DATE OF OPERATION:
MM/DD/YYYY
PREOPERATIVE DIAGNOSIS:
Ischemic gangrene and rest pain, right foot, with nonreconstructable arterial occlusive disease.
POSTOPERATIVE DIAGNOSIS:
Ischemic gangrene and rest pain, right foot, with nonreconstructable arterial occlusive disease.
OPERATION PERFORMED:
Right below-the-knee amputation with immediate fit prosthesis.
SURGEON: John Doe, MD
ANESTHESIA:
General endotracheal.
COMPLICATIONS:
None.
INDICATIONS FOR OPERATION:
This is a patient on chronic hemodialysis, who presented with a right great toe gangrene and underwent a right great toe amputation, which was felt to have the possibility of healing despite mildly abnormal transcutaneous oxygen measurements. This was attempted because of her severe inframalleolar arterial occlusive disease identified on angiography.
Despite attempts at conservative management, the wound did not heal. She also developed progressive rest pain and developed ulcerations on the ball of her foot and lateral foot as well as other toes. The patient no longer was manageable with conservative care, and it was recommended she undergo below-knee amputation. The patient understood the risks, benefits, and agreed to proceed.
DESCRIPTION OF OPERATION:
The patient was brought to the operating room and placed on the operating table in the supine position. After adequate induction of anesthesia and placement of a nonsterile tourniquet on the thigh, the right leg was prepped and draped in a sterile fashion. The intended level of amputation was chosen approximately a hand’s breadth or more below the level of the tibial plateau.
A skin incision was mapped out for the long posterior flap. Skin incision was then made after inflation of the tourniquet to 350 mmHg. The skin was incised along the course of the marked incision down through the fascia of the compartments. The muscles of the anterior compartment were then divided using scalpel to identify the anterior tibial vascular structures. These were clamped and divided and then oversewn with 3-0 Prolene. The entire anterior compartment was opened. The tibia was then mobilized using a periosteal elevator. It was then divided using the oscillating saw. The fibula was then mobilized and was divided with a hand bone cutter approximately 1 cm above the level of the tibial transection. An amputation knife was then used to complete the amputation through the muscles of the lateral and posterior compartment.
The posterior tibial and peroneal arteries and veins were identified, dissected and clamped. They were then oversewn with 3-0 Prolene. The tibial nerve was mobilized and suture ligated with 3-0 chromic. Other bleeding points were controlled with limited electrocautery as well as 3-0 chromic suture ligations. At this point, the tourniquet was deflated. Other bleeding points were identified and once again controlled with limited electrocautery and 3-0 chromic sutures. The anterior surface of the tibia was then beveled.
After hemostasis had been obtained, the wound was irrigated with antibiotic solution. The fascia of the posterior calf was then approximated to the fascia of the anterior calf using 2-0 Vicryl sutures in a buried fashion. After this was completed, the skin was approximated using staples. A light clean dressing was applied and an immediate prosthesis was placed. The patient was then extubated and transferred to the recovery room in stable condition with no apparent complications following the procedure.
