Minor Surgery at a Glance E-Book

Helen Mohan

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Serie: At a Glance
• Sprache: Englisch

Seitenzahl: 210

Veröffentlichungsjahr: 2016

Beschreibung

Minor Surgery at a Glance is an essential companion for those who wish to learn or familiarise themselves with minor surgery, including trainees and practising surgeons, dermatologists, GPs, and emergency medicine physicians. Covering the basic principles of minor surgery, as well as offering an overview of techniques and common procedures accompanied by step-by-step illustrations, this book also provides concise summaries of vital information and the clinical practicalities.

Providing an accessible and practical introduction to a rapidly expanding area of practice, Minor Surgery at a Glance is ideal for medical students, foundation programme doctors, and trainees in a wide variety of disciplines who perform minor operations.

Leseprobe

This title is also available as an e-book.

For more details, please see

www.wiley.com/buy/9781118561447

or scan this QR code:

Minor Surgery at a Glance

Edited by

Helen Mohan

Department of Surgery St. Vincent's University Hospital Dublin, Ireland

Des Winter

Department of Surgery St. Vincent's University Hospital Dublin, Ireland

This edition first published 2017 © 2017 by John Wiley and Sons, Ltd.

Registered office:  John Wiley & Sons, Ltd, The Atrium, Southern Gate, Chichester, West Sussex,          PO19 8SQ, UK

Editorial offices:    9600 Garsington Road, Oxford, OX4 2DQ, UK           The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK           111 River Street, Hoboken, NJ 07030-5774, USA

For details of our global editorial offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please see our website at www.wiley.com/wiley-blackwell

The right of the author to be identified as the author of this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.

Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought.

The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by health science practitioners for any particular patient. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation and/or a potential source of further information does not mean that the author or the publisher endorses the information the organization or Website may provide or recommendations it may make. Further, readers should be aware that Internet Websites listed in this work may have changed or disappeared between when this work was written and when it is read. No warranty may be created or extended by any promotional statements for this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.

Library of Congress Cataloging-in-Publication Data

Names: Mohan, Helen, 1983- editor. | Winter, Desmond, 1969- editor. Title: Minor surgery at a glance / edited by Helen Mohan, Desmond Winter. Other titles: At a glance series (Oxford, England) Description: Chichester, West Sussex : John Wiley & Sons, Ltd,  2017. | Series: At a glance series | Includes bibliographical references  and index. Identifiers: LCCN 2016019921 (print) | LCCN 2016020560 (ebook) | ISBN  9781118561447 (pbk.) | ISBN 9781118561423 (pdf) | ISBN 9781118561430 (epub) Subjects: | MESH: Minor Surgical Procedures--methods | Perioperative Care |  Handbooks Classification: LCC RD111 (print) | LCC RD111 (ebook) | NLM WO 39 | DDC  617/.024–dc23 LC record available at https://lccn.loc.gov/2016019921

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Cover image: © Getty/image source

CONTENTS

Contributors

Preface

Part 1 Avoiding and managing problems: principles of safe surgery

1 Consent

The nature of consent

How detailed should information be?

What is material risk?

The adult patient

The child patient

The patient with cognitive impairment or intellectual disability

Seeking medico-legal advice

2 Physical environment

Suitable settings for minor surgery

Facilities required

3 Set-up

Patient positioning

Surgical safety

Preparation of the surgical site

4 Instruments

Scissors

Grasping forceps

Clips

Tissue holders

Needle holder

Retractors

5 Infection control and prevention

Infection prevention

Types of pathogens

Minor surgery and infection

6 Human factors

What are human factors?

Safe surgery initiatives

Asking for help

7 Focused history

Focused history for minor surgery

Past medical history

Drug history

Social history

Family history

Systems review and summary

Patient-centred care

Day surgery

8 Specimen processing and reporting

Specimen handling and labelling

Tissue preservation

Processing and staining of tissue

The frozen section technique (intraoperative consultation)

Stage of disease

The surgical pathology report

9 Follow-up

Introduction

Dressings

Analgesia

Complications

Follow-up plan

Information for GP letter

10 Anaphylaxis

Anaphylaxis

Recognition of anaphylaxis

Medical interventions for anaphylaxis

Surgical interventions for anaphylaxis

Follow-up for anaphylaxis

11 Emergencies and resuscitation

Advanced life support algorithm

12 Audit and practice

Clinical governance

Audit

13 Communication and conflict resolution

Communication skills

Conflict resolution

Part 2 Basic pain control and anaesthesia

14 Local anaesthesia

What is a local anaesthetic?

