PREOPERATIVE DIAGNOSES:
1. Wound to the left foot, status post incision and drainage.
2. Gangrene of the left forefoot.
3. Peripheral vascular disease.
POSTOPERATIVE DIAGNOSES:
1. Wound to the left foot, status post incision and drainage.
2. Gangrene of the left forefoot.
3. Peripheral vascular disease.
PROCEDURE PERFORMED: Transmetatarsal amputation of the left foot.
SURGEON: John Doe, MD
ANESTHESIA: Local with sedation.
HEMOSTASIS: Pneumonic ankle tourniquet.
OPERATIVE INDICATIONS: The patient had been admitted to the hospital for an infection of the left foot, gangrenous changes, as well as PVD. The patient also had significant coronary artery disease and CABG is pending. At this point, after revascularization procedures, decision was made for transmetatarsal amputation to remove any remaining necrotic tissue, but primary to close the wound to prepare the patient for CABG without presence of infection. Informed consent was read and signed.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and placed on the operating room table in the supine position with an IV intact for intravenous sedation. Local anesthesia was then obtained utilizing a total of 20 mL of 0.5% Marcaine, 1% Xylocaine in the form of a regional block of the left ankle. The patient was prepped and draped in the usual and aseptic manner.
The foot was elevated and pneumatic ankle tourniquet was elevated to 250 mmHg. Our attention was then directed to the distal aspect of the left foot. At this time, a transverse incision was performed across the dorsal aspect of the left foot, across the base of the remaining second and third toes. This incision encompassed all sites of necrotic tissue with one proximal extension on the plantar distal aspect. At this time, the metatarsals were exposed into the surgical site. The distal metatarsals were resected utilizing a sagittal saw. Approximately two-thirds of the fifth metatarsal was resected.
At this time, the skin edges could easily be well opposed. At this time, the inspection was completed. The sesamoid apparatus was removed from the plantar soft tissue structures of the first metatarsal. Any residual hematoma was removed. There was no pus, no further necrosis about the soft tissues as well. One final copious irrigation was completed. At this time, subcutaneous tissues were reapproximated utilizing 3-0 Vicryl suture. A 7 round Jackson-Pratt drain was placed. At this time, the decision was made for skin closure as well. This was completed with skin staples and 4-0 nylon suture.
The surgical site was dressed with Xeroform and a dry sterile dressing with minimal compression. The patient was discharged from the operating room with vital signs stable in apparent stable condition and transported to recovery room without complication.
FINDINGS: No further significant necrosis, no pus, no further soft tissue breakdown. Positive perfusion of soft tissues. Osseous structures appeared to be viable as well.
