Removal of retained foreign body

28192 OR 27620?

TIA

MB,CCS,CPC

PREOPERATIVE DIAGNOSES:

1. Foreign body, right ankle

POSTOPERATIVE DIAGNOSES:

Same

PROCEDURE:

1. Excision of foreign body, right ankle

ANESTHESIA:

Local MAC

HEMOSTASIS:

A well padded tourniquet was placed about the right ankle set at 250 mmHg

INJECTABLES:

10cc of 2% lidocain eplain injected preop

10 mL of 0.5% marcaine plain was infiltrated post op

FLUIDS:

300 mL of Normal Saline

ESTIMATED BLOOD LOSS:

Less than 5 mL

SPECIMENS:

Culture was taken and sent to microbiology for culture and sensitivity.

Foreign body sent to surgical pathology.

COMPLICATIONS:

None.

DISPOSITION:

Stable.

MATERIALS:

1. Dressing Supplies

2.2-0 Vicryl

3. 3-0 nylon

SUMMARY:

The patient was brought to the operating room, placed in the supine position on the operative table. Time-out was performed reconfirming the patient's identity, planned procedure, and procedure site. All team members identified themselves. After adequate induction of anesthesia, the tourniquet was placed and the lower extremity was prepped and draped in the usual aseptic manner.

OPERATION:

Atterntion was directed to the lateral right ankle. Using fluoroscopy the foreign body was triangulated. A 3 cm linear incision was placed at the distal right lateral ankle approximately 5 cm proximal to the tip of the lateral malleolus. Incision was deepened through subcutaneous tissues, retracting all neurovascular structure and ligating all bleeders.

Intraoperatively it was noted there was a large foreign body granuloma that was invested in the peroneal muscle fascia. No purulence was noted upon incising the granuloma. Within the granuloma the foreign body was identified and removed from the soft tissues and passed from the surgical field to be sent to pathology. A culture was taken of the intra-granuloma material. Fluoroscopy was used to ensure total removal of the foreign body.

The incision was flushed with normal saline and closed in a layered fashion with the above suture. A dry sterile dressing was placed.

Tourniquet was released, noting immediate capillary refill time to all digits of the lower extremity. The patient was then transferred to the postanesthesia care unit with vital signs stable and vascular status intact.

Removal of retained foreign body