Minor Surgery Study Tips PDF

MINOR SURGERY 669 Minor Surgery Study Tips Nail Surgery Suturing Pre-Operative Precautions Alternatives to Suturing General Cryosurgery Post-Operative Procedures Electrocautery...

MINOR SURGERY 669 Minor Surgery Study Tips Nail Surgery Suturing Pre-Operative Precautions Alternatives to Suturing General Cryosurgery Post-Operative Procedures Electrocautery Dressings Suturing Removal Contraindications Drains Preparations Dressings Sutures Wound Care Post-Operative Complications Before wound closure Dog ears During wound closure Fever and infection After wound closure Hematomas and seromas Interference of wound healing Hemorrhage Hypertrophic scarring and keloids Phases of Wound Healing Wound dehiscence Equipment Operative Procedures by Lesion Biopsy punch Abscess Cryogens Acrochordon (skin tags) Curette Actinic keratosis Electro and chemical cautery Basal cell carcinoma Forceps Cherry Hemangioma Hemostats Condylomata Accuminata Hyfrecator Cysts Needle holders Ganglion cysts Scalpels Hemorrhoids Scissors Felon Sutures Keratoacanthoma Lentigo Operative Procedures Lichen Planus Anesthesia Lipoma Selecting an anesthetic Milia Injecting an anesthetic Molluscum contagiosum Adverse effects to monitor Nevi Adding epinephrine Paronychia Cryosurgery Pyogenic Granuloma Electro and chemical cautery Seborrheic keratosis Excision and Removal Spider nevi Hyfrecation Squamous cell carcinoma Incision and Drainage Verrucae 669  670 MINOR SURGERY MINOR SURGERY STUDY TIPS As part of the NPLEX format, the minor surgery section is also case-based. Cases focus mainly on dermatology. It is important that you are able to diagnose based on lesion presentation and symptoms, and able to recommend the best surgical option for that type of lesion. Read the list of medications carefully. If a corticosteroid or blood thinner is present, minor surgery is contraindicated. Read the patient’s medical history carefully. MINOR SURGERY If conditions such as diabetes, PVD, and bleeding disorders are present, minor surgery is contraindicated. If an allergy to anesthesia exists (which is rare), minor surgery cannot be performed unless anesthesia is not necessary (i.e. in cryosurgery or chemical cautery). Read the presentation of the wound carefully. If it is a bite or puncture wound, never suture the wound closed. Doing so risks entrapment of microbial pathogens and potential infection. Do not skip studying the mundane, specific details of minor surgery, including but not limited to: ▪ Phases of wound healing and what happens in each phase ▪ Calculating the maximum mL dose of anesthetic for a patient’s body weight ▪ Sutures: types, absorption rates, specific sizes per body location Timing of suture removal ▪ Dressings & Drains: types and indications Timing of dressing & drain removal – in general, remove after 48 hours Be familiar with the potential side effects from an anesthetic. Be able to differentiate the following: Allergic reaction Cardiovascular reaction Central nervous system reaction Vasovagal reaction You are not expected to memorize every single sequence of a surgical procedure. However, you are expected to know which instruments are involved, critical step sequences (ex. biopsy BEFORE destroying a lesion) and what the procedure is best indicated for. Always refer suspicious lesions & lesions with complex vasculature or innervation (ex. face, wrists). Time is especially against you when writing the minor surgery section. Do not spend too much time reading a single case, but do make sure that you've pinpointed the essential information (anything that contraindicates minor surgery or suturing a wound closed). And most importantly, good luck to you future NDs!  MINOR SURGERY 671 PRE-OPERATIVE PRECAUTIONS General When operating in lower extremities, caution with Diabetes Mellitus & Peripheral Vascular Disease due to higher risk of post-operative wound infections and poor wound healing. When operating in areas of risk that have superficial vasculature & nerves highly-prone to injury: ▪ Face ▪ Groin ▪ Supraclavicular areas ▪ Popliteal fossa ▪ Axillae ▪ Feet ▪ Fingers, hands, wrists Patients on corticosteroids (immunosuppressants) due to higher risk of post-operative infection. Patients on anticoagulants or antiplatelets (blood thinners) due to higher risk of hemorrhaging. MINOR SURGERY ▪ If patient is taking aspirin, it is recommended to delay surgery 7-10 days in order to clear the effects on platelet aggregation. Patients with bleeding disorders/coagulopathies. ▪ History of easy bruising, petechia, nosebleeds, low platelet count, high clotting times. Cryosurgery Patients with high levels of cryoglobulins, cold urticaria, Raynaud's Disease, paroxysmal cold hemoglobinuria. Do not operate on any areas of blood circulation impairment as it may lead to necrosis of tissues. Do not operate on areas where potential hair loss is a concern. Risk of hypopigmentation in dark skin. Electrocautery & Hyfrecation Do not use flammable agents like alcohol for disinfecting; electrocautery itself is a sterile procedure. Wear latex gloves for insulation. Caution with metallic implants, IUD, metal dentures, and prosthetics. Patient should not be wearing any