rockylopez
Networker
Hello 
I really need help with this OP report. Patient had csection and returned back to Or the following day for dehiscence of csection wound.
Post-procedure diagnosis:
1.Dehiscence of C/S wound in its entire length
2.Herniation of bowels and omentum.
3.H/O primary C/S , day #7
4.Advanced maternal age
5.Positive for Influenza A
6. Past H/O syphilis and treatment
7. Current URI, hacking cough and pneumonia
8. H/O amphetamine and THC use.
Procedures performed:
1. Reduction of herniated bowel and omentum.
2. Closure of fascial dehiscence.
Technique/Procedure:
S/P primary LTCS day 2 has been suffering from hacking cough, URI and pneumonia. As a result of her violent cough and possibly decreased immunity sutem, her wound completely dehisced in its entire length and had herniation of partial large bowels with omentum..She was promptly taken to the OR for repair.
Operative findings:
Partial bowel with omentum had extruded outside of the abdominal wall through the C/S wound.
The bowels appeared healthy, non injured and uncompromised. No laceration or contusion was noted.
The fascia appeared mildly fragile and was torn through the suture. The suture material was was seen with the knots still present bilaterally. Some of the absorbable staples were seen embedded in the skin layers.
The uterine sutures were intact and appeared to be healing well.
There was no drainage,bleeding, gangrene or any other abnormality noted.
Complications: none
Estimated blood loss in ml's: none
Blood products: none
Specimens removed/altered: none
Cultures sent: No
Drain(s)/tube(s): none
Implant(s): none
Fluids:
IV per anesthetist.
Tourniquet:
none
Approach: open
Disposition: return to floor, stable
Recommendations:
Continue with IV Abx per ID physicians.
Otherwise routine post op care.
Counts:
Sponge count: correct
Instrument count: correct
Needle count: correct
Wound class: clean
Debridement Procedure
Debridement procedure:
Time out completed: yes
Wound location: facial
Wound description: new
Anesthetics: none
Type: non-excisional
Tissue debrided: fascia, fat, skin, subcutaneous
Bleeding: none
Hemostasis: none required
Instruments used: pickups
Dressings: Perineo with Dermabond
Free Text Op Notes
Free Text Op Notes:
Details of the procedure:
The patient was taken to the operating room and placed supine on the operating table. Time out was completed. She received General Endotracheal anesthesia without any difficulty.
Patient was prepped and draped in usual sterile manner. The bowels and the omentum which were lying on top of the abdomen were first cleansed with betadine followed by hibiclens solution 1000 ml. Then it was washed off with 1000 ml of 0.9% NS. The bowels and the omentum were reduced and gently placed back in the abdominal cavity. The abdominal walls were then lifted up and a solution containg 2 G of vancomycin mixed in 0.9% NaCl was poured in the abdominal cavity on top and around the bowel.
Once the bowels were reduced, the closure of the abdominal wall was carried out.
All the old sutures and absorbable staples were removed from the wound edges. The upper and lower abdominal wall edges were cleansed thoroughly. As stated before, the fascia appeared mildly fragile and was torn through with the previous suture. There were no signs of tissue necrosis.
The rectus fascia was closed using 0-PDS and 0-Vicryl in alternate, interrupted vertical mattress sutures for reinforcement in its entire length.
Once the rectus fascia was closed, the bed of the wound was irrigated with NS. The Scarpa's fascia was closed using 2-0 vicryl in interruped manner. The skin was approximated using 3-0 monocryl suture in running subcuticular manner. A Perineo mesh and Dermabond was used on the skin.
The patient tolerated the procedure well. There were no complications of the procedure.
Needle, sponge and instrument counts were correct x 2 at the end of the procedure.
The patient was extubated and taken to the RR in satisfactory condition with stable vital signs and spontaneous respirations.
I really need help with this OP report. Patient had csection and returned back to Or the following day for dehiscence of csection wound. Post-procedure diagnosis:
1.Dehiscence of C/S wound in its entire length
2.Herniation of bowels and omentum.
3.H/O primary C/S , day #7
4.Advanced maternal age
5.Positive for Influenza A
6. Past H/O syphilis and treatment
7. Current URI, hacking cough and pneumonia
8. H/O amphetamine and THC use.
Procedures performed:
1. Reduction of herniated bowel and omentum.
2. Closure of fascial dehiscence.
Technique/Procedure:
S/P primary LTCS day 2 has been suffering from hacking cough, URI and pneumonia. As a result of her violent cough and possibly decreased immunity sutem, her wound completely dehisced in its entire length and had herniation of partial large bowels with omentum..She was promptly taken to the OR for repair.
Operative findings:
Partial bowel with omentum had extruded outside of the abdominal wall through the C/S wound.
The bowels appeared healthy, non injured and uncompromised. No laceration or contusion was noted.
The fascia appeared mildly fragile and was torn through the suture. The suture material was was seen with the knots still present bilaterally. Some of the absorbable staples were seen embedded in the skin layers.
The uterine sutures were intact and appeared to be healing well.
There was no drainage,bleeding, gangrene or any other abnormality noted.
Complications: none
Estimated blood loss in ml's: none
Blood products: none
Specimens removed/altered: none
Cultures sent: No
Drain(s)/tube(s): none
Implant(s): none
Fluids:
IV per anesthetist.
Tourniquet:
none
Approach: open
Disposition: return to floor, stable
Recommendations:
Continue with IV Abx per ID physicians.
Otherwise routine post op care.
Counts:
Sponge count: correct
Instrument count: correct
Needle count: correct
Wound class: clean
Debridement Procedure
Debridement procedure:
Time out completed: yes
Wound location: facial
Wound description: new
Anesthetics: none
Type: non-excisional
Tissue debrided: fascia, fat, skin, subcutaneous
Bleeding: none
Hemostasis: none required
Instruments used: pickups
Dressings: Perineo with Dermabond
Free Text Op Notes
Free Text Op Notes:
Details of the procedure:
The patient was taken to the operating room and placed supine on the operating table. Time out was completed. She received General Endotracheal anesthesia without any difficulty.
Patient was prepped and draped in usual sterile manner. The bowels and the omentum which were lying on top of the abdomen were first cleansed with betadine followed by hibiclens solution 1000 ml. Then it was washed off with 1000 ml of 0.9% NS. The bowels and the omentum were reduced and gently placed back in the abdominal cavity. The abdominal walls were then lifted up and a solution containg 2 G of vancomycin mixed in 0.9% NaCl was poured in the abdominal cavity on top and around the bowel.
Once the bowels were reduced, the closure of the abdominal wall was carried out.
All the old sutures and absorbable staples were removed from the wound edges. The upper and lower abdominal wall edges were cleansed thoroughly. As stated before, the fascia appeared mildly fragile and was torn through with the previous suture. There were no signs of tissue necrosis.
The rectus fascia was closed using 0-PDS and 0-Vicryl in alternate, interrupted vertical mattress sutures for reinforcement in its entire length.
Once the rectus fascia was closed, the bed of the wound was irrigated with NS. The Scarpa's fascia was closed using 2-0 vicryl in interruped manner. The skin was approximated using 3-0 monocryl suture in running subcuticular manner. A Perineo mesh and Dermabond was used on the skin.
The patient tolerated the procedure well. There were no complications of the procedure.
Needle, sponge and instrument counts were correct x 2 at the end of the procedure.
The patient was extubated and taken to the RR in satisfactory condition with stable vital signs and spontaneous respirations.
