DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Right foot abscess.
POSTOPERATIVE DIAGNOSIS:
Right foot abscess.
OPERATION PERFORMED:
Incision and drainage of right foot.
SURGEON: John Doe, DPM
ASSISTANT: Jane Doe, DPM
ANESTHESIA: Combination of MAC with local, 1:1 mixture of 0.5% Marcaine plain and 2% lidocaine plain were infiltrated into the right foot.
PATHOLOGY: Soft tissue mass, right foot.
HEMOSTASIS: Obtained with right pneumatic ankle tourniquet inflated to 250 mmHg.
ESTIMATED BLOOD LOSS: Less than 5 mL.
MATERIALS: Prolene suture.
INJECTABLES: There were no postoperative injectables.
COMPLICATIONS: No complications in the perioperative period.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old female who presented with a soft tissue mass present on the plantar aspect of her right foot. The patient states this has been present since many years, but has recently been causing problems. The patient has had three incisions and drainages in the past. The patient presented to the emergency room. It was believed that possibly an abscess was present in this area due to increased white blood cell count as well as redness and pain in the area, and the patient was scheduled for incision and drainage as well as excision of the soft tissue mass.
DESCRIPTION OF OPERATION: The patient was brought to the operating room lightly sedated and placed in the supine position on the operating room table under monitored anesthesia care. A 1:1 mixture of 0.5% Marcaine plain and 2% lidocaine plain was infiltrated into the right foot in a Mayo-type block, and pneumatic ankle tourniquet was placed upon the right ankle. The right leg was draped and prepped in the normal sterile fashion, elevated for 3 minutes to exsanguinate, at which time the pneumatic ankle tourniquet was inflated to 250 mmHg.
Attention was then directed to the plantar aspect of the right foot where a soft tissue mass was present. An elliptical incision was made around this with the apex distal and proximal on the plantar aspect of the foot. This wedge of skin was removed and had a small pocket of pus on the deepest aspect. The remaining wound was now assessed for any tracking that was noted, and the only thing left in this area was healthy tissue consisting of normal fat that was present there. This was then copiously irrigated with bacitracin and 3 liters of normal saline using pulse lavage.
Next, 3 small retention sutures were placed across this area to just pull the edges together but not allow for primary closure. It was then packed with a 4 x 4 that had been moistened with normal saline and wrapped with more 4 x 4s, Kling and an Ace wrap.
The patient finished the procedure with vital signs stable, neurovascular status intact in digits 1 through 5 of the right foot, and was placed on recovery where vitals were taken, and the patient was readmitted once again to the hospital due to the increased white blood cell count and postoperative pain.
