DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Sternal wound infection.
POSTOPERATIVE DIAGNOSIS:
Sternal wound infection.
OPERATION PERFORMED:
Incision and drainage of sternal incision and culture.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
DRAINS: None.
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old Hispanic male with a past medical history significant for previous MI, COPD, type 1 diabetes, hypertension, high cholesterol, status post pectoral muscle flap closure of a sternal wound infection. The patient did well for a couple of weeks and then returned with some evidence of drainage from the lower portion of the sternal incision. Due to his diabetes and his other comorbidities, we brought the patient into hospital for incision and drainage of the wound and for starting him on IV antibiotics.
DESCRIPTION OF OPERATION: The patient was identified in the holding area, brought to the operating room, and placed on the operating table in the supine position. General endotracheal anesthesia was induced. The chest was prepped and draped in normal sterile fashion. The patient was given IV antibiotics prior to start of the case.
We opened up the previous flap closure incision and noted a purulent pocket in the mid portion of the incision, as well as at the base of the incision, near the level of xiphoid. We opened this up widely and debrided it extensively. The infection appears to be superficial for the most part. There was no clear involvement of the bone. We debrided it extensively back to normal bleeding tissue.
Once this was done, we assured there was no evidence of any undrained fluid pockets. We then Pulsavac’d with 3 liters of antibiotic solution and suctioned until clear. We obtained meticulous hemostasis with Bovie cautery. When we were sure there was no bleeding, we then packed the wound with Betadine and Kerlix. We sent the tissue off for culture and sensitivity. The wounds were then clean and dry. The sterile bandages were placed.
All needle, sponge, and instrument counts were correct at the end of the case. The patient will be extubated and taken to the recovery room at this time.
