Date of Surgery -
Preop Diagnosis - abscess
Postop Diagnosis - Same
Surgeon - Dr. Luk / Dr. Tran
Anesthesia - General anesthesia
Estimated Blood Loss - Minimal
Complication - none
Findings - abscess
Specimen - tissue for culture and pathology
Procedure performed - Debridement
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, 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 understands 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.
Patient was properly positioned to expose the wound.
Debridement was carried out using both sharp and electrocautery.
The wound was debrided to healthy tissue. Cultures were obtained.
Hemostasis was obtained using electrocautery.
Wound 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.
Patient tolerated procedure well. Was transferred to recovery in stable and satisfactory condition.