DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Splenic laceration.
2. Submental facial laceration.
POSTOPERATIVE DIAGNOSES:
1. Splenic laceration.
2. Submental facial laceration.
OPERATION PERFORMED: Laceration repair.
ANESTHESIA: General endotracheal anesthesia.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
COMPLICATIONS: None.
DRAINS: None.
ESTIMATED BLOOD LOSS: Minimal for the specific procedure.
SPECIMENS: None.
This procedure directly followed the exploratory laparotomy and splenectomy. The patient suffered no complications from this procedure. The laceration was completely sewn up without difficulty and full approximation. He was taken to the postoperative anesthesia care unit following this where he recovered uneventfully.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old Hispanic male who was involved in a motor vehicle accident earlier on this day. He was taken to the emergency room where he was noted to have a profusely bleeding submental facial laceration, approximately 4 cm in total length; however, it was L shaped.
DESCRIPTION OF OPERATION: The patient was in the operating room where an exploratory laparotomy and splenectomy had already been performed. Following this, attention was turned towards his laceration while the patient was still under general anesthesia from the previous aforementioned procedure.
The patient was already lying supine on the operating room table. He had a cervical spine collar, which was carefully removed while anesthesia held inline cervical stabilization. The inferior aspect of the patient’s chin was examined, and he was noted to have an L-shaped laceration, in total approximately 3 to 4 cm in length. It was approximately 0.5 cm deep and had undermining on the anterior edge, of approximately 1 cm. The wound was irrigated profusely with a total of about 1 liter of normal saline.
Minimal skin edge debridement was required. Following irrigation, the patient’s chin was prepped with Betadine and draped in a sterile manner. A 4-0 Prolene was utilized to approximate the skin edges. Prior to approximation, the wound was again re-explored for any further penetration. In total, the wound exploration yielded only superficial findings.
The laceration was sutured up using simple interrupted suture of 4-0 Prolene. The entire wound edge was reapproximated in the configuration in which it had been avulsed. A complex closure was not performed. In total, approximately 10 sutures were placed. The site was cleaned and dried, and sterile gauze and dressing were laid over the laceration repair. This completed the procedure. The patient tolerated the procedure well without any complications. He will be transferred to the postoperative anesthesia care where he will be followed for his postop splenectomy as well as laceration repair.
