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Foot Incision and Drainage Transcribed Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Right foot abscess.

POSTOPERATIVE DIAGNOSIS:
Right foot abscess.

OPERATION PERFORMED:  Right foot incision and drainage.

SURGEON:  John Doe, MD

ANESTHESIA:  Combination of MAC with local, 1:1 mixture of 0.5% Marcaine plain and 2% lidocaine plain infiltrated into the right foot.

ESTIMATED BLOOD LOSS:  75 mL.

PATHOLOGY:  Bone, sent for Gram bone culture.  Drainage sent for culture and sensitivity, aerobic and anaerobic, Gram stain, as well as AFB and fungal.

MATERIALS:  Graftjacket as well as Graftjacket Xpress and PDS suture.

INDICATIONS FOR OPERATION:  The patient is a (XX)-year-old female who presents today with a right foot chronic abscess as well as ulcer for approximately 4 months. Currently healed over, but there is underlying abscess, reason the patient is being brought into surgery. Informed consent has been obtained. The patient has been medically cleared and n.p.o. for the appropriate time. There are no contraindications for surgery and all questions regarding surgery have been answered prior to the procedure. There were no postop injectables and no complication during the perioperative period.

DESCRIPTION OF OPERATION:  The patient was brought into the operating room lightly sedated and placed in the supine position on the operating room table under monitored anesthesia care. Then, 1:1 mixture of 0.5% Marcaine plain and 2% lidocaine plain was infiltrated into the right foot. A total of 12 mL was used. A pneumatic ankle tourniquet was placed on the right ankle.

The right leg was prepped and draped in the normal sterile fashion, elevated and exsanguinated using Esmarch bandage, at which time pneumatic ankle tourniquet was inflated to 250 mmHg.  Attention was directed to the right first metatarsal area, where a small ulcer was present on the skin. Hemostat was used to puncture through this area, and in doing so, fluid leaked out. This was then sent for culture and sensitivity. The wound opening was then further opened using 2 semi-elliptical incisions around original wound site where the skin was removed. The rest of the drainage that was present in this area was removed. There was also noted packing from prior, approximately 5 days ago, that was also removed. The wound was then investigated for any devitalized or necrotic tissue, which was then removed at this time. There was also a small piece of bone taken from the first metatarsal; this was sent for Gram bone culture. The plantar aspect of the right first metatarsal was also smoothed away. A small stab incision was made underlying this abscess area on the plantar aspect to allow for drainage. The incision site was then copiously irrigated with 3 liters of normal saline that had bacitracin in it. Next, one suture was then placed on the plantar opening so some drainage would be able to seep out. Next, Graftjacket Xpress was then used to fill the abscess void. Graftjacket dermal tissue was then placed on the dorsal aspect and sutured into place using PDS suture.

Vaseline gauze, sterile 4 x 4's, Kling, Ace wrap and Betadine-soaked 4 x 4's were then introduced as a dressing. Kling, Kerlix and Ace wrap were then further used as dressing. At this time, pneumatic ankle tourniquet was deflated and removed. The patient tolerated the procedure with vital signs stable and neurovascular status intact to digits 1-5 of the right foot.  The patient is to keep the dressing clean, dry and intact.