PREOPERATIVE DIAGNOSIS: Wound dehiscence secondary to infection.

POSTOPERATIVE DIAGNOSIS: Wound dehiscence secondary to infection.

OPERATION PERFORMED: Debridement of wound with closure of fascia.

SURGEON: John Doe, MD

ASSISTANT: None.

ANESTHESIA: General endotracheal.

ANESTHESIOLOGIST: Jane Doe, MD

FLUIDS: 800 mL of crystalloid.

DRAINS: #7 Blake to peritoneal cavity.

COMPLICATIONS: None.

ESTIMATED BLOOD LOSS: Approximately less than 200 mL.

DESCRIPTION OF OPERATION: The patient was taken to the operating room and placed on the operating table in the supine position. General endotracheal anesthesia was performed. A Foley catheter was inserted using the aseptic technique. The patient’s abdomen was prepped and draped using the aseptic technique.

Attention was then turned to the patient’s incision. The edges of subcutaneous fat were excised using electrocautery. There was good healthy bleeding tissue noted. Edges of the fascia on each side were then incised using electrocautery. There was healthy bleeding tissue noted. Cultures of aerobic and anaerobic were taken of the wound. The wound was then irrigated out with saline, hydrogen peroxide half-and-half solution. A #7 Blake drain was introduced through a stab wound and placed in a subfascial level in the peritoneal cavity. This was sutured to the skin using 2-0 silk. The midline fascia was then approximated from the upper portion of the wound to the mid portion and then from the lower portion up with #1 Prolene running continuous suture.

The wound was then irrigated out with sterile water. Good hemostasis was obtained. The wound was then packed with Kerlix, normal saline drenched gauze. Sterile 4 x 4s, ABD, and tape were applied. A central line was placed. The patient was then extubated and transported to the recovery room in stable and satisfactory condition. Postoperative instructions, including signs to watch for, as well as followup instructions were provided to the patient and family.

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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.

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REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Worsening left lower extremity ulcers.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old who resides in a local life care facility. She reports that she has had a chronic ulcer of her left lower extremity for the last 30 years. Over the past 30 years, she has had an extensive array of therapies for this nonhealing, extremely chronic leg ulcer. These therapies have included a variety of local therapies, hyperbarics, multiple hospitalizations, and innumerable antibiotic courses. In spite of all these efforts, these lesions were never completely healed, though until recently the patient was able to ambulate and have some reasonable quality of life with the left lower extremity. She reports in the recent months, she has had more pain, unsteadiness, and inability to ambulate, and has been essentially confined to a wheelchair for the past four months. She is admitted today with worsening swelling and pain of the left lower extremity and particularly the area around the chronic ulcerations. She was treated as an outpatient at the life care facility with a course of ceftriaxone as well as good local care and in an attempt to turn the tide of this worsening ulcerative process involving the left lower extremity, but this was unsuccessful. The patient denies any recent fevers, chills, sweats, worsening headaches, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea or genitourinary symptoms.

PAST MEDICAL HISTORY:
1. Peripheral vascular disease.
2. Lymphedema, left greater than right lower extremity.
3. History of DVT in the past.
4. Diabetes mellitus.
5. Degenerative joint disease.
6. Coronary artery disease.

ALLERGIES: The patient has no known allergies.

SOCIAL HISTORY: The patient lives at the life care facility. She does not smoke nor drink.

REVIEW OF SYSTEMS: Review of systems was done in its entirety and the pertinent positives and negatives have been included in the history of present illness.

FAMILY HISTORY: Noncontributory and not relevant.

PHYSICAL EXAMINATION: At this time, reveals an elderly Hispanic woman who appears somewhat younger than her stated age, lying supine comfortably in her hospital bed. She is alert, conversant, and able to give a good history. She is currently afebrile than she has been since the time of admission. Blood pressure of 104/52, pulse 80, and respiratory rate 18 and unlabored. Examination of the head reveals no evidence of trauma. The eyes are notable for bilateral arcus senilis and diminished vision bilaterally, which the patient reports is due to macular degeneration. Examination of the oral cavity reveals no thrush or oral leukoplakia. There are no pharyngeal abnormalities present. The patient’s neck is without JVD and there is no supraclavicular adenopathy. Lung examination is clear. Cardiac exam reveals regular rate and rhythm without murmurs, rubs or gallops. The patient’s abdomen is soft and nontender without organomegaly and without ascites. Examination of the lower extremities is notable for venous stasis changes on both feet. There are diminished peripheral pulses in both lower extremities as well and, in fact, we cannot palpate any pulses in the left lower extremity below her level of the femoral artery. The patient’s major abnormal physical findings were on the left leg, below the knee. There is an area of erythema and diffuse tenderness, which extends below the level of the mid chin. There are three large purulent venous ulcers; the largest one measuring 8.5 x 2.5 cm. Two other ulcers are present, one on the dorsum and one on the medial aspect of the ankle. These are approximately 2.5 cm in circumference and all three of these are covered with a purulent exudative material.