jewelry. Suturing Avoid suture tension in the surgical wound, which may lead to ischemia of the skin edges. Always insert the suturing needle 90o (perpendicular) to the skin plane to evert the skin edges. As the wound heals, the edges will flatten. Never suture wounds with possible contamination (puncture or bite wounds, wounds with discharge). Toe-Nail Removal Do not perform if paronychia is present (infection around the base of the nail). Contraindications Allergy to anesthetics Heart or liver failure Flu or pneumonia - post-pone the surgery until recovery Malignant skin lesions (including suspected lesions) No informed consent obtained Pregnancy Psychiatric disorders 671  672 MINOR SURGERY WOUND CARE BEFORE WOUND CLOSURE 1. Hemostasis It is imperative that hemostasis is achieved before cleaning and closing a wound. Neglecting hemostasis risks wound hematoma & risk of infection upon closure. 2. Cleansing All foreign bodies and nonviable tissue must be removed before closing a wound. Step 1: Remove visible foreign bodies. Step 2: Debride nonviable tissue via resection. Step 3: Irrigate with 0.9% saline solution for microscopic removal of debris & bacteria. MINOR SURGERY DURING WOUND CLOSURE 1. Primary Closure Indication: Low risk of infection (clean wound, minimally contaminated). Method: Skin edges are approximated together and closed (i.e. sutured). Timing: Shortly after wound incident (< 12 hours). 2. Secondary Closure Indication: High risk of infection or already infected (bite or puncture wounds). Method: Wound is left open to heal by epithelialization & wound contraction. Timing: N/A 3. Delayed Primary Closure (Tertiary) Indication: If a heavily contaminated wound no longer has residual contamination, the wound can undergo primary closure. Method: Wound is left open to heal by epithelialization & wound contraction. Timing: After 3-5 days 4. Skin Grafts Indication: For secondary closure, if the wound is too large for epithelialization and closure. Method: Graft taken from a normal skin donor site – requires epidermal & dermal layers. Timing: N/A AFTER WOUND CLOSURE 1. Dressings for sutured wounds Indication: To absorb wound drainage, and to provide moisture for epithelialization and wound closure to occur (epithelial cells cannot migrate without moisture). Timing: 48 hours before removal 2. Dressings for open wounds Indication: To clean and debride the wound for optimal healing. Wet-to-Dry: for wounds with necrotic debris – may debride viable tissue Wet-to-Wet: follows wet-to-dry dressings – provides moisture for epithelialization and wound closure to occur Timing: 48 hours before removal  MINOR SURGERY 673 INTERFERENCE WITH WOUND CLOSURE Malnutrition – especially protein deficiency Diabetes Jaundice – sign of liver dysfunction Uremia – sign of renal dysfunction Medications – steroids or chemotherapy Smoking PHASES OF WOUND HEALING 1st Phase: Coagulation Right after injury, the injured tissue and local blood vessels release chemical mediators to induce MINOR SURGERY vasoconstriction, fibrin formation, and platelet aggregation to achieve hemostasis. 2nd Phase: Inflammation The initial vasoconstriction transitions to inflammatory vasodilation, leading to fluid and healing mediators accumulating in the wounded area. The result is erythema and edema. Days 1-4: Macrophages come in to remove necrotic tissue and microbial pathogens. Days 3-4: Fibroblasts and epithelial cells have finished bridging across both edges of the wound to facilitate wound closure. Time period: Day 1-4 3rd Phase: Proliferation Fibroblasts in the wound form collagen to strengthen the wound for the next 3 weeks. Myofibroblasts migrate into the wound and contract, thus contracting the wound itself until the skin edges are approximated. Time period: Day 5-20 4th Phase: Wound Remodeling After 3 weeks, a scar is formed. The collagen produced during the proliferative phase is broken down. New collagen is formed, which has more cross-linking, to increase the strength of the scar. The scar tissue can attain up to 90% strength of the original tissue by 6 weeks. Note that the remodeling phase can continue for years. Time period: Day 21+ 673  674 MINOR SURGERY EQUIPMENT Biopsy Punch Definiton: A hollow cutting instrument used to obtain a full-thickness biopsy of a lesion. ▪ 2-8 mm diameters available. 4 mm is most commonly used. ▪ Diameter must allow sampling of 1-2 mm beyond the lesion's border to compare the abnormal tissue to normal tissue. ▪ Procedure: traction the skin perpendicular to the resting skin tension lines in order to create an elliptical biopsy. ▪ Complications: if the biopsy is stuck in the instrument, remove with a fine needle to prevent damaging the biopsied specimen. MINOR SURGERY Cryogens Definition: A freezing agent that crystallizes and destroys the cells of tissue. Types: ▪ Liquid Nitrogen Most commonly used for its rapid and deep tissue destruction. ▪ Nitrous Oxide (gas) Most expensive cryogen. ▪ Carbon dioxide Not commonly used due to its poor tissue destruction. (gas, dry ice, or slush) Curette Definition: A cutting ring that scrapes down and destroys the lesion. ▪ Used for superficial lesions or raised partial-thickness lesions. ▪ Often combined with