Surgeon(s): ***
Assistant Surgeon(s): ***
Preoperative Diagnosis: ***
Postoperative Diagnosis: Same
Procedure(s): ***
Anesthesia: General
Implants: None
Specimen:***
Drains: None
Fluids: See anesthesia record
EBL: Minimal
Complications: None
Counts: Correct x2
Indications: ***
Findings: As expected
Procedure in Detail:
The patient was seen in the preoperative holding area with a H&P was updated, consents were verified, surgical site marked, and all questions and concerns related to the proposed procedure were discussed in detail. The patient was transferred to the operating room by the anesthesia team. The patient underwent general anesthesia with endotracheal intubation. Tegaderms were placed over the eyes. The patient was prepped and draped in the standard fashion for maxillofacial procedures. A time-out was performed and the procedure began.
A 3 cm incision was made over the most fluctuant area of the submandibular region. Pus was encountered immediately upon incision, confirming the presence of an abscess. Approximately 15 ml of purulent material was evacuated. The cavity was explored thoroughly for any loculations, which were broken down, and the abscess cavity was irrigated with sterile saline solution. Attention was turned to the source tooth. The overlying gum was incised and retracted, exposing the tooth. The tooth was sectioned using a surgical drill, and the pieces were carefully extracted. The area was thoroughly debrided and irrigated to ensure complete removal of all dental debris and potential sources of infection.A small Penrose drain was placed to facilitate continued drainage and was secured with a skin suture.
The patient's face was then cleaned and the posterior pharynx was suctioned. An OG tube was used to suction out the contents of the stomach. Tegaderms were removed from the eyes. Dressings were placed. The patient was then transferred back to the care of the anesthesia team for extubation and recovery.