DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Left shoulder deep wound infection.
POSTOPERATIVE DIAGNOSIS: Left shoulder deep wound infection.
OPERATION PERFORMED: Irrigation, debridement, left shoulder.
SURGEON: John Doe, MD
ANESTHESIA: Scalene block.
TOURNIQUET TIME: None.
ESTIMATED BLOOD LOSS: Less than 5 mL.
DRAINS: None.
COMPLICATIONS: None.
DESCRIPTION OF OPERATION: The patient was taken to the operating room, and after a scalene block was administered by the anesthesia team, the patient was positioned on the operating room table in a beach-chair position. Of note, preoperative antibiotics were given. The left shoulder was prescrubbed with Betadine. Next, the left upper extremity, including the left base of the neck and shoulder, was prepped and draped in the usual sterile fashion.
After incorporating the anterior portal, a longitudinal skin incision was made over the anterior aspect of the left shoulder. The portal site was lipped to help the bleeding subcutaneous tissue. The deltoid did demonstrate minimal necrosis, but at the portal site, there was some mild fatty necrosis and this was evacuated. The deltoid was then opened to expose the glenohumeral joint itself. There were really no signs of purulence, but there was still some drainage from the subacromial region. This was debrided, and the rotator cuff repair was inspected, and there was no evidence of breakdown. The wound was then liberally irrigated with 3 liters of bacitracin solution under power irrigation. The edges of the deltoid were debrided to bleeding tissue. The deltoid was then repaired with 0 Vicryl in a simple interrupted fashion. The shoulder underwent range of motion and there was 180 degrees of forward flexion and there was 50 degrees of external rotation. There was no evidence of drainage after this. The wound was again liberally irrigated with normal saline solution.
The subcutaneous tissue was closed with 2-0 Vicryl in a simple interrupted fashion. The skin was closed with 3-0 Monocryl in a running subcuticular stitch. All sponge and instrument counts proved to be correct and estimated blood loss was less than 5 mL. The wounds were then cleaned, steri-stripped and dressed under the sterile field. It should also be noted that after opening the joint, deep tissue was taken and sent to the microbiology department for Gram stain and culture and sensitivity. A sling was placed to the left upper extremity, and the patient was escorted to the recovery room in stable condition. Exam in the recovery room revealed that radial pulse was 4/4; however, due to scalene block, neurologic exam could not be completely assessed.