electrosurgery. Electro and Chemical Cautery Electrocautery Definition: A sterile electrode applies electrical current to destroy tissues or coagulate blood vessels, followed with curettage to scrape down and target deeper tissue levels. Note: A grounding pad must be placed on the patient's thigh to complete the electrical circuit Types: ▪ Large surface electrodes (i.e. ball or plate electrode, and the side of a cutting electrode) o Low current density = low temperature output o Used for coagulation ▪ Thin-pointed electrodes (cutting electrode) o High current density = high temperature output o Used for incision Chemical Cautery Definition: A chemical agent that destroys tissues or coagulates blood vessels. Types: ▪ Phenol If accidental spill on healthy tissue, dilute phenol with alcohol first, before irrigating with water. ▪ Silver nitrate Most commonly used for hemostasis. ▪ Salicyclic acid Most commonly used for warts. ▪ Trichloroacetic acid  MINOR SURGERY 675 Forceps Toothed Adson forceps are used to handle tissue without crushing it. Toothed forceps are important for handling biopsies and viable tissue. Toothless Adson forceps are used to handle sutures. Hemostats Definition: A special, toothless forceps used for hemostasis or for blunt dissection. ▪ Has interlocking teeth at its handles to lock gauze within its jaws. ▪ The jaws have straight or curved variants, both of which achieve the same purpose. Hyfrecator Hyfrecators are equipped with 2 modes: Types: MINOR SURGERY ▪ Dessication: - Uses electricity to destroy deep tissue of a lesion. - Probe must make contact with the lesion. ▪ Fulguration: - Uses sparks to destroy superficial tissue of a lesion. - Probe must NOT contact the lesion to minimize burns and scars. Needle Holders Definition: An instrument to safely handle needles while suturing. ▪ Angle of needle entry should be 90o to the skin plane, following a pronation-supination movement, to allow proper eversion of wound edges Scalpels Most common blades: 11 For puncturing abscesses 15 For non-blunt dissection to biopsy or eliminate a lesion Most common handle: 3 Scalpels should be oriented perpendicularly to the skin for clean incision lines. Scissors Metzenbaum scissors are used for blunt dissection. Insert with tips closed, then open to blunt dissect. May scissors are used for fine dissection. Insert with tips open, and then close to dissect tissue. Sutures Absorbables Indication: For suturing deep tissue layers. More risk of tissue reaction than non-absorbables. Synthetics are absorbed via hydrolysis. Naturals are absorbed via enzymatic degradation. Synthetic Absorbables Half-Life Indications ▪ Polyglecapone (Monocryl) 1-2 weeks Subcuticular skin closure ▪ Polyglactin (Vicryl) 2-3 weeks Bowel, subcutaneous tissue, fascia ▪ Polyglycolic acid (Dexon) 2-3 weeks Bowel, subcutaneous tissue, fascia ▪ Polydioxanone (PDS) 4 weeks Bowel, fascia, biliary & urinary tract Natural Absorbables Half-Life Indications ▪ Plain surgical gut 7-10 days Rarely used ▪ Chromic surgical gut 2 weeks Degrades longer due to chromic salts 675  676 MINOR SURGERY Non-Absorbables Indication: For suturing superficial tissue layers. Synthetics and naturals are retained in the tissue, and must be removed after adequate healing. Synthetic Non-Absorbables Indications ▪ Nylon Skin closure, handling is similar to silk ▪ Polypropylene Cardiovascular, hernias, fascia Low tissue reactivity for contaminated wounds Slippery surface tension for continuous sutures Natural Non-Absorbables Indications ▪ Surgical silk Has the best handling, can be used for hemostasis MINOR SURGERY ▪ Surgical cotton Not used due to high tissue reactivity and weak strength ▪ Surgical polyester Heart valves, fascia – has risk of infection ▪ Surgical steel For high tensile strength requirements: Orthopedics, neurosurgery (skull), sternum, abdominal wall closure OPERATIVE PROCEDURES Step 1: Select the site of operation. Disinfect area with isopropyl alcohol (70%). Step 2: Anesthetize the site of operation (in necessary) Step 3: Apply betadine in a circular motion from inside to out ▪ Recommended to apply the betadine with an area greater than the size of the fenestrated drape Step 4: Prepare a fenestrated drape over the area of operation. Step 5: Perform the operation. STEP 2: ANESTHETIZATION SELECTING AN ANESTHETIC Topical Anesthetics LET (lidocaine + epinephrine + tetracaine) ▪ Onset: effect takes 30 minutes from the time of application ▪ Duration: variable ▪ Indications: face and scalp lacerations pre-anesthetic for local anesthetic injection ▪ Adverse effects: none EMLA ▪ Onset: effect takes 60-120 minutes from the time of application ▪ Duration: 30-120 minutes ▪ Indications: pre-anesthetic for local anesthetic injection anesthetic for curettage, cryosurgery, electrosurgery ▪ Contraindications: deep lesions ▪ Adverse effects: may cause contact dermatitis To determine the max injectable dosage of an anesthetic into a patient: [Patient’s weight (kg) x Max dose of anesthetic (mg/kg)] ÷ [10 (1% anesthetic contains 10 mg/mL)]  MINOR SURGERY 677 Question: What is the maximum dose of 1% lidocaine with epinephrine in an 80 kg patient? Answer: [80 kg x 7 mg/kg] ÷ [10 mg/mL] = 56 mL Amide Injectables