Conditions of Minor Surgery Flashcards
1
Q
What are some of the indications for performing a skin biopsy?
A
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
2
Q
What are some of the contraindications for performing a skin biopsy?
A
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
3
Q
What are some of the instruments that are used for a skin biopsy?
A
1) Punch biopsy tool
2) Sterile scalpel
3) Curved Iris scissors
4
Q
What anesthesia is used?
A
1% lidocaine using 0.2 -0.4 ml
5
Q
What is the best site to obtain the biopsy?
A
It is best to collect from the edge of the lesion adjacent to healthy tissue and that should be included in the biopsy
6
Q
How do you actually collect a punch biopsy?
A
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
7
Q
How is a biopsy specimen transported to a lab?
A
In 10% formalin
8
Q
What do you do if the sample is stuck in the skin?
A
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
9
Q
What is an incisional biopsy?
A
A full-thickness partial excision of a larger lesion for diagnostic purposes
10
Q
When would an incisional biopsy be used?
A
To perform an initial evaluation on a large skin lesion when complete excision is undesirable for cosmetic or functional purposes
11
Q
What is an excisional biopsy?
A
A full-thickness incision of smaller lesions where the entire lesion is removed
12
Q
What is important to do when performing an excisional biopsy?
A
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
13
Q
What are some of the indications of shave biopsy?
A
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
14
Q
What are the contraindications for performing a shave biopsy?
A
1) Malignant melanoma
2) Squamous cell carcinoma and other known malignancies
3) Areas of vascular compromise
15
Q
How do you perform a shave biopsy?
A
The lesion is removed from the skin in a horizontal manner parallel to the skin surface
16
Q
When is cryosurgery usually used?
A
For lesions that are benign and shallow, <3 mm in depth
17
Q
What kinds of lesions be safely removed with cryosurgery?
A
1) Verruca
2) Hemangioma
3) Actinic Keratosis
4) Basal Cell Carcinoma
5) Scars
6) Papular Nevi
7) Acrochordon
8) Condylomata
9) Seborrheic Keratosis
18
Q
What are some the contraindications for cryosurgery?
A
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
19
Q
What is the main type of cryosurgery?
A
Liquid Nitrogen
20
Q
What is important to remember about cryosurgery?
A
Histological evaluation cannot be performed on destroyed tissue
21
Q
Is anesthesia necessary with cryosurgery?
A
Not usually
22
Q
When using the swab technique of cryosurgery how long do you apply constant pressure?
A
30-60 seconds
23
Q
How far should the freeze zone extend?
A
1-3 mm around the lesion
24
Q
What must be applied to the skin when using a cryoprobe?
A
A thin film of water soluble jelly
25
When using a cryoprobe how far should the freeze zone extend?
1-2 mm beyond the rim of the probe
26
How many applications of a cryoprobe are usually necessary?
3 freezes are performed
27
What usually happens to the lesion after the cryosurgery?
It will blister and form a scab and heal over
28
What is important to tell patients about cryosurgery?
The scar may not tan as well as normal skin
29
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
30
What do you do if you spill liquid nitrogen on a patient?
Wipe it off as soon as possible. It usually does not burn
31
What is hyfrecation?
A unipolar diathermy that generates high voltage with low current
32
What are the indications of hyfrecation?
1) Quick effective destruction of lesions without blood loss
2) Good for vesicular lesions
33
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
34
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
35
Why do you not hyfrecate suspicious lesions?
Hyfrecation destroys the tissue and thus prevents histological evaluation
36
Is anesthesia indicated?
Yes, 1% lidocaine without epinephrine
37
What are the 3 types of hyfrecation?
1) Desiccation (Electricity)
2) Coagulation
3) Fulguration (Sparks)
38
Which method of hyfrecation has the electrode inserted into the lesion?
Desiccation : Destroy deep tissue of lesion; probe makes contact with the lesion
39
How deep do you put the electrode into the lesion in desiccation hyfrecation?
No deeper than 2-3 mm
40
How long do you apply current?
1-5 seconds
41
Which hyfrecation method uses a stream of sparks from the electrode to the lesion?
Fulguration
42
How far away from the lesion is the fulguration type of hyfrecation held?
1-3 mm
43
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
44
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
45
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
46
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
47
What is the greatest hazard of hyfrecation?
Burns
48
What are the 2 types of cautherization?
1) Chemical
2) Electrical
49
What is the usual use of cautherization?
To control bleeding
50
What are the different forms of chemical cauterization?
