DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Tibial sesamoiditis, right foot.
POSTOPERATIVE DIAGNOSIS: Tibial sesamoiditis, right foot.
OPERATION PERFORMED: Excision of tibial sesamoid, right foot.
SURGEON: John Doe, DPM
ANESTHESIA: MAC with local.
HEMOSTASIS: Pneumatic ankle tourniquet.
ESTIMATED BLOOD LOSS: Minimal.
DESCRIPTION OF OPERATION: The patient was placed on the operating room table in the supine position. Following IV sedation, a local anesthetic block was obtained in a Mayo block fashion consisting of 10 mL of 0.5% Marcaine plain. It must be noted that the ankle pneumatic tourniquet was about the well-padded right ankle. The right lower extremity was scrubbed and draped sterilely. It must be noted that the injection of local anesthesia was performed after the sterile prep and draping. An Esmarch was utilized for exsanguination, and the pneumatic ankle tourniquet was inflated to 220 mmHg.
A 2.5 cm curvilinear incision was created at the medial aspect of the first metatarsal head tibial sesamoid junction. The incision was deepened through the subcutaneous layer utilizing blunt and sharp dissection with care being taken to identify and retract neurovascular structures.
The incision was deepened down to the level of bone, and with a #15 blade and tenotomy scissors, the tibial sesamoid was gently freed from all soft tissue surroundings and passed from the operative field. A Freer elevator was utilized to identify the flexor hallucis longus and brevis, which were noted to remain intact. The wound was flushed with normal saline solution.
The capsule was closed with 4-0 Vicryl, the subcutaneous layer was reapproximated with 4-0 Vicryl, and the skin was closed in a horizontal mattress and simple interrupted suture technique with 4-0 nylon. Decadron phosphate 1 mL and 1 mL of 0.5% Marcaine plain was injected for postoperative block. The incision was dressed with Adaptic, gauze, Kerlix and Elastoplast. The pneumatic ankle tourniquet was deflated, and prompt hyperemic response was noted to all digits of the right foot.
The patient tolerated the procedure and anesthesia well and was transferred to the recovery room in an apparent satisfactory condition with vital signs stable and vascular status intact.