Lidocaine 1% Lidocaine is the most commonly used anesthetic ▪ Adult concentration: 0.5-1% Child concentration: 0.25-0.50% ▪ Dose without epinephrine: 3-4 mg/kg - maximum amount is 300 mg ▪ Dose with epinephrine: 7 mg/kg - maximum amount is 500 mg Ratio is 1:100 000 or 1:200 000 ▪ Onset: 2 minutes MINOR SURGERY ▪ Duration: 1-2 hours 2-6 hours with epinephrine Mepivacaine ▪ Adult concentration: 1% Child concentration: 0.25-0.50% ▪ Dose without epinephrine: 4-5 mg/kg - maximum amount is 400 mg ▪ Dose with epinephrine: 7 mg/kg - maximum amount is 500 mg ▪ Onset: 2-5 minutes ▪ Duration: 1.5-2 hours Bupivacaine (Marcaine) Bupivacaine is the longest solo-acting amide, used for long-duration surgeries such as dental, spinal, epidural, and caudal ▪ Adult concentration: 0.25% Child concentration: 0.25% ▪ Dose without epinephrine: 2 mg/kg - maximum amount is 200 mg ▪ Dose with epinephrine is not needed, but generally comes in a 0.5% concentration with 1:200 000 epinephrine for epidurals ▪ Onset: 5 minutes ▪ Duration: 2-4 hours Ester Injectables Note that esters are not used as frequently due to higher incidence of patient sensitization, with higher allergenic risk and less effectiveness than the Amide Anesthetics. Procaine ▪ For ophthalmology: foreign body removal, eye irrigation, intraocular pressure testing. Tetracaine ▪ Also used for ophthalmology. ▪ Topical derivative of tetracaine is TAC, which consists of Tetracaine + Epinephrine + Cocaine. ▪ TAC is a controlled substance due to the cocaine ingredient, and has been replaced with topical LET. Benzocaine ▪ OTC topical as a spray, cream, or gel – can be used on skin and mucous membranes. 677  678 MINOR SURGERY INJECTING AN ANESTHETIC Local Techniques Direct Infiltration ▪ Involves injecting an anesthetic at the site of operation, starting superficially and moving to deeper levels. ▪ Or it may involve the topical application of an anesthetic (LET, EMLA). Field Block The goal is to create a diamond-field around the area of operation. This technique has a greater range of anesthetic effect than Direct Infiltration. MINOR SURGERY ▪ Step 1: Insert the needle proximal to the lesion, aiming distally, and inject. ▪ Step 2: Partially withdraw the needle. ▪ Step 3: Redirect the needle 90o from original position, aiming distally, and inject. ▪ Step 4: Repeat distal to the lesion, now aiming proximally. Regional Techniques Nerve Block Nerve blocks numb all the downstream distal body parts innervated by a nerve(s). ▪ Minor nerve block: involves only 1 nerve ▪ Major nerve block: involves 2+ nerves, especially nerve plexi ▪ Inject anesthetic around a nerve (NOT INTO!) to prevent nerve damage. ▪ If the patient feels distal paresthesia, you’ve injected into the nerve. Remove the needle and reposition. ▪ Types: Interscalene – numbs from shoulder to arm – for shoulder or upper arm surgery Axillary – numbs from arm to hand – for forearm, elbow, wrist, or hand surgery Femoral – numbs from hip to knee – for hip, upper leg, or knee surgery Ankle – numbs the foot – for ankle, foot, or toe surgery Digital Nerve Block DO NOT add epinephrine to the anesthetic. ▪ Step 1: Insert the needle into the webspace between the fingers/toes. ▪ Step 2: Angle the needle towards the dorsal nerve and inject distal to the MCP/MTP. ▪ Step 3: Partially withdraw the needle. ▪ Step 4: Redirect the needle towards the palmar nerve and inject distal to the MCP/MTP. ▪ Step 5: Repeat for the other side of the finger/toe. Note that when operating on multiple fingers or toes, it is better to go for nerve blocks at the wrist or ankle.  MINOR SURGERY 679 ADVERSE EFFECTS TO MONITOR ▪ Local: pain, hematoma ▪ Systemic (will occur if an anesthetic is overdosed or given intravenously) CNS: dizziness, metallic taste, numbness, tinnitus, twitching CV: arrhythmia, cardiac arrest, hypotension Vasovagal syncope: flushing, nausea, pallor, sweating, weakness Treat with Trendelenburg position, administer oxygen & IV fluids as necessary. MINOR SURGERY Allergic reaction: hives, angioedema, dyspnea, bronchospasm with wheezing Caused by the metabolic breakdown of anesthetic compound into PABA, which may trigger an immune reaction. Can be a Type I (immediate) or Type IV (delayed) hypersensitivity reaction. Extremely rare (< 1% of all reactions), especially for amide anesthetics. ADDING EPINEPHRINE ▪ Concentration: 0.1 mg of 1:1000 epinephrine in 10 mL of anesthetic ▪ Indications: induces vasoconstriction, decreases anesthetic's toxic effects, and increases the duration of anesthesia. ▪ Contraindications: poor circulation areas (fingers, toes, nose, penis, earlobes) due to a risk of ischemia and necrosis STEP 5: PERFORM OPERATION Cryosurgery Cotton Tip Applicator Note: an anesthetic is not necessary. Step 1: Pour a small amount of liquid nitrogen into a Styrofoam cup. Step 2: Disinfect the lesion area. Step 3: Dip a cotton tip applicator into the cup and apply onto the lesion until the frozen margin extends 1-2 mm beyond the lesion’s visible border. Step 4: Allow tissue to thaw before repeating applications. Step 5: Depth of freeze should be similar to width of freeze. Cryoprobe Note: frequently used for small facial lesions due to the availability of various probe sizes. An anesthetic is not necessary. Step 1: Select a probe that matches the size of the lesion. Step 2: Load a cryogen cartridge into the cryoprobe. Step 3: Disinfect the lesion area. Step 4: Apply a water soluble gel to optimize the probe's contact with the lesion. Step 5: Apply the probe onto the lesion until the frozen margin extends 1-2 mm beyond the lesion’s visible border. Note that the probe will adhere to the tissue. 