DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Abdominal dermatolipodystrophy.
2. Diastasis recti.
POSTOPERATIVE DIAGNOSES:
1. Abdominal dermatolipodystrophy.
2. Diastasis recti.
PROCEDURE PERFORMED:
Abdominoplasty.
SURGEON: John Doe, MD
ANESTHESIA: General.
ESTIMATED BLOOD LOSS: Minimal.
COMPLICATIONS: None.
DRAINS: A 10 mm flat Blake.
COUNTS: Sponge, instrument and needle counts reportedly correct.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old Hispanic female who presented to the office desiring improvement of her abdomen contour with abdominoplasty. The patient was counseled preoperatively regarding the risks associated with abdominoplasty and agreed to proceed. The patient also is undergoing a mini lap for tubal ligation at the time of her abdominoplasty by Dr. Jane Doe.
DESCRIPTION OF OPERATION: The patient was marked preoperatively in the standing position for abdominoplasty markings and then brought to the operating room. The patient was placed on the table in the supine position. After the induction of general anesthesia, her arms were padded with blankets, wrapped in blankets, and secured to arm boards at her side. Her abdomen was prepped and draped in the usual sterile fashion.
The abdominoplasty incision was then made with a 10 scalpel through skin and subcutaneous tissue. Cautery was then used to deepen the incision through the underlying Scarpa’s fascia and sub-Scarpa’s fat to the anterior sheath. Undermining of the flap to the level of the umbilicus was then accomplished with cautery dissection. A mini laparotomy was then performed by Dr. Jane Doe. With the laparotomy completed and the tubal completed, the midline incision was closed with interrupted 0 Vicryl sutures. The umbilicus was then everted with skin hooks and incised and dissected out along its stalk to its fascial attachments. The flap was put in the midline to the umbilical opening. Undermining continued to the costal margins and xiphoid.
A 4 cm diastasis was then repaired with interrupted 0 Ethibond figure-of-eight sutures. With the rectus plication completed, the wound was irrigated with antibiotic solution. A 10 mm flat Blake drain was placed through a stab incision and secured with a 3-0 Vicryl suture. The patient was then flexed on the operating room table. Excessive skin and subcutaneous fat were marked for excision. Tissue was excised, and hemostasis achieved on the cut flap edge with cautery. A flap inset was then performed with 2-0 Vicryl sutures in the Scarpa’s fascial layer throughout, 3-0 Vicryl sutures in the subcutaneous and deep dermis, 4-0 Monocryl intracuticular stitches were then used to approximate the skin edges.
Umbilicoplasty was performed through the previously marked midline via a vertical oval skin and subcutaneous excision. The umbilicus was secured with interrupted 3-0 Vicryl dermal sutures and 5-0 nylon horizontal half-buried mattress sutures to approximate the skin edges. Steri-Strips, Xeroform dressings, dry gauze dressings and Micropore tape were used to dress the wounds. The patient was placed in a postop abdominoplasty garment and taken to the recovery room in satisfactory condition.
