Conditions of Minor Surgery Flashcards
What are some of the indications for performing a skin biopsy?
Unkown lesion
Suspicion of malignancy
Unusual rashes or pigmented areas
Differentiating various autoimmune dermatological conditions
ABCDE: Asymmetry, Irregular Boarders, <.25 in /<6 mm Diameter, Evolving
What are some of the contraindications for performing a skin biopsy?
1) Malignant melanoma
2) Squamous Cell Carcinoma or other know malignancies
3) Any technique that may spread any cancer to other locations
4) Poor wound healing
5) Areas of vascular compromise
6) Inappropriate are of the body: eyes, groin, inner triangle of the face
7) Young children and compromised elderly
What are some of the instruments that are used for a skin biopsy?
1) Punch biopsy tool
2) Sterile scalpel
3) Curved Iris scissors
What anesthesia is used?
1% lidocaine using 0.2 -0.4 ml
What is the best site to obtain the biopsy?
It is best to collect from the edge of the lesion adjacent to healthy tissue and that should be included in the biopsy
How do you actually collect a punch biopsy?
1) Stretch the skin taut perpendicular to the natural skin tension lines
2) Press the punch into the skin to a depth of 4 mm or more and rotate it
3) Pull the punch out with the tissue sample
4) Apply hemostasis or suture as needed
How is a biopsy specimen transported to a lab?
In 10% formalin
What do you do if the sample is stuck in the skin?
If the biopsy is stuck in the instrument, remove with a fine needle to prevent damaging the biopsied specimen
Use iris scissors to cut base, pull out with forceps
What is an incisional biopsy?
A full-thickness partial excision of a larger lesion for diagnostic purposes
When would an incisional biopsy be used?
To perform an initial evaluation on a large skin lesion when complete excision is undesirable for cosmetic or functional purposes
What is an excisional biopsy?
A full-thickness incision of smaller lesions where the entire lesion is removed
What is important to do when performing an excisional biopsy?
1) All the lesion is removed with one half of the ellipse in the lesion and one half of the ellipse in normal tissue at the boundary of the lesion
A mark is made on the biopsy sample as to its orientation on the body
What are some of the indications of shave biopsy?
1) Benign, superficial lesions less than 3 mm in depth thought to be epidermal or high dermal
2) Seborrheic Keratosis
3) Acrochordon
4) Verrucae
5) Molluscum contagiosum
6) Epidermal benign nevi
What are the contraindications for performing a shave biopsy?
1) Malignant melanoma
2) Squamous cell carcinoma and other known malignancies
3) Areas of vascular compromise
How do you perform a shave biopsy?
The lesion is removed from the skin in a horizontal manner parallel to the skin surface
When is cryosurgery usually used?
For lesions that are benign and shallow, <3 mm in depth
What kinds of lesions be safely removed with cryosurgery?
1) Verruca
2) Hemangioma
3) Actinic Keratosis
4) Basal Cell Carcinoma
5) Scars
6) Papular Nevi
7) Acrochordon
8) Condylomata
9) Seborrheic Keratosis
What are some the contraindications for cryosurgery?
1) Recurrent BCC
2) Malignant Melanoma
3) On area where hair loss or pigment change would be undesirable
4) Lesions of poor circulation
5) Lesions in nasolabial folds, periorbital area and periauricular area
What is the main type of cryosurgery?
Liquid Nitrogen
What is important to remember about cryosurgery?
Histological evaluation cannot be performed on destroyed tissue
Is anesthesia necessary with cryosurgery?
Not usually
When using the swab technique of cryosurgery how long do you apply constant pressure?
30-60 seconds
How far should the freeze zone extend?
1-3 mm around the lesion
What must be applied to the skin when using a cryoprobe?
A thin film of water soluble jelly
When using a cryoprobe how far should the freeze zone extend?
1-2 mm beyond the rim of the probe
How many applications of a cryoprobe are usually necessary?
3 freezes are performed
What usually happens to the lesion after the cryosurgery?
It will blister and form a scab and heal over
What is important to tell patients about cryosurgery?
The scar may not tan as well as normal skin
What are some of the potential problems with cryosurgery?
1) Poor healing of the lesion
2) Pain : Usually a dull ache that may last for several hours
3) Damage to an underlying nerve, vein or tendon
4) Inflammation
What do you do if you spill liquid nitrogen on a patient?
Wipe it off as soon as possible. It usually does not burn
What is hyfrecation?
A unipolar diathermy that generates high voltage with low current
What are the indications of hyfrecation?
1) Quick effective destruction of lesions without blood loss
2) Good for vesicular lesions
What lesions can be removed with hyfrecation?
1) Condyloma
2) Verruca
3) Hemangioma
4) Spider nevi
5) Xanthelasma
6) Actinic Keratosis
7) Papilloma
8) Small Nevi
9) Acrochordon
What are some of the contraindications of hyfrecations?
1) People with a pacemaker
2) Nerby metal joints or pins
3) Malignant lesions
4) Suspicious Lesions
Why do you not hyfrecate suspicious lesions?
Hyfrecation destroys the tissue and thus prevents histological evaluation
Is anesthesia indicated?
Yes, 1% lidocaine without epinephrine
What are the 3 types of hyfrecation?
1) Desiccation (Electricity)
2) Coagulation
3) Fulguration (Sparks)
Which method of hyfrecation has the electrode inserted into the lesion?
