Date of Surgery -
Preop Diagnosis - Sacral Wound
Postop Diagnosis - Sacral Wound
Surgeon - Dr. Luk/Dr. Dan Tran
Anesthesia - GETA
Blood Loss - Minimal
Complication - None
Findings - Sacral Wound
Specimens -
Sacral Wound Tissue
Bone Biopsy
Procedure Performed-
1) Excisional Debridement of complex Sacral wound requiring post op packing
2) Bone Biopsy
Patient comes in with the above diagnosis and was consented for the above procedures. Risks, benefits, and alternatives were discussed with patient, which includes, but are not limited to, postoperative or chronic pain, bleeding, wound infection, hematoma, injury to other organs, or need for further procedures or workup. Other Complications may include deep vein thrombosis(blood clots), as well as other side effects affecting other organ systems such as the heart or lungs, and in rare circumstances, death as a result of the above complications. The patient understand and agrees to proceed with the proposed procedure.
The Patient was given preoperative antibiotics.
After consent was obtained, the patient was brought to the OR and underwent general anesthesia. The patient was prep and draped in the standard manner.
Timeout was performed and all was in agreement.
The patient was brought to the OR today for debridement
The patient underwent anesthesia without any complication.
Sacral Wound Debridement:
Patient was properly positioned to expose the wound.
Combination of sharp debridement as well as debridement using the electrocautery was used to remove the necrotic tissue
The size of the debridement is as follows:
Length:
With:
Depth:
The wound was debrided to healthy tissue. This was performed using combination of sharp debridement as well
as debridement using the electrocautery.
Hemostasis was obtained using electrocautery.
Bone Biopsy --------------------------------- if done
After the procedure was completed, the w ound cavity was irrigated using sterile saline
Wound packed for post-op moist to dry dressing and expectant secondary healing
At the end of the case, counts were carried out. Instrument, sponge, and needle counts were completed and reported to me as correct.
Because this is a complex wound, the patient may need staged debridement.
Will start dressing changes postoperative day 1.
Hemostasis was obtained,. Patient tolerated procedure well. Was transferred to recovery in stable and satisfactory condition.