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Index Trigger Finger Release Transcription Sample Report

DATE OF PROCEDURE:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:
Left index trigger finger.

POSTOPERATIVE DIAGNOSIS:
Left index trigger finger.

PROCEDURE PERFORMED:
Release of left index trigger finger.

SURGEON:
John Doe, MD

ANESTHESIA:
Local.

TUBES AND DRAINS:
None.

SPECIMENS:
None.

ESTIMATED BLOOD LOSS:
Less than 10 ml.

COMPLICATIONS:
None.

INDICATIONS FOR PROCEDURE:
The patient is a (XX)-year-old gentleman with a long history of trigger finger releases in the past.  The patient has failed conservative measures for this finger and is indicated for operative release.

DESCRIPTION OF OPERATION:
The patient was brought back to the operating room after informed consent was obtained. Preoperative antibiotics were not given. The patient was prepped and draped in the usual sterile fashion over a nonsterile forearm-based tourniquet after local anesthesia in the form of 5 mL of 0.5% Marcaine was infiltrated into the area surrounding the left index A1 pulley. A time-out was performed, and the patient's name, operative site and procedure to be performed were verified against the consent and all were in agreement.

The incision was carried down initially through the proximal palmar crease at the level of the intersection with the index tendons. This was made sharply through the skin and then bluntly dissected down through the subcutaneous tissue until the synovium surrounding the tendon was isolated. There was an extensive amount of synovitis present, and this was debrided. The A1 pulley was then found and incised using tenotomy scissors.

Following this, range of motion was checked, and the patient was noted to be still triggering. The incision was carried further and explored more distally; however, the patient was still triggering. Thus a Bruner-type incision was made and a flap was elevated, and the dissection was carried down until the entire A1 pulley could be fully visualized. It was noted to have some marginal stenosis at the level of the A2 pulley. The A1 pulley was incised all the way to the level of the A2 pulley.

Following this, the patient's tendon range of motion was clear. There was no triggering and no catching. Areas of scarring of the tendon were isolated and excised. The patient's tendon was noted to be free falling into the wound. The tourniquet was let down after a total of 7 minutes, and the wounds were irrigated copiously, and hemostasis was obtained.

The wounds were suture closed with 5-0 nylon sutures in an interrupted horizontal mattress fashion. The wounds were then cleaned and covered with bacitracin, Adaptic gauze, dry gauze fluffs and a soft dressing was applied.