DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Stage IV sacral pressure sore.
POSTOPERATIVE DIAGNOSIS: Stage IV sacral pressure sore.
PROCEDURES PERFORMED:
1. Excisional prep of sacral decubitus ulcer.
2. Partial sacrectomy.
3. V to Y myocutaneous gluteal flap.
SURGEON: John Doe, MD
ANESTHESIA: General.
SPECIMENS: Sacral bone sent for culture and pseudobursa sent for permanent pathology.
DRAINS: Jackson-Pratt x 2.
ESTIMATED BLOOD LOSS: 200 mL.
COMPLICATIONS: None immediate.
DISPOSITION: Stable to PACU.
DESCRIPTION OF OPERATION: After obtaining written consent, the patient was taken to the operating room by gurney, intubated via endotracheal tube, and transferred to the operating room table in the prone position. After assuring that all pressure points were well padded and that the airway was stable, we then prepped the patient’s lower back, buttocks, and upper thighs with Betadine and draped in standard sterile fashion. One gram of Ancef was given preoperatively. A time-out was performed indicating patient, procedure, and side to be operated on.
First, attention was turned to excision of the pseudobursa. This was done by soaking a gauze sponge in methylene blue and placing it within the bursal cavity. The cavity was then excised circumferentially with 15 blade and electrocautery. The pseudobursa was moved off of the sacrum with a combination of electrocautery and periosteal elevator. The intact bursa was then sent for permanent pathology. Several bony spurs were reduced with a rongeur and a portion of the sacrum was removed via rongeur inferiorly. A few of the bony specimens were sent for culture to rule out osteomyelitis.
After removal of the pseudobursa and the partial sacrectomy, we next moved forward with the dissection of the V to Y myocutaneous gluteal flap on the patient’s left buttock. The anatomy was mapped out with a marker and the anticipated sites of the perforating arteries from the inferior and superior gluteal artery system were marked. We then drew out a large V-shaped flap that measured approximately 20 cm in length x 10 cm in width. This was raised using a 15 blade to incise down through dermis and subcutaneous fat. Electrocautery was used to dissect through the subcutaneous tissue, beveling out away from the flap down to muscle and fascia. The muscle and fascia were incised circumferentially. The myocutaneous flap was then mobilized up on what we know was the inferior gluteal pedicle, possibly the superior gluteal pedicle. However, there was a good palpable pedicle within the territory of the flap.
We bluntly dissected around this pedicle for maximal mobilization. The flap was divided from its sacral attachment. This freeing up allowed the flap to be mobilized medially up over the sacrum. An additional bony ridge along the sacrum was removed with the rongeur. The flap was then secured up over the sacrum with 2-0 PDS sutures through the fascia across the bony prominence. Additional 2-0 PDS sutures were used to close the donor site of the wound in a V to Y fashion. The rest of the flap was secured with 2-0 PDS sutures through the fascia and Scarpa’s fascia. 3-0 PDS deep dermal sutures were placed around the periphery of the flap for additional closure of the dermis. The epidermis was approximated with surgical staples.
Prior to closure of the flap, two drains, one 15 French and one 19 French Blake, were placed superiorly and inferiorly along the underside of the flap. These were placed to suction. Once all the wounds were closed, the area was cleansed. Bacitracin and Adaptic were placed over the incision, as well as sterile gauze and paper tape. The patient tolerated the procedure well.
