Techniques and websites to assist with minor operations
Mr. A. Ismail MBChB MRCS (Eng)
SHO in Plastic Surgery
St Thomas’ Hospital
London SE1 7EH, UK.
Miss K. Jarvi MBChB(Hons) MRCS (Eng)
Registrar in General Paediatric Surgery
Barts and The London NHS Trust.
Dr G Elias MB ChB
Leeds Vocational Training Scheme.
Minor surgical operations are more frequently being undertaken by General Practitioners. These procedures include excision of benign lesions such as sebaceous cysts and lipomas, and excision biopsies of possible skin neoplasms. During our surgical training we have noted several techniques and found websites that have been useful to our practice and are worth considering for minor surgery.
Incisions require planning and consideration of ultimate scar placement. The incision to be made should be marked with ink before administration of local anaesthesia which may distort the appearance of the lesion. Fine-tipped sterile marking pens, or 'Sommerlad' pens and bonnie blue ink produce more precise markings than felt-tip pens. Margins taken should be measured accurately and documented in the operation note. Excision margins for basal- and squamous cell carcinomas are available on the British Association of Dermatology website: www.bad.org.uk
A mixture of lidocaine and bupivicaine provides quick, long-lasting anaesthesia. For larger lesions, a lower concentrations of local anaesthetic (i.e 1% rather than 2%) allows a greater volume to be used. Adrenaline should not be used in extremities with an end-arterial supply, such as digits. Information on local anaesthetics is available at www.4um.com/tutorial/anaesth/Locals.htm
Mobile skin should be fixed with the non-incising hand or with the aid of an assistant. The blade should be kept perpendicular to the skin surface. Incisions are best made along lines of relaxed tension (Langer's Lines). On the face these can be identified by asking the patient to frown or smile. Langer's lines are shown at http://www.fpnotebook.com/SUR32.htm. Skin hooks can be more useful than forceps when retracting and excising small lesions.
Good apposition of skin edges and minimal tension are important for obtaining a good cosmetic result. A variety of suture materials and suturing techniques are available and is largely down to personal preference. The following sites provide the advantages and disadvantages of each: http://www.surgical-tutor.org.uk/default-home.htm?core/preop2/sutures.htm~right
Further information is available at http://www.modern.nhs.uk/protocolbasedcare/sample_suturing.doc
Finally, ensure histopathology forms are filled in accurately indicating orientation of specimens with marking sutures and any margins taken.
We hope this information will be as useful to others as it has been to us.
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First published January 2007