679  680 MINOR SURGERY Step 6: Activate the probe’s thaw function to detach from the tissue. Allow tissue to thaw before repeating. Step 7: Depth of freeze should be similar to width of freeze. Cryospray Note: frequently used for large areas of treatment. Not recommended for small lesions due to the spread of the cryogen's spray. An anesthetic is not necessary. Step 1: Disinfect the lesion area. Step 2: Spray the nozzle at a distance of at least 1 cm away. Step 3: Allow the tissue to thaw before repeating applications. Step 4: Take caution with the depth of freeze. There is more potential to damage underlying tendons and nerves. MINOR SURGERY Complications ▪ Accidental cryosurgery of healthy tissues Discontinue the surgery ▪ Minor peripheral neuropathy Transient adverse effect ▪ Liquid nitrogen spill onto the skin Wipe off immediately. Within seconds, it will not burn the skin due to its rapid evaporation. However, exposure for any longer will risk frostbite development. Electro and Chemical Cautery Electrocautery Note: do not use an alcohol disinfectant due to potential flammability. Step 1: Inject an anesthetic until the entire edges of the lesion are covered. Step 2: Apply a grounding pad onto the patient’s thigh. Step 3: Use a cutting electrode, for a maximum of 5 seconds, for incision. Step 4: Scrape the lesion down with a curette. Step 5: Repeat electrode incision and curettage until the lesion is completely destroyed. Complications ▪ Hemorrhaging does not stop Decrease the current if blood vessels are being destroyed. Increase the current if blood vessels are intact but coagulation is not occurring. ▪ Tissue adherence to the electrode Decrease the current – tissue proteins are binding to the metal surface. Chemical Cautery Note: an anesthetic is not necessary. Step 1: Disinfect the lesion area. Step 2: Apply the cauterizing applicator. Repeat applications as necessary until the full destruction of the lesion is achieved. Step 3: Monitor for adverse reactions. Complications ▪ Accidental cauterization of healthy tissues  MINOR SURGERY 681 Immediately irrigate the area with cool water (except if phenol – dilute with alcohol first). Treat as a 1st, 2nd, or 3rd degree burn. Excision and Removal Step 1: Draw the incision with a length 3x longer than the width. The length axis should be parallel to skin tension lines. Allow a 1-2 mm margin between the lesion border and the incision. The ends of the incision border should be less than 30o to prevent dog-ears. Side note for Punch Biopsies: stretch skin perpendicular to skin tension lines to create an elliptical biopsy. Step 2: Prepare a fenestrated drape over the lesion and disinfect. Step 3: Inject an anesthetic until the entire edges of the planned incision are covered. MINOR SURGERY Step 4: With your non-dominant hand, stretch skin along the incision lines. With your dominant hand, cut vertically along the incision lines in 1 direction only (no back-and-forth movements), using a No. 15 bladed scalpel. Side note for Shave Biopsies: same steps, but cut horizontally across the lesion's base. Step 5: Pick up the lesion with Adson toothed forceps and free the lesion from the dermal layer with the scalpel. Step 6: Place the lesion in a container of 10% formalin. Step 7: If bleeding occurs, achieve hemostasis by applying gauze to the area with pressure. Step 8: Suture the wound. Step 9: Place dressings over the wound. Complications ▪ Dehiscence: wound edges separate before fully healed Re-do the suture. ▪ Dog ears: skin puckering due to excess tightening of the wound edges Re-do the suture. ▪ Infection: discharge, erythema, edema, tenderness, systemic symptoms (ex. fever, chills, malaise, N+V) Open the suture, culture any discharge, begin antimicrobial treatment, and allow the wound to close by secondary intention. Hyfrecation Note: do not use an alcohol disinfectant due to potential flammability. Step 1: Inject an anesthetic until the entire edges of the lesion are covered. Step 2: On dessication mode, place the electrode onto the lesion. On fulguration mode, hold the electrode 1-2 mm above the lesion. Step 3: Apply the current for no longer than 5 seconds. Step 4: Assess the amount of lesion destruction, and reapply current until full destruction is achieved. Complications ▪ Burns Treat as a 1st, 2nd, or 3rd degree burn. 681  682 MINOR SURGERY ▪ Scarring It is likely to occur. Incision and Drainage Note: a sterile field is not necessary for I & D since the wound is already contaminated. A clean field will suffice. Step 1: Plan the incision line parallel to the skin tension lines. Step 2: Prepare a fenestrated drape over the lesion and disinfect. Step 3: Inject an anesthetic until the entire edges of the planned incision are covered. Step 4: Take an aspiration biopsy if needed. Step 