LABORATORY STUDIES: White count was 5000, hematocrit 42, creatinine 0.6, AST of 44. Two blood cultures have been done, and they are negative at this point. A Gram stain obtained from the purulent material from the left foot has revealed 3+ gram-negative rods. A chest x-ray shows cardiomegaly, which is old without an infiltrate.

IMPRESSION: This (XX)-year-old woman has had an impressive 30-year history of nonhealing stasis ulcers on her left leg. She now reports that these ulcers have progressed to the point where they are the worst they have ever been. This is in spite of good local care at the extended care facility as well as her recent course of ceftriaxone. At this point, all three of these are chronic ulcers. They appear to be heavily superinfected, and the wound care team has initiated a program of Accuzyme topical therapy. In addition to this, systemic antibiotics will be necessary. Zosyn has already been started and we think that is the reasonable choice pending evaluation of what these gram-negative rods are, but it is certainly possible that highly resisting gram-negative rods will be found given the pretreatment with ceftriaxone. One question which obviously stands out in this patient is whether or not her left lower leg, below the knee, is still viable given the history of worsening ulcers, which now seem refractory to conventional measures.

RECOMMENDATIONS:
1. Agree with Zosyn.
2. We will reevaluate when we have back the culture information tomorrow.
3. We agree with the plans for local care as outlined by the wound care team.

Thank you very much for allowing us to see this patient in consultation.

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HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old diabetic female who is here for a followup. She denies any new complaints. She is clinically doing well.

PAST MEDICAL HISTORY: Unchanged.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature is 98.2, respiratory rate is 20, pulse is 90, and blood pressure is 120/64. Her blood sugar today was 122.
INTEGUMENT: On examination of the left posterior thigh, the wound is 0.4 x 0.5 x 0.1 cm, the left shin wound is 9.5 x 12.6 x 0.1 cm, the right abdominal wound is 0.3 x 1.2 x 0.1, and right lateral leg wound is 2 x 1 x 0.1 cm.

TREATMENT: After the application of 5% lidocaine for topical anesthesia, under clean surgical technique, the left posterior thigh wound, the left shin wound, and the right abdominal wound were all debrided with a curette into the subcutaneous tissue. The patient tolerated the procedure well. Hemostasis was obtained by pressure alone. Post-debridement measurements for the left posterior thigh wound were 0.4 x 0.6 x 0.2, left shin wound was 9.5 x 12.7 x 0.2, and the right abdominal wound was 0.4 x 1.3 x 0.2. The patient tolerated the procedure well. Hemostasis was obtained by pressure alone.

IMPRESSION: Venous insufficiency ulceration involving lower extremities and decubitus ulcer involving the posterior thigh area. The decubitus ulcers on the thigh were doing better, but she has a small opening since last week on the left posterior thigh. The right leg appears to be doing a little bit better. After the debridement, it was strongly emphasized that no Band-Aids be applied to her skin. When she came in today, she had a Band-Aid on her right thigh, which when taken off started to bleed, as she is on Coumadin. Also, the patient is using lidocaine ointment, so we have asked not to use any lidocaine ointment to the abdominal folds or buttock area. The patient can use it in the perineal area as has been recommended by her primary physician. Bactroban with betamethasone with barrier cream should be applied to the periulcer skin on the right and left shin with Acticoat Flex to ulcer, Xtrasorb, ABD, 3M Coban. The right abdominal wound should be covered with barrier cream, Allevyn Gentle to be changed every two to three days. The leg dressings do not need to be changed. Zinc barrier cream should be applied liberally to the right and left posterior thigh, abdominal folds, and buttock b.i.d., Allevyn Gentle to the left posterior thigh or cream to be changed every two to three days. All this was discussed with the patient and spouse in detail. The patient will come back and see us next Wednesday.

