelitis of the exposed bone, foul odor, and elevated white count. The patient was subsequently taken to the operating room for debridement of these areas. She has been informed that she will most likely need a below-the-knee amputation in order to have a functional limb; however, she is not amenable to this course of treatment at this time.
DESCRIPTION OF OPERATION: After informed consent had been obtained and all risks and benefits were discussed with the patient, the patient was taken to the operating room where she was placed supine on the operating table. Sedation was then induced by Anesthesia without difficulties, and the patient was monitored throughout the case in this fashion. The patient had received IV Zosyn on the floor at 9 o’clock this morning prior to being brought to the operating room. There was no further need for IV antibiotics.
The right leg, below the knee, was circumferentially prepped and draped in the usual surgical fashion. The skin edges surrounding the open wound were debrided sharply using a #10 blade along with any necrotic muscle and tendon that was exposed within the wound. Rongeurs were used to debride all necrotic and exposed bone. The remainder of her lateral cuboid bone was removed back to the talus. The overlying periosteum of the talus was debrided using rongeurs, and the wound was then pulsavac’d using 3 liters mixed with bacitracin antibiotic.
The wound was then inspected at the end of the case. Good hemostasis was obtained using Bovie electrocautery. There was no gross bleeding at the conclusion of the case. The wound was then packed with damp gauze and wrapped with Kerlix and Ace bandage. The patient tolerated the procedure well without difficulties. The patient was awakened at the end of the case and transferred to PACU in good condition.
