Office-based dermatologic surgery should always start with a detailed surgery checklist that covers everything a physician needs to ensure a seamless procedure, according to Dr. Roger I. Ceilley.
The focus is on documentation and, ultimately, safety. "Document, document, document," he said during a talk at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.
A sample checklist that he shared included the following items:
• Referring physician.
• Who did the biopsy?
• Sign consent.
• Circle surgery site with patient verification.
• Verify and record pacemaker/defibrillator or other electronic implants.
• Review allergies to any anesthesia/antibiotics/latex/bandages.
• Check and record anticoagulants.
• Prophylactic antibiotics needed? If so, why?
• Record blood pressure and pulse – notify provider if elevated or too low.
• Check for special health concerns such as diabetes, etc.
• Buffered and unbuffered anesthesia on the field.
• Mapping card.
• Verify pathology report.
• Miscellaneous patient concerns.
Using such a checklist will ensure that all aspects of the pending procedure have been documented and discussed with the patient and also that the clinical assistant and physician are "on the same page" as to what will be happening before the procedure begins, said Dr. Ceilley of the University of Iowa, Iowa City.
Preoperative photography is a particularly important item on this list, as it can help to prevent wrong-site surgery, he noted, adding that it is also imperative to site confirm with the patient (one of the steps on the checklist) prior to beginning the procedure.
This information should be readily available because of the proper prior documentation. An accurate diagram and measurement also will help, he said.
Dr. Ceilley covered several other topics:
• Surgical equipment needs. A properly preselected, prewrapped, autoclaved pack of surgical instruments is a necessity; it should include a curette, forceps, scalpel blade holder, needle driver, hemostat, iris scissors, and straight scissor, he said.
The surgical tray also should include readily available gauze, cotton swabs, and extra anesthesia, and the equipment should be arranged on a tray in a standard fashion and kept organized during the procedure, with the sharps placed consistently in the same area on the tray.
• Local anesthesia. Dr. Ceilley described alternatives, including diphenhydramine and bacteriostatic saline, for the very rare patient with anesthesia allergies and provided a number of pearls for using local anesthesia. He discussed the use of topical versus subcutaneous lidocaine, the use of ice or alternate refrigerants, and the benefits of rubbing the area after infiltration.
He also noted that a number of other nonpharmacologic measures – including "talk-esthesia" (use of conversation to keep the patient’s mind busy and distracted from some of the more invasive aspects of the procedure), ice packs, accupressure, headphones, and even stuffed animals – that can provide pain relief or comfort for surgical patients.
• Sutureless closures. Among the options for sutureless closures are staples, steri-strips/paper tape, and Dermabond or other tissue glues. Tapes and glues are best for low-tension wounds, he noted.
• Closing tight wound defects. Pinching and stretching the wound can help with closure of tight wounds, as can the use of antitension clamps, he said, adding that a temporary horizontal mattress or pulley stitch also may help stretch tissue and facilitate closure.
• Hemostasis. Stretching, pinching, and applying ring pressure can help with hemostasis, he said.
• Surgical wound dressing. Keep a dressing tray handy and "do them with pride," Dr. Ceilley said of wound dressings.
"You will want to have on-hand items that you have learned are the most useful for wound dressing. These should include tan/skin-colored tapes, mupirocin or petrolatum, Coban (3M), Hypafix, and steri-strips, to name a few. Only use the minimum necessary for proper dressing of any item to ensure the least visibly noticeable appearance for your patient," he said.
Also, provide patients with supplies for dressing changes if possible, or with information on where to obtain the appropriate supplies, and include detailed wound care instructions, he said.
• Postoperative care. In addition to information on wound care and dressing, also provide patients with handouts on various aspects of postoperative care, including information on resuming activities and warnings about swelling, hematoma, drainage, and infection, he advised.
"I can’t overemphasize the importance of attention to detail in all aspects of dermatologic surgery, from evaluation and explanation to procedure, dressing, and postoperative care. The final results bear your signature and enhance or detract from your reputation and that of all dermatologic surgeons," he said.
Dr. Ceilley reported having no relevant disclosures. SDEF and this news organization are owned by the same parent company.
*This story was updated March 1, 2013.