DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Right ring finger tip amputation.
POSTOPERATIVE DIAGNOSIS:
Right ring finger tip amputation.
OPERATION PERFORMED:
Right ring fingernail matrix ablation, revision of amputation, V to Y advancement flap.
SURGEON: John Doe, MD
ANESTHESIA: General
TOURNIQUET TIME: 25 minutes.
COMPLICATIONS: None.
CONSENT: Discussion was made of the risks, potential complications, and treatment alternatives. The patient understands that the risk of surgery include but are not limited to bleeding, infection, nerve injury, blood vessels injury which may cause potentially permanent numbness, pain, tingling, stiffness, regional pain syndromes, and that he may be worse off after surgery than he is at present. The patient understands that he may require a full-thickness skin graft and he may require a cross-finger flap, which would necessitate an additional procedure. The patient understands that he may require additional procedure were he to have some sort of complication, in particular infection or neurovascular injury. The patient understands these risks. The patient was given the opportunity to ask questions, has demonstrated understanding of risks of surgery, and has agreed to proceed with the procedure.
DESCRIPTION OF OPERATION: The patient was transported to the operating room where the anesthesia service administered antibiotics and performed a Betasept prep from the fingertips to the axilla. Sterile tourniquet was applied. The arm was elevated, and the tourniquet was inflated to 250 mmHg for a total of 25 minutes.
The nail matrix was sharply excised. The ulnar spike of the distal phalanx was recontoured to realign the base of the distal phalanx, which did have flexor digitorum profundus attached to it in a fashion that would be less likely to be painful in the future. The bone was copiously irrigated and scrubbed with a sterile scrub brush. A V to Y advancement flap was created and contoured and repaired to the dorsal nail folds with 5-0 nylon. The V flap was turned into a Y flap with the most proximal aspect of the wound closed with 5-0 nylon and the remainder of the advancement flap repaired also with 5-0 nylon.
At the completion of the procedure, brisk capillary refill was noted within the skin flap. Sterile dressing was applied, including Xeroform, single 4 x 4, 2-inch Conform, 4 x 15 inch one-step extension block splint. At the end of the procedure, all sponge and needle counts were correct. The patient was transported to the recovery room in good condition.
