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PREOPERATIVE DIAGNOSIS: Necrotizing infection of the left lower abdomen and left peritoneal area.

POSTOPERATIVE DIAGNOSIS: Necrotizing infection of the left lower abdomen and left peritoneal area.

PROCEDURE PERFORMED: Debridement of the necrotic tissue of the left lower abdomen as well as the left peritoneal area.

ANESTHESIA: General.

FLUIDS: 800 cc given.

ESTIMATED BLOOD LOSS: 350 cc.

SPECIMEN: Pannus and left peritoneal specimen sent to Pathology.

REASON FOR PROCEDURE: This is a 53-year-old white male who presented to ABCD General Hospital on 09/05/03 with a chief complaint of drainage from his left groin. The patient is a diabetic who requires insulin, but has been noncompliant and states that his blood sugars have been out of control. He has had a groin abdominal wound drained for about four days. The patient states that there has been pus that has saturated his sheath. He has had a possible fever at home that he did not chart with a thermometer. He has had the same groin infection twice in the past with tunneling lesions. The patient states that his wife noted there was a round scar on his abdomen and that was black and had crept up in the last day. Bowel habits and eating were essentially normal.

Urinary habits were normal. The patient is morbidly obese and is approximately 450 lb. He has not been following a diabetic diet or using insulin secondary to lack of funds to put his medications.

PAST MEDICAL HISTORY: Diabetes, morbid obesity, and nephrolithiasis.

PAST SURGICAL HISTORY: Appendectomy and stone extraction.

PROCEDURE: The patient was examined in the Emergency Room by Dr. X and was found to have multiple areas of erythematous tissue, which could potentially be consistent with a necrotizing fascitis texture. The patient had a white count of 11.4 and a hemoglobin of 13.4. Please note that the patient is a Jehovah's Witness and has adamantly refused receiving any blood products. The risks and benefits of such were discussed with the patient at length prior to surgery and he was permitted to make sure not to receive blood and his wishes will be granted. In the operative suite, he was prepped and draped in the usual sterile fashion. The patient was placed in a lithotomy position to visualize the peritoneum as well as the abdomen. Copious amounts of Betadine solution were used to cleanse the area and the wound was visualized. Approximately, 10 cm x 5 cm elliptical incision was made on the lower left quadrant of the abdomen surrounding the area of necrosis. Necrotic tissue comprised approximately 2 cm x 2 cm area and was indurated. The abdomen appeared to have a large erythematous border, however, the true indurated tissue was approximately the size of a deck of cards. The area was incised using a #10 blade scalpel and then Bovie cauterization was used to achieve good hemostasis. The tissue was removed using an Allis forceps as well as a Bovie to double the incision down to the fascia. The necrotic tissue was lifted out of the abdomen. All bleeding was cauterized using the Bovie. A solution of gentamicin and sterile saline was placed into a high-powered water pump device and the wound was copiously irrigated and suctioned. A wet Kerlix dressing was passed into the wound and it will be left opened with wet-to-dry dressing. The left groin area was also incised using an elliptical incision that was approximately 13 cm x 6 cm. The tissue was incised to the muscle layer of the muscle. There was a pus pocket that was visible with capsule as well and there was an area of the necrotic tissue as well. There was a mild amount of pus that drained from the wound. Cultures were taken from the groin wound and were sent to pathology. The specimen was excised using traction with the Allis clamps as well as Bovie set on coag. Once the tissue was excised from the ________, the area was fully irrigated using the gentamicin sterile saline solution in the high-powered water irrigation unit. After the irrigation, the wound was packed using a wet Kerlix dressing and will be left open to heal.

It was determined at this time that both wounds will be left open to heal with the wet-to-dry dressings in place and we will come back and close the wounds at a later date. The skin excised from the left lower abdominal quadrant as well as the left groin was sent to pathology. The patient tolerated the procedure well and was taken to recovery in good condition.

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