5: With your non-dominant hand, stretch the skin along the incision lines. With your dominant hand, cut straight across the lesion, from one end to the other, using a No. 11 bladed scalpel. The depth should reach the junction between the dermis and the MINOR SURGERY adipose tissue. Step 6: Culture the discharge and place in the appropriate container. Step 7: Use sterile gauze and cotton-tipped applicators to control hemostasis and allow the full evacuation of pus from the cavity. Step 8: Once fully evacuated, irrigate the cavity with normal saline and break any adhesions with blunt dissection using hemostats. Breaking up the adhesions facilitates optimal healing of the entire cavity. Step 9: Pack iodoform gauze into the cavity. If packing is too tight, this may lead to tissue necrosis. Leave part of the gauze exposed, to allow easy removal after 2 days. No suturing is necessary. The cavity will close by secondary intention. Complications ▪ Infection: discharge, erythema, edema, tenderness, systemic symptoms (ex. fever, chills, malaise, N+V) Culture any discharge and begin antimicrobial treatment. Nail Surgery Step 1: Prepare a fenestrated drape over the lesion and disinfect. Step 2: Inject an anesthetic using the digital nerve block technique – no epinephrine. Step 3: Tourniquet the toe to minimize the amount of bleeding during nail removal. Step 4: Lift the nail with a nail elevator. Step 5: Use surgical scissors to vertically split the nail all the way up to the base of the nail. Step 6: Grasp a nail portion with hemostats, gently twist and pull, and remove the portion. Step 7: Repeat with the other half portion of the nail. Step 8: Apply an anti-microbial topical to the nail base. Step 9: Cover the exposed toe with sterile gauze. Step 10: Remove the tourniquet. Step 11: The operated foot should be kept elevated as much as possible for 1 day. Complications ▪ Recurring ingrown toe nail Repeat nail surgery, but apply an 80% phenol-soaked cotton tip applicator to the exposed nail base for 2-3 minutes. Then, use a 70% alcohol swab to neutralize the phenol. ▪ Edema of the foot or leg Keep the foot elevated as much as possible for 1 day  MINOR SURGERY 683 Suturing Interrupted Independent sutures in which the needle is inserted on one side of the lesion, exits through the other side of the lesion, and knotted. The distance between each suture should match the length of each suture. ▪ Advantages: easy stitch removal, allows wound drainage ▪ Disadvantages: railroad scarring, not a quick method Buried Similar to interrupted suturing, but with absorbable sutures buried in the deeper layers of the wound. The knots are oriented downwards. ▪ Advantages: eliminates any dead space in the deep layers, before closing the MINOR SURGERY superficial layer Horizontal Mattress Technique is to enter the needle farfar. Far-far placement is 4-8 mm from the wound edge. After the needle is threaded from one side of the wound to the other, the needle is placed backwards in the needle driver, and driven to the other side again at 4-8 mm from wound edge. ▪ Indications: for thick skin (palms & soles of feet) ▪ Advantages: excellent eversion of wound edges Vertical Mattress Suturing is done vertically within the wound, forming a “U”. Technique is to enter the needle farfarnearnear. Far-far placement is 4-8 mm from the wound edge. Near-near placement is 1-2 mm from the wound edge. ▪ Indications: for loose skin (ex. elbow, dorsal hand), and thick skin (palms, soles) to prevent skin invagination. ▪ Advantages: eliminates dead space without the need for buried suturing Running/Continuous After making a knot at the edge of the wound, the needle travels at a 45o angle across the lesion length, NOT perpendicular to the length. Bring the needle through to the other side. Carry the needle over, on the direct opposite side, and re-insert the needle at a 45o angle. Hence, the needle zigzags down the lesion’s length. ▪ Advantages: quick and useful in emergencies ▪ Disadvantages: poor tension, poor wound edge eversion, prevents wound drainage ▪ Contraindications: infection, contamination Intradermal Running A complicated suture technique where the needle is threaded through the cutaneous layer, horizontally on one side, before crossing to the other side of the cutaneous layer. The needle is crossed back and forth in a zig-zag fashion until the lesion is closed. ▪ Advantages: good cosmetic results due to the prevention of "cross-hatching" ▪ Disadvantages: difficult to perform Tying the Knot 683  684 MINOR SURGERY 1st knot: double loop 2nd knot: double loop 3rd knot: single loop (for multifilaments) 4th knot: single loop (for monofilaments like nylon) ▪ The double loops prevent the suture from untying. ▪ Orient knots to the side of the wound, to allow better healing and visualization of the wound. ALTERNATIVES TO SUTURING Adhesives Cyanoacrylate glue MINOR SURGERY Indication: ▪ For superficial lesions only; useful for facial lesions. ▪ Holds wound edges together for 7-14 days while the wound repairs itself. Afterwards the glue is naturally shed off. Procedure: Step 1: Approximate the wound edges with forceps. Step 2: Apply glue on the outer skin surface ONLY. Do not allow it to