DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Right knee abscess.
POSTOPERATIVE DIAGNOSIS: Superficial right knee abscess.
OPERATION PERFORMED: Incision and drainage along with debridement of right knee abscess with cultures.
SURGEON: John Doe, MD
ASSISTANT: None.
ANESTHESIA: Local 0.25% Marcaine with MAC.
ESTIMATED BLOOD LOSS: Minimal.
TRANSFUSIONS: None.
DRAINS: None.
SPECIMEN: C&S from purulent materials.
INDICATIONS FOR OPERATION: The patient is a very pleasant (XX)-year-old gentleman with a two-week history of a lesion in the middle of his right knee, which he attributed initially to an injury, which became progressively worse. The patient presented to the emergency department and was found to have an area of fluctuation. This began to drain spontaneously. Cultures were taken to show MRSA. The patient was placed on vancomycin. Because of this area of fluctuation, incision and drainage is being recommended. The procedure, risks, complications which include, but are not limited to, bleeding, infection, the possibility of requiring further treatment was thoroughly explained to the patient, and he agreed to proceed.
OPERATIVE FINDINGS: There was a 2.5 x 2.5 cm area of what appeared to be partially necrotic superficial skin and subcutaneous tissue down to the tendinous fascia; after debriding out, this area appeared nice and viable. Cultures were taken from purulent material.
DESCRIPTION OF OPERATION: The patient was in the main operating room under adequate IV sedation care provided by Anesthesia. He had been already receiving vancomycin and Zosyn.
Attention was directed to the right knee region along the patella and anterior tibial plateau region. This area was then identified. There was a 1 x 1 cm area of opening where he had been draining spontaneously. At this point, this area was infiltrated using 0.25% plain Marcaine. This area was then sterilely prepped using iodoform and draped in sterile fashion.
At this point, an incision was made to remove the area of the partially necrotic skin, carried through the subcutaneous tissue where at this point an area of purulent material was encountered. At this point, aerobic and anaerobic cultures were taken. Some of the more superficial subcutaneous tissue appeared to be somewhat necrotic; this was all debrided down to good viable tissue down to the tendinous fascia, down to the patellar area. At this point, the area was thoroughly debrided and thoroughly irrigated. There were no further pockets of purulent material or necrotic skin. Once having debrided all necrotic tissue and drained all the purulent material, this area was then thoroughly washed as mentioned with saline.
Next, after adequate hemostasis was obtained, this was then packed with 4 x 4 gauze along with a sterile dressing. The estimated blood loss was minimal. None was transfused. No drains were placed. Sponge, needle, and instrument counts were correct x3 at the end of the case. The patient subsequently tolerated the procedure well. He was then returned to the recovery room in a very stable condition.
