PREOPERATIVE DIAGNOSIS: Right medial leg ulcer/abscess.
POSTOPERATIVE DIAGNOSIS: Right medial leg ulcer/abscess.
PROCEDURE PERFORMED: Irrigation and debridement of right leg ulcer/abscess.
SURGEON: John Doe, MD
ANESTHESIA: General anesthesia.
TOURNIQUET TIME: 0 minutes.
ESTIMATED BLOOD LOSS: 20 mL.
SPECIMENS: Abscess to microbiology for tissue culture.
COMPLICATIONS: None noted.
DISPOSITION: Stable to postanesthesia care unit.
DRAINS: Penrose drain x1.
INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old Hispanic female who sustained an ankle injury. She was placed into a splint and upon removing the splint noticed ulceration along the medial aspect of her cast. This ulceration has persisted for approximately two months and has continued to have swelling around the wound and minimal serosanguineous drainage. It is approximately 1.5 x 1 cm in size.
The patient underwent an MRI of her right tib-fib, which demonstrated no evidence of osteomyelitis. He has also previously undergone two oral antibiotic courses and has still had persistent drainage and ulceration on this wound. We did recommend to her, at this point, that her MRI was concerning for possible soft tissue abscess at the site of this ulceration, which would account for her recalcitrant conservative course.
We recommended that she undergo surgical irrigation and debridement of her right leg ulceration. The risks and benefits were discussed, and informed consent was obtained.
DESCRIPTION OF PROCEDURE: The patient was properly identified in the preoperative holding area. She was brought back to the operating room and placed in the supine position on the operating room table. After satisfactory induction of general anesthesia, a well-padded tourniquet was applied to the right upper thigh. The right leg was then prepped and draped in the usual sterile manner. It was noted that she had a 1.5 x 1 cm size ulceration along the medial side of her leg, approximately at the midway point of her tibia. This area of necrotic ulcerated tissue was ellipsed to a healthy bleeding edge.
Upon exploring the tissue in the subcutaneous layer, it was noted that she had a small abscess. The subcutaneous tissue was curetted until no further necrotic material was noted. She was then irrigated with 6 liters of saline by Pulsavac irrigation with 3 liters of that being Bacitracin infused. Her wound was extended to allow for adequate aesthetic closure of the wound and ellipsed accordingly.
The wound was then closed over a Penrose drain using 2-0 nylon horizontal mattress. Her incision was dressed with dry gauze, ABD pad, Webril, and Ace wrap was applied. The patient was placed back into her fracture boot, which she had been previously wearing. The patient received 1 gram of Ancef prior to incision. The tourniquet was not utilized during the surgery. The patient was in stable condition upon leaving the operating room.
