DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Ischemic muscle tissue, left lower extremity.
POSTOPERATIVE DIAGNOSIS: Ischemic muscle tissue, left lower extremity.
OPERATION PERFORMED: Debridement of left anterior and lateral compartments.
SURGEON: John Doe, MD
ASSISTANT: Jane Doe, MD
ANESTHESIA: IV sedation.
ESTIMATED BLOOD LOSS: Less than 100 mL.
POSTOPERATIVE CONDITION: Critical.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old Hispanic male who suffered a gunshot wound to the pelvis. As part of his injury pattern, he developed a compartment syndrome of his left lower extremity for which he underwent fasciotomies. Serial dressing changes have suggested; there is necrotic muscle tissue in his left anterior and lateral compartments. The patient now presents for a debridement of this nonviable tissue.
DESCRIPTION OF OPERATION: The patient remained in the surgical intensive care unit. His left lower extremity was prepped with Betadine and draped in a standard sterile fashion. IV sedation was induced with propofol, fentanyl, and Versed.
Once an appropriate level of IV sedation had been reached, we examined the patient’s left compartments. The posterior deep and posterior superficial compartments contained completely viable muscle tissue. In the anterior and lateral compartments, however, a fair amount of the muscle tissue appeared nonviable. Thus, we began with sharp debridement of this. These compartments were debrided back to viable tissue. This was a fairly extensive debridement, but the patient did have some remaining viable tissue, especially in his lateral compartment, that was left intact and in his anterior compartment as well. We debrided each of the sets of muscle tissue back to viable tissue.
Hemostasis was obtained with electrocautery. Once excellent hemostasis had been obtained, the cavity was packed, and the leg was then redressed. The patient tolerated the procedure well, and he remained in the surgical intensive care unit in critical condition at the termination of the case.