enter the wound. If the glue enters the wound, it must be removed through debridement. Step 3: Hold the wound edges together for 1-2 minutes. Step 4: Check the strength of glue’s hold by attempting to gently pull the wound edges apart. Step 5: The patient should keep the wound dry for 5 days. Contraindications: ▪ Animal bites, puncture wounds, or pressure sores ▪ Peripheral vascular disease ▪ Local or systemic infection ▪ Mucosal lesions Adhesive sutures (Ex. steri-strips) Indication: ▪ For superficial, linear lesions with minimal tension only. Advantages over sutures: ▪ Quick and easy ▪ No anesthesia is required ▪ No rail-road scarring Disadvantages – Cannot be used in the following scenarios: ▪ Presence of discharge from wounds ▪ Irregular, non-linear wounds ▪ Wounds on joint surfaces (frequent motion will wear down the strip) ▪ Wounds on skin folds and hairy areas (poor adhesion to these surfaces) ▪ Wounds under tension  MINOR SURGERY 685 POST-OPERATIVE PROCEDURES Dressings Functions: ▪ Absorption of exudates while preventing excessive fluid loss. ▪ Aids in debriding necrotic or infected tissue from the wound. ▪ Provides hemostasis. ▪ Provides pain relief. ▪ Provides protection and support for the wound. Removal: ▪ In general, dressings are removed after 48 hours. The wound can then be washed MINOR SURGERY gently. Types: Adherent ▪ Purpose: to debride wounds. ▪ Caution: removal of adherent dressings tends to be a painful process, and may end up debriding viable (healthy) tissue. Apply warm saline to help with the removal. ▪ Recommendation: only use adherent dressings during the inflammatory phase, and avoid during the wound-healing phases. ▪ Types: Dry-to-dry: Use for wounds with watery exudates. When bathing, the dressing cannot be wetted. Wet-to-dry: Use for wounds with sticky exudates. Non-Adherent ▪ Purpose: to retain moisture in the wound to optimize wound healing. The process of epithelialization requires moisture. ▪ Caution: removal of non-adherent dressings should be done every 2-3 days due to it continuously promoting debridement. You do not want the non-adherent dressing to promote debridement of viable (healthy) tissue. ▪ Recommendation: use during the wound’s granulation healing phase. ▪ Types: Gauze with calcium alginate, Vaseline, etc. Hydrocolloid sheets Hydrogels 1-Layer Dressing ▪ Purpose: a transparent dressing that provides visualization of the surgical wound. ▪ Caution: only use for wounds with little-to-no drainage expected. ▪ Types: Bioclusive Ensure Opsite 685  686 MINOR SURGERY 3-Layer Dressing ▪ Purpose: Inner layer: made of non-adherent material, acts as barrier to microbes and retains moisture. Intermediate layer: secondary absorbent layer for exudates. Superficial layer: binds all layers together to the body and has elasticity to accommodate for any swelling. ▪ Recommendation: use for wounds with heavy drainage expected. REMOVAL Drains MINOR SURGERY Definition: Connects a body cavity to a sealed reservoir. Timing: Remove after 48 hours, or until no more substantial drainage is occurring. Types: ▪ Gravity Drain Fluid drains into a reservoir at a lower level Ex. Foley bladder catheter for urinary retention ▪ Underwater-seal Drain Prevents air and fluid from re-entering the body Ex. Chest tube for pneumothorax ▪ Suction Drain Suction drains large volumes of fluid Ex. GI tract tube for abdominal distention ▪ Sump Drain Allows irrigation fluid to enter one lumen, while suction evacuates the other lumen Ex. Nasogastric tube for continuous irrigation ▪ Open Drain Not sealed at either end, allowing bacteria or medical instruments to access the draining area Ex. Penrose drain to passively drain fluid after I & D procedure Dressings In general, remove after 48 hours. Sutures Notes: Size O (“Oh”, not “zero”) is the largest suture, whereas size 10-O is the thinnest suture. If patient has delayed healing from diabetes or corticosteroid usage, remove the sutures in 14-21 days.  MINOR SURGERY 687 Superficial Non- Deep Absorbable When to Remove Absorbable Scalp 4-O to 5-O 3-O to 4-O 6-8 days Face 6-O 5-O 3-5 days Ear, Eyelid 6-O 14 days Mouth, Tongue 3-O to 4-O Chest, Abdomen 4-O to 5-O 3-O to 4-O 8-10 days Back 4-O to 5-O 3-O to 4-O 12-14 days Hand 5-O 5-O 10-14 days Foot 3-O to 4-O 4-O 12-14 days Genitals 5-O to 6-O 8-10 days MINOR SURGERY POST-OPERATIVE COMPLICATIONS Anaphylaxis ▪ Sx: angioedema, urticaria, rashes, hypotension, bronchospasms ▪ Treatment: place the patient into shock position. Administer steroids or antihistamines, fluids, and oxygen as necessary. Dog ears ▪ Sx: skin puckering due to excess tightening of the wound edges ▪ Treatment: remove the sutures, excise the dog ears, and re-suture properly. Fever and infection ▪ Sx: discharge, erythema, edema, tenderness, chills, malaise, N+V ▪ Treatment: remove the sutures (if present), incision and drainage (if abscess present), begin antimicrobial therapy, allow wound to close by secondary intention. Hematoma-seroma ▪ Sx: evident bruising ▪ Prevention: make sure that hemostasis is achieved before closing the wound. Hemorrhage ▪ External hemorrhage sx: evident bleeding ▪ Internal hemorrhage sx: hypotension, bradycardia/tachycardia, thirst, restlessness, skin becomes moist or pale, difficulty urinating ▪ Treatment: control hemorrhaging with pressure gauze, electro or chemical cautery. o Monitor for dehydration Hypertrophic scarring and keloids ▪ Sx: overgrowth of scar tissue ▪ Treatment: Centella asiatica or Calendula officinalis topical, vitamin A or E topical. Wound dehiscence ▪ Sx: wound edges separate before fully healed ▪ Treatment: re-do the suture properly. 