1) Silver Nitrate
2) Liquefied phenol
3) Monochloracetic acid
51
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
52
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
53
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
54
What are some of the contraindications of electrocautery?
1) Pacemaker
2) Metal objects in the body
3) Lesion where a biopsy is needed
55
Is anesthesia indicated for cauterization?
Yes, lidocaine 1% without epinephrine
56
What type of electrocautery tool is used for subungal hematoma?
Cold point electrode
57
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
58
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
59
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
60
When don't you use epinephrine?
With appendages that have a single entry and exit point for blood: Ears, Finger, toes, and genitals
61
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
62
What wound preparation antispetic is the most caustic to tissue?
Isopropyl alcohol
63
How many times do you need to clean the surgical site with Betadine?
3 times
64
How are the excision lines orientated?
Parallel to the skin tension lines
65
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
66
How far do you cut into the healthy tissue?
A 2 mm border of healthy tissue is usually needed
67
How is hemostasis managed?
1) Direct Pressure
2) Electrocautery
3) Tying of bleeders
68
What is done with the tissue if it is needed for biopsy?
It is placed in 10% formalin and transported to the pathologist.
69
What should be done to the skin prior to suturing?
It should be undermined to help approximate skin edges without tension
70
What can be placed on the skin to support the sutures?
Steri-strips
71
What needs to be written on the biopsy request?
Patient name, procedure, date, type and orientation of the specimen
72
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
73
How can you deal with dog-ears?
Excise the dog ear and re-suture the wound
74
What is the time limit for suturing up a wound?
It has to be done within 12 hours from tome receiving the wound
75
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
76
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
77
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
78
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
79
Is suture necessary?
Do not suture after I&D ! Apply a non-adhering dressing and secure
80
How soon does the gauze need to be changed?
The Iodoform gauze needs to be changed daily initially and less as the tissue heals
81
How soon should the Penrose drain be removed?
Usually within 24 hours
82
What are some of the possible problems with incision and drainage procedures?
1) Infection continues
2) Hemorrhage
3) Dehiscence- i.e sutures come out
4) Allergic reaction to local anesthetic
83
What is the best way to manage infection?
1) Prevent it from occurring: use sterile technique
2) Do good initial history to make sure patient is in good enough shape for surgery
3) Patient handouts and education on post-operative care
84
What do yo need to check for in any puncture wound or bite would?
Assess for tetanus status
85
When is it okay to administer a tetanus shot?
If it has been more than 5 years since their last booster
86
What is the most feared complication of an infection?
Septic Shock
87
What is the best way to avoid excessive scarring?
1) Remove the sutures in a timely manner
2) Make incision in the correct plane of the skin
3) Proper wound management
88
What is a keloid?
A hypertrophic scar that is common to certain ethnic groups
89
What can you do to help prevent keloids in a keloid former?
Inject anti-inflammatory into the tissue before closing
90
What can help prevent scar formation?
Calendula succus, Vitamin E or A topically
91
What should not be used in open wounds due to its caustic properties?
Betadine
92
How do wounds heal when a drain is placed?
Via 2nd and 3rd intention
FYI:
Secondary intention is when a wound is not surgically closed either completely or partially. This happens when a wound has a large amount of tissue loss or the edges cannot be safely brought together surgically
Tertiary intention is often labeled as delayed primary intention and is used when there is a need to delay wound closing. With this type of closure, there is a planned period where the superficial layers of the wound are left open. If the situation allows, later, these layers are closed in a similar fashion to what is performed with primary intention, but in this case, the process is more prolonged.
93
How long after the surgery should the would be kept dry and clean?
First 24-48 hours
94
How soon after surgery should the patient return for follow-up inspection and re-dressing?
2-3 days
95
Under what conditions should the patient contact the physician?
Problems, questions, worsening of symptoms: redness, pain, swelling, etc.
96
Describe the process of hemostasis
Local vasoconstriction, extravasation of blood constituents, initiation of the coagulation cascade, and clot formation
97
What methods can be applied to promote hemostasis?
1) Electrocautery
2) Chemical cautery
3) Lesion elevation
4) Addition of epinephrine to anesthesia
98
What is an example of chemical cautery?
Silver nitrate
99
What is the best way to avoid hemorrhage?
1) Use proper hemostasis during the procedure
2) Proper screen for potential bleeding disorders
100
What is the way to deal with surgical hemorrhage?
Find the bleeder and attempt to either tie it off or cauterize it
101
What post-operatively can be done to prevent hemorrhage?
