DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Painful fasciotomy scar, right forearm.
POSTOPERATIVE DIAGNOSIS: Painful fasciotomy scar, right forearm.
OPERATIONS PERFORMED:
1. Revision of right forearm fasciotomy scar.
2. Staged excision of skin graft.
3. Layered closure.
SURGEON: John Doe, MD
ANESTHESIA: General with 10 mL of 0.5% lidocaine plain and 0.5% Marcaine plain.
ESTIMATED BLOOD LOSS: Minimal.
TOURNIQUET TIME: Less than 20 minutes.
COUNTS: Correct.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: After explaining the potential risks and benefits of the procedure to the patient, written consent was obtained. The patient was taken to the operating room by gurney and transferred to the operating room table in the supine position. The right arm was placed on a hand table, and an endotracheal tube was placed. General anesthesia was induced and clindamycin was given preoperatively IV. A time-out was performed indicating the patient, procedure, and site to be operated on. Betadine prep was used for the right forearm, and the patient was draped in a sterile manner. A nonsterile tourniquet had been placed on her right upper extremity.
Next, we outlined the skin graft sites and the incisions to be made. They measured 14 x 3.5 cm, and these were made with a 15 blade. The skin was then taken up off of the deep fascia, taking care to protect any overlying cutaneous nerves and tendons. Once the skin graft was removed, the outer aspects of the wound were mobilized and brought in to cover the defect.
The wound closed easily with minimal tension, 3-0 Vicryl sutures were used to close deep as well as running 5-0 nylon superficially. The radial pulse was palpable. The hand was pink after the tourniquet was taken down. Prior to closing the wound, the tourniquet was taken down, and hemostasis was achieved with electrocautery. After completion of closure of the forearm, it was clinically soft. A volar safe position splint was fashioned.
The patient tolerated the procedure well without any immediate complications. At the end of the procedure, all sponge, needle, and instrument counts were correct.