Safety considerations

Adrenaline

15 Sedation

Sedation and analgesia

Levels of sedation and analgesia

4 P’s of safe sedation

Patient

Procedure

Provider

Place

Monitoring the level of sedation

Complications of sedation

Reversal of sedation (if required)

Discharge

16 General and regional anaesthesia

Introduction

General anaesthesia

Regional anaesthesia

Spinal anaesthesia

Epidural anaesthesia

Peripheral nerve blocks

Part 3 Core surgical knowledge

17 Skin incisions

Scalpels

Holding the scalpel to make an incision

Basic principles for incision

Minor surgical incisions

Techniques for a good scar

Electrodissection to incise

18 Principles of wound closure

Plan the skin incision

Choosing the suture size

Choosing the suture material

Suture placement

Technique for simple interrupted sutures

When should I use a different suturing technique?

Removing sutures

Anaesthesia

19 Sutures

Introduction

Properties of the ideal suture material

Types of suture material

Suture sizes

20 Needles

Understanding surgical needles

Selecting a needle

21 Diathermy

Introduction

Principles in electrosurgery

Types of diathermy

Tissue effects

Using diathermy

Risks and complications

22 Dressings

Choosing a dressing

23 Haemostasis

Pressure and elevation

Diathermy for haemostasis

Ligation or suture ligation

What to do if haemostasis cannot be achieved?

24 Hypertrophic and keloid scarring

What are they?

Part 4 Practice of minor surgery

25 Biopsy techniques

Introduction

Biopsy techniques

Anatomical areas for caution

Punch biopsy

Shave biopsy

26 Benign and premalignant skin lesions

Introduction

Benign pigmented lesions

Seborrhoeic keratosis

Pyogenic granuloma

Skin tag

Keratin horn

Keratoacanthoma

Actinic keratosis

Bowen’s disease

Dermatoses

27 Melanoma

Malignant melanoma

Excisional biopsy and margins

Procedure of excisional biopsy

Wider excision of margins

Referral to specialist skin cancer multidisciplinary team

Staging

28 Non-melanoma skin cancers

Introduction

Basal cell carcinoma

Squamous cell carcinoma

29 Neck lumps

Introduction

Anatomical considerations

Differential diagnosis

Lymph nodes

Investigation and management

30 Sebaceous cysts

Introduction

Consent

31 Lipoma

Preoperative planning

32 The reconstructive ladder

The reconstructive ladder

Skin grafting (Table 32.1)

Flap reconstruction

33 Cryotherapy for verrucae (plantar wart)

Verrucae

Existing treatment options

Cryotherapy

When to refer to a specialist service

34 Muscle and nerve biopsy

Introduction

Indications and contraindications

Open muscle biopsy procedure

Needle muscle biopsy procedure

35 Ingrown toenail

Introduction and pathogenesis

Aetiology/risk factors

Anatomy

Management

Note

36 Lymph node excision

Preparation

Procedure

Specimen preparation

37 Sclerotherapy

Indications

Considerations

Consent/risks

Preparation

The procedure

Post-procedure

38 Botulinum toxin

Botulinum toxin

Injection

Side effects

39 Tetanus

What is tetanus?

Epidemiology

The disease

Prophylaxis

Tetanus immunoglobulin (TIG)

40 Scalp lacerations

Introduction

Anatomy and neurovascular supply

Wound preparation

Techniques of repair

Follow-up care

When to refer

41 Foreign bodies

Introduction

Assessment for foreign bodies

Removal of foreign bodies

42 Facial trauma and lacerations

Assessment of facial lacerations

Management of facial lacerations

Management of trauma to the ear

Management of eyebrow lacerations

Management of lip lacerations

43 Hand injuries

Assessment

Management

44 Trauma assessment

Mechanism of injury

Primary survey

45 Psychosocial considerations

Domestic violence

Dealing with domestic violence presentations

Deliberate self-harm

Non-accidental injury in children

46 Incision and drainage of abscesses

Definition of an abscess

Causes

Clinical features

Management

Anal abscesses

Hidradenitis supparativa

47 Complications

Background

Common complications in minor surgery

48 Difficult locations

Where are difficult locations?