Apply ice to the wound every 15 minutes/hour
Elevate the effected part
102
What criteria do you use in selecting on anesthetic over another?
1) Length of time required for pain control
2) Potential reactions to various agents
103
What criteria do you use in selecting a syringe for drawing up an anesthetic?
Use a size larger than you actually need to have some anesthetic on hand for emergencies
104
How is a field block performed?
A wall of anesthetic is injected across the path of all nerves supplying the operative field
105
How is a nerve block performed ?
The injection is made at a s site proximal to the incision area, near nerves supplying a specific area
106
What type of anesthetic has a long duration?
Bupivicaine (Marcaine)
107
What concentration of bupivicaine (marcaine) is usually used?
0.25%
108
What size need do you draw up and administer anesthetic?
109
What size need do you draw up and administer anesthetic?
110
What is the maximum dose of bupivicaine (marcaine) in mg total, mg/kg and cc?
140 mg maximum or no more than 4mg/4kg, 14 ml of 1%
111
What are the fast acting and short duration local anesthetics?
1) Lidocaine
2) Prilocaine
112
What will extend the duration of most local anesthetics?
Epinephrine
113
What is the maximum dose of lidocaine in mg total, mg/kg and cc?
200 mg, 4-5 mg/kg, 30 cc of 1%
114
What is the maximum dose of prilociane in mg total, mg/kg and cc?
400 mg, 4 mg/kg, 40 cc of 1%
115
What is the usual cause of dizziness and fainting?
Vasovagal response
116
What is the big systemic risk when using local anestheitcs?
Anaphylaxis
117
What are the potential cardiovascular reactions to anesthetic?
Hypotension
Bradycardia
118
What are the potential CNS reactions anesthetic?
Giddiness
Restlessness
Convulsions
Respiratory Failure
119
What are the contraindications for local anesthetic?
1) Pregnancy
2) Previous reaction to anesthetic
3) Using epinephrine on toes, fingers, genitals, nose, and ears
4) Hypertension or peripheral vascular disease
5) Epileptic patient
6) Cardiovascular, renal or liver dysfunction
120
What are the 2 different types of suture materials?
Absorbable
Non- absorbable
121
Catgut is what type of suture material?
Absorbable
Catgut: Made from animal intestines- used on instruments as well
122
Silk is what type of suture material?
Non-absorbable
123
Dexon and Vicryl are what type of suture material?
Absorbable
124
Dacron is what type of suture material?
Non-absorable
125
When do you use absorbale sutures?
When you are suturing up a deep closure
126
What type of needle would you use for plastic surgery and delicate work such as suturing children or working on the face?
Precision Point
127
What type of needle you you use to suture tough, difficult to penetrate tissues such as fascia and skin?
Reverse Cutting
128
What is the problem with non-absorbable sutures?
Some patients have a local reaction to the material
129
Which of the absorbable sutures is absorbed quickest?
Chromic catgut
130
Which of the absorbable sutures is absorbed the slowest?
Vicryl, Maxon and PDS (Polydioxanone Suture ) all can last for up to 180 days
131
Which is absorbable suture thread has the least tissue reactivity?
Maxon
132
Which of the absorbale suture threads has the most tissue reactivity?
Plain and chromic catgut
133
What are the different sizes of thread?
1-0 is the largest to 10-0 the smallest
134
When would you use 3-0 or 4-0 suture material?
Minor wounds and lacerations on the scalp, trunk, and extremities
135
What size of suture would you use on the face and hand?
5-0 to 6-0
136
What is the gold-standard suturing technique?
Simple interrupted
137
What suturing technique leaves a nice scar?
Subcuticular
138
What suturing techniques are used in situations of deep wounds or increased tension ?
Horizontal and vertical mattress
139
What should be used along with subcuticular suture?
Steri-strips
140
When would you use running or continuous stithes?
When you are working with areas of thick skin e.g. back and thighs
141
When do you not suture a laceration?
If it is greater than 8-12 hours old
142
What do you do to a wound that is older than 8 hours?
Cut off the outer layer of the wound until you have fresh tissue, clean up the wound and suture closed
143
How does this change with a laceration on the face?
More than 24 hours, up to 24 to suture
144
What is often used when you are using anesthesia on the scalp?
Epinephrine should be used
145
When should antibiotics be considered?
Animal Bites
Human Bites
Ischemic wounds (especially hands/fingers)
146
Where is the incision made when removing a lipoma?
Right over the top of the lipoma following skin lines
147
What is the best method of dissecitng the lipoma out? Why?