Desiccation : Destroy deep tissue of lesion; probe makes contact with the lesion
How deep do you put the electrode into the lesion in desiccation hyfrecation?
No deeper than 2-3 mm
How long do you apply current?
1-5 seconds
Which hyfrecation method uses a stream of sparks from the electrode to the lesion?
Fulguration
How far away from the lesion is the fulguration type of hyfrecation held?
1-3 mm
How long is current applied in the fulguration type of hyfrecation?
1-2 minute or until the top layer of the tissue is destroyed. 1 minute is usually enough because more will potentially cause a bad burn
What do you do to the lesion between bouts of fulguration?
Scrape the top crusty layer away with a curette or a gauze pad with alcohol on it
What are some of the possible complications with hyfrecation?
1) Poor healing
2) Scarring
3) Burns
4) Potentially infectious drops or spray from the burning the burning tissue
How long does it take for the wound to heal in hyfreaction?
About 3 weeks. A crust will form and drop-off in 7-10 days
What is the greatest hazard of hyfrecation?
Burns
What are the 2 types of cautherization?
1) Chemical
2) Electrical
What is the usual use of cautherization?
To control bleeding
What are the different forms of chemical cauterization?
1) Silver Nitrate
2) Liquefied phenol
3) Monochloracetic acid
What does electrocautherization involve?
The use of hyfurcation of the heating of a fine platinum wire to red hot and then applying to the tissue
What are lesion that can be removed with cautherization?
1) Skin tags
2) Subungal hematoma
3) Condyloma
4) Epistaxis
5) Small benign intradermal lesions
6) Molluscum Contagiosum
7) Spider Nevi
What are some of the contraindications of chemical cautherization?
1) In area that are difficult to control the exact area to be treated
2) Only superficial lesions can be treated
What are some of the contraindications of electrocautery?
1) Pacemaker
2) Metal objects in the body
3) Lesion where a biopsy is needed
Is anesthesia indicated for cauterization?
Yes, lidocaine 1% without epinephrine
What type of electrocautery tool is used for subungal hematoma?
Cold point electrode
What are some of the indications for excision and removal?
1) Elective removal of epidermal or intradermal skin lesions for cosmetic, prophylactic, diagnostic or therapeutic reasons
2) Pathology in the deep dermis or fat
3) Foreign bodies
4) Small- to medium sized benign masses on the skin
What are some of the contraindications for excision and removal?
1) Suspected malignancies
2) Diagnosis of cancer
3) Poor Location
4) Extensive size
5) If elective patient is in poor health
6) Patients with vascular or bleeding disorders
7) Patients on blood thinning medications
8) Keloid former
What instruments are needed for excision and removal?
1) Scalpel with blade (10,11, or 15)
2) Forceps (hemostats, rat-toothed or atraumatic)
3) Scissors (iris, Mayo or metsenbaum)
4) Needleholder
5) Suture Pack
When don’t you use epinephrine?
With appendages that have a single entry and exit point for blood: Ears, Finger, toes, and genitals
What is a potential problem of using epinephrine?
It causes vasoconstriction so that during the surgery there may appear to be no bleeding but after the epinephrine has worn off and the patient has been closed up there may be significant bleeding into the wound
What wound preparation antispetic is the most caustic to tissue?
Isopropyl alcohol
How many times do you need to clean the surgical site with Betadine?
3 times
How are the excision lines orientated?
Parallel to the skin tension lines
What is the ratio of length to width when marking the excision? Why is this important?
A 3:1 ratio of length to width is used to prevent dog-ears
How far do you cut into the healthy tissue?
A 2 mm border of healthy tissue is usually needed
How is hemostasis managed?
1) Direct Pressure
2) Electrocautery
3) Tying of bleeders
What is done with the tissue if it is needed for biopsy?
It is placed in 10% formalin and transported to the pathologist.
What should be done to the skin prior to suturing?
It should be undermined to help approximate skin edges without tension
What can be placed on the skin to support the sutures?
Steri-strips
What needs to be written on the biopsy request?
Patient name, procedure, date, type and orientation of the specimen
What are some of the possible complications of excision and removal of lesions?
1) Infection
2) Dog ears
3) Hemorrhage
4) Sutures come out early: dehiscence
5) Allergy to local anesthetic
How can you deal with dog-ears?
Excise the dog ear and re-suture the wound
What is the time limit for suturing up a wound?
It has to be done within 12 hours from tome receiving the wound
What are some of the indications for incision and drainage?
1) Abscesses
2) Infected wounds especially puncture wounds
3) Foreign bodies
4) Furuncles and carbuncles
5) Infected hematomas, glands or lymph nodes
What are some of the contraindications for incision and drainage?
1) Usual contraindications for surgery
2) Cellulitis and lymphangitis
3) Diabetes
4) Severe and systemic infections
5) Recurrent abscesses
Is anesthetic indicated for incision and drainage?
Injection of anesthesia into an infection is usually ineffective and painful. A nerve or field block may be indicated
What is the incision and drainage procedure?
1) Follow as for any surgery
2) Make a small incision and squeeze purulent material out
3) Irrigate well with sterile saline
4) If it is a large wound a Pinrose drain may be indicated
5) Loosely pack the abscess with Iodoform gauze leaving a tail hanging out to drain
Is suture necessary?
Do not suture after I&D ! Apply a non-adhering dressing and secure
How soon does the gauze need to be changed?
The Iodoform gauze needs to be changed daily initially and less as the tissue heals