Pretibial lacerations

INDEX

End User License Agreement

Pages

1

2

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

24

25

28

29

30

31

32

33

34

35

38

39

40

41

42

43

44

45

46

47

48

49

50

51

52

53

56

57

58

59

60

61

62

63

64

65

66

67

68

69

70

71

72

73

74

75

76

77

78

79

80

81

82

83

84

85

86

87

88

89

90

91

92

93

94

95

96

97

98

99

100

101

102

103

104

105

106

107

108

Contributors

Tan Arulampalam, Chapters 2, 3

Robert Baigrie, Chapter 36

Ishwarya Balasubramanian, Chapters 26, 28

Andrew J Beamish, Chapter 39

Dara Breslin, Chapters 14, 16

Michelle Carey, Chapter 13

Michael Chung, Chapter 24

David J Clark, Chapter 47

Maura Cotter, Chapter 8

Denis Cusack, Chapter 1

Joana Ferrer Fábrega, Chapter 34

Christina Fleming, Chapter 27

Charlotte Florence, Chapter 47

Jessica J Foster, Chapter 39

Greg Fulton, Chapter 37

Olivier Gié, Chapters 9, 21, 22, 23

Amy Godden, Chapter 33

Graeme JK Guthrie, Chapter 30

Hanafiah Harunarashid, Chapter 17

Masakazu Hasegawa, Chapter 38

Anna Heeney, Chapter 37

Paul Horgan, Chapter 30

Steve Hornby, Chapters 13, 46

James Horwood, Chapter 47

Michael Hu, Chapter 43

Jeong Hyun, Chapter 32

Farrah-Hani Imran, Chapter 17

Anand Alister Joseph Ramachandran, Chapter 15

Josep M Grau Junyen, Chapter 34

Mortimer Kelleher, Chapters 14, 16

Genevieve Kelly, Chapters 25–28

Michael Kelly, Chapter 35

Rory Kennelly, Chapter 45

Brian Kirby, Chapters 25–28

Walter Koltun, Chapters 19, 20

Nik Ritza Kosai, Chapter 17

Stavros Koustais, Chapter 31

David Lo, Chapter 18

Michael T Longaker, Chapters 18, 24, 32, 38, 42, 43

Marie-Laure Matthey, Chapters 9, 22

Adrian McArdle, Chapters 18, 24, 32, 38, 42, 43

Frank D McDermott, Chapters 5–7, 33

Keno Mentor, Chapter 36

Helen Mohan, Chapters 4, 23, 25, 31, 37, 41, 48

Nigel Noor, Chapters 2, 3

Maeve O'Connor, Chapter 14

Peter Radford, Chapter 29

Meenakshi Ramphul, Chapter 12

Rish Sehgal, Chapters 19, 20

Kshemendra Senarath-Yapa, Chapter 42

Rishi Sharma, Chapter 29

Neil Smart, Chapters 5-7

Abel Wakai, Chapters 10, 11, 45

Derrick Wan, Chapters 18, 24, 32, 38, 42, 44

Rory Whelan, Chapters 10, 11, 45

Adam Williams, Chapter 40

Des Winter, Chapters 4, 23, 31, 35, 41, 43, 44

Preface

Minor surgery is a generic term encompassing a variety of elective and emergency procedures. The term minor surgery can be misleading, as these operations are far from trivial and serious consequences can arise. Therefore, minor surgery requires due care and consideration. This book provides an overview of minor surgical techniques and common minor surgical procedures.

The first half of the book deals with general principles of minor surgery. These include non-technical factors, for example, how to deal with patients and their families, consent, and technical considerations such as asepsis, wound closure and choice of suture material. The second half of the book covers common minor procedures in both the elective and emergency setting.

This book does not attempt to provide an exhaustive review of minor surgery, but rather to provide a useful starting point to adjunct clinical learning for those embarking on minor surgery, including surgical trainees, GPs and emergency medicine physicians.