Blunt dissection because you don't cut cells or cut capillaries, veins or arteries. The instruments just slide past such structures
148
What should you do after removing the lipoma?
Probe with your fingers to make sure you have all the lobes
149
From what direction does the blood usually enter the lipoma?
From below via its stalk. Clamp if needed
150
What are some of the contraindications for removing a wart?
Usual CIs for surgery
Location: on the face, anywhere that causes lots of scarring
Extreme size
151
What are some of the chemical agents used for cauterizing warts?
Podophyllin (10%)
Salicylic Acid (40%)
Thuja or tea tree oil
152
What are some of the surgical method used to remove warts?
Electrosurgery (i.e. hyfercation)
Cryosurgery
Curettage and cautery
Excision
153
Why is cryosurgery a good method for wart removal?
Less painful
154
What procedure is usually the last resort in removing a wart?
Excision
155
What are some of the contraindications for removing a toenail?
Usual surgical CIs especially DM patients
156
What type of anesthesia is used?
1 % lidocaine without epinephrine, for toes
157
What is placed over the toe prior to anesthesia?
A tourniquet
158
What is the maximum length of time for having the tourniquet in place?
15-20 minutes
159
What can you do with recurring ingrown toenails ?
Use phenol on the germinal tissue
160
How long should the phenol be held on the tissue?
3 sets of 1 minute each
161
How do you neutralized phenol after you have applied it to the nail bed?
Neutralized with methyl alcohol
162
What is a contraindication for foreign body removal?
1) When removing will cause additional trauma or further bleeding
2) Usual contraindication for surgery
163
What is important to include when removing a sebaceous cyst?
Any excess skin or tissue and the central punctum
164
What are some possible complications of cyst removal?
If there is a large or unusual vascularity or any alarming components it be biopsied
165
What are some of the contraindications for sebaceous cyst removal?
166
What kind of dissection is used with cyst removal? Why?
Blunt dissection to precent the accidental release of fluid from the cyst
167
What is the treatment of choice for a dermatofibroma?
Excision and removal, however, removing a dermatofibroma will leave a larger scar than the actual lesion
Dermatofibroma: Cutaneous nodule
168
What size need do you draw up and administer anesthetic?
169
What are some of the contraindications for sebaceous cyst removal?
170
How can you tell whether or not you are dealing with a dermatofibroma?
Applying pressure toward the center from the 2 side will cause the lesion to dimple in the middle
171
What size need do you draw up and administer anesthetic?
172
What are some of the contraindications for sebaceous cyst removal?
173
What size need do you draw up and administer anesthetic?
174
What are some of the contraindications for sebaceous cyst removal?
175
What size need do you draw up and administer anesthetic?
176
What are some of the contraindications for sebaceous cyst removal?
177
What size need do you draw up and administer anesthetic?
178
What are some of the contraindications for sebaceous cyst removal?
179
What size need do you draw up and administer anesthetic?
180
What are some of the contraindications for sebaceous cyst removal?
181
What size need do you draw up and administer anesthetic?
181
What are some of the contraindications for sebaceous cyst removal?
182
What size need do you draw up and administer anesthetic?
183
What are some of the contraindications for sebaceous cyst removal?
184
What size need do you draw up and administer anesthetic?
185
What are some of the contraindications for sebaceous cyst removal?
186
What size need do you draw up and administer anesthetic?
187
What are some of the contraindications for sebaceous cyst removal?
188
What size need do you draw up and administer anesthetic?
Draw up with 20-22 gauge needle Administer with 25-27 gauge
189
What are some of the contraindications for sebaceous cyst removal?
190
What size need do you draw up and administer anesthetic?
Draw up with 20-22 gauge needle Administer with 25-27 gauge
191
What are some of the contraindications for sebaceous cyst removal?
192
What size need do you draw up and administer anesthetic?
Draw up with 20-22 gauge needle Administer with 25-27 gauge
193
What are some of the contraindications for sebaceous cyst removal?
194
What size need do you draw up and administer anesthetic?
Draw up with 20-22 gauge needle Administer with 25-27 gauge
195
What are some of the contraindications for sebaceous cyst removal?
196
What size need do you draw up and administer anesthetic?
Draw up with 20-22 gauge needle Administer with 25-27 gauge
197
What are some of the contraindications for sebaceous cyst removal?
198
What size need do you draw up and administer anesthetic?
Draw up with 20-22 gauge needle Administer with 25-27 gauge
198
What are some of the contraindications for sebaceous cyst removal?
1) The usual CIs for surgery
2) Poor location
