DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Nonhealing left first and second toe amputation with third toe gangrene.
POSTOPERATIVE DIAGNOSIS: Nonhealing left first and second toe amputation with third toe gangrene.
OPERATION PERFORMED: Completion left transmetatarsal amputation.
SURGEON: John Doe, MD
ANESTHESIA: General endotracheal.
INDICATIONS FOR OPERATION: The patient is an (XX)-year-old lady who has had progressive gangrene of her left first and second digit. She developed foot infection and required emergent amputation of these. Prior to that time, she had undergone balloon angioplasty of her popliteal artery, which was severely stenotic. During this hospitalization, with dressing changes, the central portion of the wound improved and granulated. However, the peripheral tissue showed full-thickness slough, including the adjacent third toe. It was recommended that the patient be brought back to the operating room for debridement and possible transmetatarsal amputation to facilitate healing. The patient agreed understanding the risks, benefits, and other options.
DESCRIPTION OF OPERATION: The patient was brought to the operating room and placed on the operating table in the supine position. After adequate induction of anesthesia, the left foot was prepped and draped in a sterile fashion. It was decided at this point, because of the extent of third toe gangrene, to proceed with a transmetatarsal amputation.
An incision was made around the base of the previously open wound and healthy tissue and continued out laterally on the dorsal surface of the foot just proximal to the web spaces and underneath the plantar aspect of the foot in a similar fashion. The incision was continued through the soft tissue down to the shafts of the metatarsal bones. Using an oscillating saw, the third, fourth, and fifth metatarsal shafts were divided. The amputation was completed to the plantar flap leaving a healthy flap intact. The specimen was passed off the field. There was noted to be no purulence. The tissue that was transected was extremely healthy with good pulsatile bleeding.
Hemostasis was obtained with limited electrocautery and several sutures of 3-0 Vicryl. The second, third, fourth, and fifth metatarsal shafts were mobilized further, and using an oscillating saw, they were debrided back approximately 1 to 2 cm further to facilitate closure of the plantar flap. After this had been done and hemostasis had been obtained, the plantar flap was brought in approximation with the dorsal incision using interrupted 3-0 nylons. Care was taken not to place the flap under severe tension in order not to jeopardize the vascular supply. At this point, the remaining shaft of the first metatarsal was debrided proximally using a rongeur back approximately 1 cm. The surrounding tissue was all very healthy. It was packed with a saline silk gauze. A clean, sterile, dry dressing was applied, and the patient was transferred to recovery in stable condition having tolerated the procedure well.