Helen MohanDes Winter

Part 1Avoiding and managing problems: principles of safe surgery

Chapters

1

Consent

2

Physical environment

3

Set-up

4

Instruments

5

Infection control and prevention

6

Human factors

7

Focused history

8

Specimen processing and reporting

9

Follow-up

10

Anaphylaxis

11

Emergencies and resuscitation

12

Audit and practice

13

Communication and conflict resolution

1Consent

The nature of consent

This medico-legal summary is based on current laws in Common Law jurisdictions (those which have their roots in the English legal system). The principles are, however, applicable to medical practice across other legal systems.

A doctor is obliged to obtain a patient’s prior agreement to any proposed treatment, intervention or procedure. This respects the patient’s right to be involved in their healthcare decisions. Consent may be implied from the conduct of the patient or circumstances of the consultation. But where there is an intervention or procedure with potential side effects or adverse outcome, then express consent, either verbal or written, must be obtained. Allegations of clinical negligence in cases of adverse or unexpected outcome now frequently include an allegation of failure to obtain proper informed consent in addition to allegations of negligent performance standard.

The three core elements of consent

Competence or capacity: A person is deemed to have capacity if they have the ability to understand the information given by the doctor, to weigh it up and to make a decision as to whether to accept or refuse the proposed treatment or procedure. The person must also be able to communicate this decision clearly. Particular care is required for a child under the age of legal consent (commonly 16 years); or where there is doubt about the mental health or intellectual ability of the patient; or if there is a physical difficulty impeding clear communication. In all of these circumstances, detailed consideration must be given to assessing capacity and there may be a need for the doctor to consult a medico-legal advisor.

Voluntariness: The doctor must also be satisfied that the patient is giving consent voluntarily and is not under any duress, coercion or undue pressure from any other person to either accept or refuse the proposed treatment or intervention.

Information disclosure: Providing sufficient information to the patient is a critical element of obtaining valid consent and the emphasis has shifted onto this element in modern clinical practice and medical law. It is also the most difficult element to define medico-legally.

The patient should be given information regarding:

Their condition, illness or disease

The nature, scope and significance of any proposed treatment or intervention

The aims and expected outcome

Any discomfort, common side effect or risks of the procedure

Any alternative or choices of treatment.

The patient must also be told that they are free to refuse treatment or to withdraw their consent at any time prior to the treatment.

How detailed should information be?

Different levels of detail are required to be given depending on the nature of the intervention. In all cases, the standard is what a reasonable person would expect to be told in order to make a fully informed decision. The standard level of information given to the patient must include an explanation of any frequent minor risks and of major risks (even if infrequent), which are sometimes referred to as ‘material risks’. In the case of medical necessity for the procedure there is a general and approved practice not to disclose minimal risks that might cause unnecessary anxiety and stress or might deter the patient from undergoing necessary treatment, but this must be the exception rather than the rule. When the procedure is not a medical necessity (sometimes called ‘elective’), the required standard of information provision is higher and tends towards full disclosure. Disclosure must also include direct and full response to specific questions raised by the patient about the procedure, including any complications. It is the substance of the disclosure that is critical to the validity of the consent rather than the mere formulaic existence of a written and signed consent form.

What is material risk?

The legal analysis of the meaning of material risk by the Courts has changed in recent times. The question of risk is no longer solely determined by the standards of the medical profession but is judged by the significance a reasonable patient would attach to the risk of the proposed treatment or intervention. What constitutes material risk involves consideration of both the severity of the potential consequences and the statistical frequency of the risk.

The adult patient

A competent adult patient must make the decision about a treatment or intervention themselves. No one else is entitled to make that decision for them. If not competent, then other persons may be in a position to contribute to such a decision using a combination of tests of substituted judgment (as if standing in the shoes of the patient) and ‘best interests’ of the patient. In the event of a dispute between next-of-kin and/or health carers over such a decision, the Courts may ultimately be asked to make the decision.

The child patient

In the majority of Common Law jurisdictions, statute laws are in place by which a child under 18 years but who is 16 years or over is considered legally competent to give consent to medical, surgical or dental treatment. However, doctors should be familiar with local, national or state legal provisions that provide for varied age thresholds (e.g. from 14 to 18 years). The parents or legal guardians of a child under the relevant legal age are considered entitled to give consent on behalf of the child. A mature child under that age may in certain defined circumstances be considered competent. The Courts will have the ultimate decision where a dispute arises or where the refusal of treatment is considered potentially detrimental to the child.