Wound Care / Pain Clinic Terms

DATE OF SERVICE: MM/DD/YYYY

This (XX)-year-old female has been treated for multiple venous stasis ulcers of the left lower extremity. The patient has been treated with an Acticoat dressing and a PolyMem foam over the Acticoat and a Profore wrap. She is having this changed twice weekly, but because of the weather, she was unable to make it into the wound center this past Thursday. When she arrived today, there was a considerable odor to the wound. The patient has had no pain from the wound. She has otherwise had no change in her medical condition or her medications.

PHYSICAL EXAMINATION:
VITAL SIGNS: Her exam today reveals blood pressure of 142/82, pulse of 72, respirations 18, and temperature 98.4 tympanically.
EXTREMITIES: Examination of the left lower extremity reveals that the ulcer, which was located laterally, has now completely healed. There is some dry scale that we removed from this area, but there was no open ulceration noted. The ulcer on the medial aspect of the left lower extremity is healing well as well. The ulcer measures 11.2 x 4.8 x 0.2 cm. There is some hypertrophic granulation tissue in the ulcer base, which we have debrided sharply with a sharp curette. Bleeding was controlled with pressure alone.

An Acticoat 3 dressing followed by PolyMem foam and a Profore wrap was then placed on the leg. The patient was asked to return to the wound center in another four days for re-examination.

Wound Care Products List

DATE OF SERVICE: MM/DD/YYYY

HISTORY OF PRESENT ILLNESS: This (XX)-year-old female presents to the Wound Care Clinic for followup treatment of a chronic nonhealing ulceration to her right leg. The patient states that the leg has not been painful and that she feels it is improving. She did not have any difficulties with the bandage.

PHYSICAL EXAMINATION:
VITAL SIGNS: Stable, patient is afebrile.
INTEGUMENT: Reveals full-thickness ulceration, medial right leg, with a large amount of beefy red granulation tissue and a small amount of serosanguineous drainage present. There is no fibrotic or black necrotic tissue noted. There is a hyperpigmentation that remains to the periwound with no signs of infection noted. The ulceration measures 1.6 x 1.2 x 0.2 cm in diameter.

IMPRESSION: Chronic nonhealing ulcer, right leg.

PLAN: Following examination of the right leg, 5% viscous lidocaine was applied for topical anesthesia. The right leg ulceration was then debrided through the level of the subcutaneous tissue. The patient tolerated this uneventfully. A new piece of OASIS was affixed to the wound surgically. Mepitel and Xenaderm were applied to the periwound. An Allevyn foam dressing was applied for compression followed by a Profore four-layer compression bandage. The patient will follow up in the Wound Care Clinic in one week.

Wound Care Sample

DATE OF SERVICE: MM/DD/YYYY

HISTORY OF PRESENT ILLNESS: This (XX)-year-old male is being treated in the Wound Center for a Wagner grade 2 ulcer of the tip of the toe and dorsum of the left ankle. The patient has been applying Regranex to the ulcers. Although, Dr. John Doe’s note stated that the patient was going to be applying Prisma and Regranex, the patient does not have any Prisma at home. The patient has not had any pain from the ulcers. His medical health has not changed since his last visit and his medications have not changed.

PHYSICAL EXAMINATION:
VITAL SIGNS: Today reveals a blood pressure of 132/72, pulse of 74, respirations 18, and temperature is 97.2 tympanically. His blood sugar is 132.
EXTREMITIES: Examination of an ulcer on the shin reveals no open ulceration but merely a crust over the ulcerated area. The same is true of the lesion on the dorsum of the left ankle, which is crusted.

TREATMENT AND PLAN: We debrided this in a partial-thickness fashion removing some of the crust from the edges, and the skin under the crust was healed. The crust is firmly in place over the central portion of the ulcer and we did not disturb it. There is also a 0.5 x 0.3 x 0.2 cm ulcer on the tip of the left second toe, which we debrided into the subcutaneous tissue plane sharply. We also removed a thick callus from the tip of the toe. After debridement, there was a quite a bit of bleeding, which was cauterized with silver nitrate. We then applied Prisma to this ulcer and have advised the patient to apply Regranex and Prisma to the ulcer on a daily basis. The patient was given the Prisma that was used to treat him. The patient was asked to return to the Wound Center in one week for followup examination.

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