DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Deep wound infection.
POSTOPERATIVE DIAGNOSIS: Deep wound infection.
OPERATION PERFORMED: Deep wound incision and drainage.
SURGEON: John Doe, MD
ANESTHESIA: General anesthesia, endotracheal intubation.
COMPLICATIONS: None.
CONDITION: Stable to recovery room.
INDICATIONS FOR OPERATION: The patient is approximately two weeks status post a left L4-5 laminotomy and diskectomy. The surgery was entirely uneventful. Approximately 10 days after the surgery, the patient began to develop increasing low back pain and then suddenly developed purulent drainage from the superior part of the incision line. The patient was examined in the office and we decided to admit him. The patient’s neurologic examination had remained unchanged and was essentially normal. The patient was admitted to the hospital where laboratory studies and an MRI were obtained. He had a markedly elevated sedimentation rate, CRP, and the MRI scan revealed fluid collection consistent with an abscess deep to the fascia. It did not seem to extend into the disk space, and there was no major epidural compression. We have discussed the findings with the patient and the treatment options, including the risks and benefits. The patient expresses his understanding and consents to the procedure.
INTRAOPERATIVE FINDINGS: There was deep pus identified deep to the fascia.
DESCRIPTION OF OPERATION: The patient was already on vancomycin, after having arrived in the operating room. General anesthesia was induced by the anesthesia department. The patient was carefully rolled into a prone position on the four-post table where all pressure-sensitive areas were carefully protected. The hips and knees were gently flexed and lumbar field was isolated with 1010 plastic drapes and then prepped and draped in the usual sterile fashion.
The existing incision was excised in an elliptical fashion so as to provide fresh tissue for healing. The existing deeper sutures were removed. Once the fascia was entered, a large amount of purulent material was evacuated immediately. The area was then copiously irrigated both with sterile saline and with an iodine-saline solution. The area of any necrotic-appearing tissue was fully debrided. Hemostasis was provided by using the Bovie. The cecal sac was identified and any loose adherent material was removed. The disk space was immediately apparent, and it was clear that the infection did extend into the disk space. The thecal sac and nerve root were gently retracted, and the disk space was again entered with various types of rongeurs or pituitaries. The majority of the disk space, we had already evacuated from his prior surgery, and he exhibited a highly collapsed degenerative disk at this level. The area was thoroughly debrided of any necrotic-appearing tissue. We then elected to irrigate the disk space with dilute iodine and saline solution. This was done with multiple syringes of fluid. It was then rinsed with sterile saline. This was again performed in the more superficial levels. Three-quarter inch iodoform gauze was packed down deep extending through the inferior portion of the incision.
The fascia was closed loosely with several interrupted 2-0 nylon sutures. The subcu was reapproximated again loosely with 2-0 nylon sutures. Staples were used on the skin and approximately one-third of the incision line was left open to allow for drainage and packing change. A sterile dry dressing was applied. The patient was rolled onto his hospital bed and taken to the recovery room in stable condition. There were no apparent complications, and the patient tolerated the procedure well.