The patient with cognitive impairment or intellectual disability

Great care must be taken in circumstances where the capacity of the adult patient to make decisions is in doubt. In cases of dispute or in the absence of clear agreement or legal authority, the Courts will be the ultimate decision maker.

Seeking medico-legal advice

When a doctor is faced with a situation where there is doubt about the validity of the consent of the patient or where there is disagreement about treatment or intervention when a patient is not considered competent to make such a decision, the doctor is advised to seek immediate expert medico-legal advice from their medical indemnity organisation. The only exception in this scenario is in circumstances of medical emergency where there is an immediate danger to the health or well-being of the patient, when the doctor may have to act in the patient’s best clinical interest. Doctors should also seek such expert advice if in doubt in any specific consent situation.

2Physical environment

Suitable settings for minor surgery

Minor surgery should ideally be conducted in an environment specifically designed for that purpose. Minor surgery services may be separated from the inpatient hospital environment in favour of hospital-integrated units or community-based free-standing units (often referred to as Treatment Centres or Ambulatory Care and Diagnostic Centres (ACADs) in the UK). There are several advantages and disadvantages to hospital-based versus community-based units (Table 2.1). Patient selection is key if using a community-based unit, as the same backup is not present as in the hospital environment.

Facilities required

Minor surgery facilities can be configured in a number of ways but generally require a day ward or waiting area to receive patients, operating theatres or procedure rooms and a recovery area for rehabilitation. In the hospital setting, anaesthetic rooms are often also used. Modernisation of medical practice has led to the replacement of beds in favour of trolleys and chairs to reduce space requirements and also to promote earlier mobilisation to aid recovery.

For general practitioners setting up a minor operating facility, it is important to be aware of health and safety legislation and to ensure that sterilisation of equipment, sharps disposal and use of chemicals such as liquid nitrogen complies with relevant health and safety legislation.

What factors are important to the layout of the operating theatre complex?

The physical layout of the operating suite can be variable; however, recognition of the importance of reducing contamination to reduce wound infection has led to the delineation of clean, hazardous and contaminated areas as seen here.

Unrestricted – contaminated

These include the patient receiving area, dressing rooms, lounges and office.

Semi-restricted – hazardous

These include hallways, instrument and supply processing area, storage areas and utility rooms.

Restricted – clean

These include the operating theatre, scrub sink areas and sterile supply rooms.

What are the design and equipment requirements for a minor 
surgery-operating suite?

Cleanliness

The surgery-operating suite must be spacious to allow scrubbed personnel to move around non-sterile equipment without contamination. In addition, it must be easy to clean – uncluttered and simple so that dust is not trapped in areas that would be difficult to clean. Surfaces must be durable and easy to clean to reduce contamination.

Ventilation

Guidelines for the design of new operating theatre facilities advocate positive pressure ventilation of 25 exchanges per hour of filtered air. Windows should not be opened. However, a facility with natural ventilation is acceptable for most minor surgical procedures. If using natural ventilation, windows can be opened but only if they have an adequate fly screen. Humidity is controlled to 50–53% to achieve minimal static and reduce microbial growth. Temperature is maintained at 20–24 °C.

Lighting and equipment

It is important to have appropriate lighting – both in terms of overhead room lights and surgical spotlights for the operative site. The operating table should be adjustable for height, degree of tilt in all directions, orientation in the room, articular breaks and length.

Safety

It is important to have a telephone to contact outside assistance. Emergency numbers should be clearly displayed.

Anaesthesia equipment and monitoring as appropriate to the surgery must be present and in good condition. Anaesthetic machines must be checked at the start of every case.

Fire safety is crucial and the theatre should be designed in keeping with fire regulations.

Further reading

Humphreys H, Coia JE, Stacey A, et al. Guidelines on the facilities required for minor surgical procedures and minimal access intervention. Journal of Hospital Infection 2012; 80: 103–109.

3Set-up

Patient positioning

Why is patient positioning important?

Operating surgeons have the ethical responsibility of treating their patients with the principle of non-maleficence. The anaesthetised patient loses their ability to communicate pain and pressure to the surgical team, and therefore it is now your responsibility to ensure the patient is positioned safely (Figure 3.1). The American Society of Anaesthesiologists (ASA) provides useful guidelines on positioning intraoperatively.

What are the goals of patient positioning?