Tailor Bunionectomy Operative Transcription Sample Report
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Tailor bunion, right foot.
2. Hammertoe, fifth, right foot.
POSTOPERATIVE DIAGNOSES:
1. Tailor bunion, right foot.
2. Hammertoe, fifth, right foot.
OPERATION PERFORMED:
1. Right Tailor bunionectomy/ostectomy of the fifth metatarsal head and proximal phalanx at the lateral aspect of the base, right fifth toe.
2. Arthroplasty of the fifth toe, right foot.
3. Hemiphalangectomy of the lateral aspect of the base of the proximal phalanx of the right fifth toe, see procedure #1.
SURGEON: John Doe, MD
ANESTHESIA: Monitored anesthesia care with local anesthetic using a total of 20 mL of 1% plain lidocaine mixed with 0.5% plain Marcaine in a 1:1 ratio, right foot.
PATHOLOGY: None.
HEMOSTASIS: Right ankle tourniquet set at 200 mmHg for 45 minutes.
ESTIMATED BLOOD LOSS: Less than 10 mL.
MATERIALS USED: 2-0, 3-0, 4-0 Vicryl and 4-0 and 5-0 nylon.
INJECTABLES: None.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: The patient was transported from the preop holding area to the operating room, followed to the operating room table in a supine position. Meanwhile, anesthesiologist applied monitoring devices onto the patient and administered slight sedation, which allowed the surgeon to perform a local right foot block utilizing a total of 20 mL of 1% plain lidocaine mixed with 0.5% plain Marcaine. The right foot was prepped and draped in a sterile aseptic fashion followed by exsanguination using an Esmarch bandage and inflation of the tourniquet to 200 mmHg.
Attention was addressed to the lateral aspect of the right foot, to be specific along the dorsolateral aspect of the fifth metatarsophalangeal joint where a linear incision was performed down to the dermal layer where all bleeders were identified and cauterized with a Colorado Bovie tip adequately. The incision was further deepened down to the level of the subcu down to the capsular layer, which was incised, and reflected the collateral lateral ligament of the exostosis that was severely noted along the lateral dorsal aspect of the fifth metatarsal head. It was noted to be intact in regards to the collateral ligament, was reflected in total using the sagittal saw, 39 blade, and the exostosis was removed.
Therefore, an ostectomy was performed using the sagittal blade, and attention was turned with reflection of all the soft tissues off of the osseous structure, off of the lateral condyle of the proximal phalanx base, using as well the sagittal saw, was resected down to spongy bone and followed by rongeur manually as well as a hand rasp rounded very nicely. The plantar aspect was noted to be smooth without any condyles protruding downward that could irritate or create any keratomas or skin disorders. The wound was copiously irrigated with sterile normal saline. The incision was then extended down to the distal aspect of the toe along the proximal phalangeal joint where a bielliptical incision was performed, excised the ellipse of skin, reflection of the tissue beneath, a tenotomy of the extensor digitorum longus to the fifth right toe performed, and a capsulotomy followed by arthroplasty of the head of the proximal phalanx was performed. Using the sagittal saw, the head was removed of the proximal phalanx, irrigation followed by repair of the tenotomized tendon extensor digitorum longus to the fifth toe, right foot, using 3-0 Vicryl.
The collateral ligament was repaired with 2-0 and 3-0 Vicryl in regards to the fifth MTPJ. The subcutaneous tissue was reapproximated with 4-0 Vicryl and the skin with 4-0 and 5-0 nylon in interrupted vertical sutures. The toe was rectus without any contracture noted intraoperatively. The toe was not elevated nor plantarflexed, optimal surgical result was noted intraoperatively. The surgeon then applied Xeroform followed by splinting the toe and maintaining it in a rectus positing regarding the right fifth toe with dry sterile dressing and Ace wrap.
The tourniquet was deflated. The capillary refill was immediate to all the toes on the right foot. There were no complications, and the patient was transferred back to recovery with vital signs stable and neurovascular status grossly intact.