687  688 MINOR SURGERY OPERATIVE PROCEDURES BY LESION Notes: Suspicious lesions (according to ABCDE) should be referred to a dermatologist. Always biopsy suspicious lesions first, before resorting to destructive surgical therapy. Abscess Definition: an accumulation of pus from local infection Procedure: incision & drainage Acrochordon Definition: a benign skin tag, most prominent in the neck, armpit, and skin folds MINOR SURGERY Procedure: lift & snip (shave biospy), cryosurgery, or hyfrecation Actinic Keratosis Definition: a yellow-brown crusty lesion on sun-exposed areas; a precursor to SCC Procedure: shave biopsy, cryosurgery, hyfrecation Basal Cell Carcinoma Definition: pink/brown/flesh-coloured papule; pearly appearance; visible, adjacent blood vessels; occurs in sun-exposed areas (face, scalp, ears, upper chest and back) Procedure: excision biopsy Cherry Hemangioma Definition: a benign proliferation of blood vessels, appearing as tiny red papule(s) Procedure: shave biopsy, cryosurgery, hyfrecation Condylomata Accuminata Definition: anogenital warts from HPV Procedure: LEEP, cryosurgery Cysts Definition: an enclosed growth of abnormal gas, liquid, or semisolid material Procedure: ▪ Needle aspiration for biopsy or full removal ▪ Small cyst – make an incision directly over the lesion; the cyst will pop out ▪ Large cyst – elliptical excision and removal Note on Ganglion Cysts: refer to a dermatologist. Do not attempt to remove it due to the complex vasculature and innervations nearby. Hemorrhoids Definition: a swelling of veins in the anal canal, with potential pain on defecation and bright-red hemorrhaging if ruptured hemorrhoid Procedure: ▪ Band & ligation – only for 1st and 2nd degree hemorrhoids ▪ Anesthesia is not required o 1st degree: bleeding on defecation, no prolapse o 2nd degree: prolapse present with spontaneous reduction o 3rd degree: prolapse present, requires manual reduction o 4th degree: prolapse present, cannot be reduced  MINOR SURGERY 689 Felon Definition: a purulent infection at the distal pad of a finger Procedure: incision & drainage Keratoacanthoma Definition: an inflamed, dome-shaped lesion that grows rapidly, and is capped with keratin Procedure: excision biopsy Lentigo Definition: a hyperpigmented macule resulting from an abnormal proliferation of melanocytes Procedure: excision biopsy MINOR SURGERY Lichen Planus Definition: small, polygonal, pink rashes thought to be autoimmune-related Procedure: none Lipoma Definition: a benign growth of adipose tissue Procedure: make an incision directly over the lesion and remove the lipoma Milia Definition: tiny, pearly-white cysts on the face, resulting from entrapped keratin Procedure: none recommended. A fine-needle can be used to cut open and express the contents. Molluscum Contagiosum Definition: pearly white papule with an umbilicated centre, existing as a single or grouped lesions. Typically affects the neck, trunk, eyelids, or anogenital area. It is common in children and in HIV/AIDS patients. Procedure: cryosurgery, curettage, hyfrecation, prick with phenol-tipped wooden applicator Nevi Definition: macules or papules that generally occur on sun-exposed areas Procedure: excision biopsy if it does not meet an abnormal ABCDE criterion Paronychia Definition: an infection at the base of a nail Procedure: incision & drainage Pyogenic Granuloma Definition: a benign skin or mucosal growth with prominent vasculature. It can present with redness and bleeding. Procedure: excision biopsy, cryosurgery, curettage Seborrheic Keratosis Definition: a benign light-brown macule that can turn into a plaque with a rough or waxy surface Procedure: excision biopsy, curettage, cryosurgery, electrosurgery 689  690 MINOR SURGERY Spider Nevi Definition: a benign red papule with radiating blood vessels Procedure: hyfrecation Squamous Cell Carcinoma Definition: appear as red, scaly papules with umbilicated centres. They have the potential to bleed or crust. Generally appear on sun-exposed areas, but can affect mucosal membranes. Procedure: excision biopsy, cryosurgery, hyfrecation Verrucae Definition: palmar or plantar warts Procedure: eschariotic agents (ex. salicyclic acid), cryosurgery, hyfrecation MINOR SURGERY REFERENCES Blanco JMA and Tejero MH. Skills in Minor Surgical Procedures for General Practitioners, Primary Care at a Glance – Hot Topics and New Insights, Dr. Oreste Capelli (Ed.). Madrid, Spain: Intech, 2012. Jarrell, Bruce E., R. Anthony Carabasi, and Eugene Kennedy. NMS Surgery. 5. ed. Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins, 2008. Print. Moses, S. 2014. Family practice notebook. January 5, 2014. Retrieved from http://fpnotebook.com/Surgery/index.htm. Zuber TJ. 2002. The Mattress Sutures: Vertical, Horizontal, and Corner Stitch. Am Fam Physician: 66(12):2231-2236.