DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Severe sternal infection.
POSTOPERATIVE DIAGNOSIS: Severe sternal infection.
PROCEDURE PERFORMED: Sternal debridement and sternal wound debridement.
SURGEON: John Doe, MD
CO-SURGEON: Jane Doe, MD
ANESTHESIA: General endotracheal.
COMPLICATIONS: None.
INDICATIONS FOR PROCEDURE: This is a (XX)-year-old African-American female with a complex past medical history, including morbid obesity, pulmonary hypertension, and sleep apnea, who is status post ascending aorta replacement, aortic valve replacement, and two-vessel bypass surgery done last year, who presented to an outside hospital with overwhelming sepsis and evidence of sternal wound infection. The patient has gone back to the operating room for several debridements and now appears to have good granulation tissue in her wound and appears to be stable for wound closure and flap closure. We will plan on taking her back to the operating room and consult with Plastic Surgery to close the wound with rectus and pectoral flap.
DESCRIPTION OF PROCEDURE: The patient was identified and placed on the operating room table in the supine position. General endotracheal anesthesia was induced. The chest, lower extremities, and abdomen were prepped and draped in the normal sterile fashion. The patient was given IV antibiotics prior to start of the case.
We opened up the previously placed sternal wound and simultaneously Dr. Jane Doe from Plastic Surgery began mobilizing the rectus flap for his flap procedure. We opened up the wound. We debrided the rest of the left side of the sternum and completed the sternectomy. We then removed any other tissue that appeared to be necrotic. The patient’s wound overall was granulating very well. There was no evidence of any residual infection at this time. We checked for any other draining fluid. There was none.
When we were sure everything was going well, we then packed the wound, and we will now allow Plastic Surgery to complete the flap closure at this time. We did send off the tissue for culture as well as sensitivities. The wound was pulsavac’d with 3 liters of sterile saline solution and suctioned until clear. The plastic surgeons will complete the procedure at this point.
