RLHORTON
New
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IMMEDIATE POST OP NOTE
PRE-OPERATIVE DIAGNOSIS:
Right leg necrotizing soft tissue infection
POSTOPERATIVE DIAGNOSIS:
The same
TYPE OF PROCEDURE:
Wide debridement of right leg necrotizing soft tissue infection, fasciotomy
FINDINGS:
Patient initially evaluated earlier today, after discussing the case further with the medical team and the wound care nurse I was very concerned that this was a progressing soft tissue infection most likely a necrotizing infection with areas of gangrene throughout the right lower extremity, and even with his high surgical risk observation could be more detrimental and I favored debridement, I discussed this also with his son explained the severity of his condition explained what a wide debridement could entail meaning resecting a significant amount of soft tissue as well as a muscle loss of muscle function peroneal nerve injuries loss of limb function, and also if the infection progresses despite aggressive debridement he may need an amputation, also explained the possibility of prolonged wound care most likely will need skin grafts etc.
DETAILS OF THE PROCEDURE:
Following COVID-19 protocol the patient was intubated in the ICU by the anesthesia team and brought to the OR, in the OR his right lower extremity which had been marked, site was confirmed the right lower extremity was prepped and draped in a sterile fashion and placed in a candycane in order to expose the posterior aspect of the right leg the necrotic skin changes extended almost circumferentially leaving an anterior healthy area of skin covering his tibia but for the most part the rest of the skin and the leg was completely necrotic to confirm the diagnosis I first debrided central aspect where there was full-thickness tissue necrosis underlying skin was completely necrotic I then proceeded to extend my incision up to the demarcated areas confirming the diagnosis of necrotizing fasciitis the area of skin necrosis reached full-thickness throughout the whole demarcated area all the skin was excised reaching the wound care edges where I started to obtain some bleeding, the debridement was done with the electrocautery it was done down to the fascia and the muscle some areas of the muscle were completely necrotic and this was mostly along the gastrocnemius which was excised with the skin specimen, so the debridement went down to the muscle, there was still some areas of questionable muscle integrity by I elected not to excise it, as I open the fascial compartments the muscle underneath was healthy and the rest of the muscle started to appear a little bit healthier to the compartments opened where the lateral and anterior compartment and the superficial posterior compartments were opened exposing the muscle which was healthy underneath. Measurements of this wound were 30 x 15 cm but to describe it. It extended from the popliteal fossa down to the ankle almost circumferentially leaving a bridge of skin anteriorly most of the edges of the skin started to have some bleeding which I was comfortable with and elected to stop my debridement at this level. Hemostasis was confirmed Adaptic was placed over the open wound and the rest of the dressing was placed sterile dressing.
IMMEDIATE POST OP NOTE
PRE-OPERATIVE DIAGNOSIS:
Right leg necrotizing soft tissue infection
POSTOPERATIVE DIAGNOSIS:
The same
TYPE OF PROCEDURE:
Wide debridement of right leg necrotizing soft tissue infection, fasciotomy
FINDINGS:
Patient initially evaluated earlier today, after discussing the case further with the medical team and the wound care nurse I was very concerned that this was a progressing soft tissue infection most likely a necrotizing infection with areas of gangrene throughout the right lower extremity, and even with his high surgical risk observation could be more detrimental and I favored debridement, I discussed this also with his son explained the severity of his condition explained what a wide debridement could entail meaning resecting a significant amount of soft tissue as well as a muscle loss of muscle function peroneal nerve injuries loss of limb function, and also if the infection progresses despite aggressive debridement he may need an amputation, also explained the possibility of prolonged wound care most likely will need skin grafts etc.
DETAILS OF THE PROCEDURE:
Following COVID-19 protocol the patient was intubated in the ICU by the anesthesia team and brought to the OR, in the OR his right lower extremity which had been marked, site was confirmed the right lower extremity was prepped and draped in a sterile fashion and placed in a candycane in order to expose the posterior aspect of the right leg the necrotic skin changes extended almost circumferentially leaving an anterior healthy area of skin covering his tibia but for the most part the rest of the skin and the leg was completely necrotic to confirm the diagnosis I first debrided central aspect where there was full-thickness tissue necrosis underlying skin was completely necrotic I then proceeded to extend my incision up to the demarcated areas confirming the diagnosis of necrotizing fasciitis the area of skin necrosis reached full-thickness throughout the whole demarcated area all the skin was excised reaching the wound care edges where I started to obtain some bleeding, the debridement was done with the electrocautery it was done down to the fascia and the muscle some areas of the muscle were completely necrotic and this was mostly along the gastrocnemius which was excised with the skin specimen, so the debridement went down to the muscle, there was still some areas of questionable muscle integrity by I elected not to excise it, as I open the fascial compartments the muscle underneath was healthy and the rest of the muscle started to appear a little bit healthier to the compartments opened where the lateral and anterior compartment and the superficial posterior compartments were opened exposing the muscle which was healthy underneath. Measurements of this wound were 30 x 15 cm but to describe it. It extended from the popliteal fossa down to the ankle almost circumferentially leaving a bridge of skin anteriorly most of the edges of the skin started to have some bleeding which I was comfortable with and elected to stop my debridement at this level. Hemostasis was confirmed Adaptic was placed over the open wound and the rest of the dressing was placed sterile dressing.