Below Knee Amputation Operative Sample Report

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Ischemic left foot.

POSTOPERATIVE DIAGNOSIS:  Ischemic left foot.

OPERATION PERFORMED:  Left below-the-knee amputation.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General, orotracheal intubation plus epidural.

DESCRIPTION OF OPERATION:  The patient was placed supine. The left lower extremity was prepped and draped in the usual aseptic fashion. The intended incision site was marked. We incorporated the medial fasciotomy incision. The anterior aspect of the incision was made four fingerbreadths distal to the tibial tuberosity. The incision was continued through the fascia. The anterior compartment muscles were divided using electrosurgical dissection. The tibia and fibula were cleared. Periosteal elevator was used to clear the periosteum from the tibia. The tibia was transected with a power reciprocating saw. The fibula was transected 1 cm proximal to the tibial transection site using the bone cutters. The amputation was then completed with an amputation knife. The flap was debulked using scissors. The nerve was placed on traction, ligated and divided sharply and allowed to retract. The wound was then closed using 2-0 and 3-0 Vicryl sutures. 3-0 nylon vertical mattress stitches were placed in the skin. The large medial fasciotomy incision complicated the closure. The wound could not be closed completely secondary to the fasciotomy incisions. The open areas were packed with gauze. The stump was then wrapped with Kerlix and an Ace wrap. The patient tolerated the procedure well. There were no apparent complications.

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Left diabetic foot infection.

POSTOPERATIVE DIAGNOSIS:  Left diabetic foot infection.

OPERATION PERFORMED:  Left open below-the-knee amputation.

SURGEON:  John Doe, MD

ASSISTANT:  Jane Doe, MD

ANESTHESIA:  General, orotracheal intubation.

DRAINS:  None.

SPECIMENS:  Left foot to pathology for permanent section.

DESCRIPTION OF OPERATION:  The patient was placed supine. A tourniquet was positioned in the left proximal leg but not inflated. The area was prepped and draped in the usual aseptic fashion. A circumferential incision was made proximal to the malleoli after the tourniquet was inflated. The incision was continued to bone. The bone was transected with the power reciprocating saw. The specimen was removed. The tourniquet was deflated. The vessels were identified and suture ligated. Other bleeding points were treated with electrosurgical cautery. The area was irrigated and examined for hemostasis. Xeroform, Kerlix, and an Ace were applied. The patient tolerated the procedure well. There were no apparent complications.