Patient was transferred from the floor to the OR holding area pt was interviewed by oral maxilla facial surgery, anesthesia, and the OR nursing service. It was established a proper H&P and consent have been obtained. All patient questions were answered.
Patient was then transferred on a gurney to the OR holding area. He was turned to the care of anesthesia in which, Pt was placed in supine position and induced for general anesthesia via IV induction and orally intubated without complication. Patient was then sterilely prepped and draped in customary fashion for oral maxillofacial surgery. Time out procedure was then held verifying patient procedure.
The *** eye was irrigated with BSS and eye shield with Lacri-Lube was then placed and a tarsorrhaphy suture was placed. Local anesthesia was placed in all facial areas requiring surgery, the doses are in the chart and can be reviewed should this be required.
15 blade was used to make an incision in a subciliary-type incision on the *** lower eyelid. Blunt and sharp dissection was then performed to the *** orbital rim. Once the periosteum was identified it was incised and the orbital rim was then identified.
Periosteum of the orbital floor was then reflected demonstrating the orbital floor fracture. A low profile Synthes plate was then contoured to the orbital floor fracture. 2 screws were used for stabilization of the plate along the orbital rim. The orbital plate was noted to be rigidly fixated and spanning the orbital floor fracture.
The incision was then closed with 6-0 fast absorbing gut suture for the skin incision. The tarsorrhaphy suture was removed, the eye shield was remove, and the eye was irrigated BSS. A forced duction test was performed revealing no orbital restrictions.
Marcaine was then placed and all surgical sites. Adequate surgical hemostasis was obtained.
Patient was then turned to the care of anesthesia in which the patient was extubated in the operating room without complication. Patient was then transferred to the post anesthesia care unit all vital signs stable and breathing spontaneously. Pt will be admitted to the floor and the trauma service. The oral maxillofacial service will continue to follow patient as an inpatient as well as outpatient.
