Preoperative Preparation

Published on 26/02/2015 by admin

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1 Preoperative Preparation

Richard P. Usatine, MD, and Jennifer Krejci-Manwaring, MD

The practice of skin surgery in the office requires careful planning and a team of well-instructed support personnel. Other keys to success are thorough patient education and informed consent, preoperative screening, good surgical technique, and sterile surgical instruments. The use of universal precautions to prevent the transmission of infectious diseases is paramount to protecting the clinician, the medical staff, and the patient.

Surgical Planning

Surgical planning should consist of the following:

• Office scheduling
• Preoperative medical evaluation
• Informed consent
• Universal precautions
• Preoperative medications
• Standby medications and equipment
• Preoperative patient preparation (skin, hair, drapes)
• Sterilization of instruments
• Sterile technique.

Scheduling of Complex Surgeries

Simple surgical procedures, such as shave or punch biopsies, need no special scheduling. These procedures can be done rapidly as the need arises. However, clinicians contemplating performing more complex surgical procedures in the office will benefit from careful, deliberate consideration of how best to integrate the surgeries into the office schedule. Proper scheduling is critical to producing the efficient, unhurried surgical atmosphere that is reassuring to both the patient and the staff.

Some offices schedule more complex surgeries at the end of the morning or the end of the afternoon to avoid being rushed by other patient responsibilities. This allows the clinician to approach surgery in an unhurried manner. Another strategy is to designate certain half-days for surgical procedures only.

Surgeons may also choose to perform more complex surgeries early in the week and avoid surgery on Friday so patients can be seen the day after surgery for a postoperative check. This type of schedule helps prevent weekend calls or unneeded trips to the emergency center if a patient develops a hematoma or other complication that can be easily handled in the office.

Preoperative Medical Evaluation

Medical History

A complete medical history and review of systems before minor surgery may not be necessary. Before a more complex skin procedure, however, the following information should be taken during the medical history:

• Current medications, especially anticoagulants, aspirin, and other nonsteroidal anti-inflammatory drugs (NSAIDs), cardiac drugs.
• Allergies, especially to antibiotics, tapes/adhesives, iodine, anesthetics (lidocaine).
• Cardiac disease (e.g., any condition requiring endocarditis prophylaxis such as a prosthetic heart valve), uncontrolled hypertension, epinephrine sensitivity, angina. The presence of a pacemaker or implantable defibrillator has implications for electrosurgery (see Chapter 14, Electrosurgery).
• Other illnesses and medical conditions (e.g., diabetes, seizure disorder, hematologic disorder or bleeding diathesis, joint replacement [positioning of grounding pad with electrosurgical device], high-risk groups for infectious diseases [e.g., injection drug users]).
• Pregnancy, lactation.
• Keloids or hypertrophic scars.
• Infectious diseases (e.g., hepatitis B or C, HIV/AIDS, methicillin-resistant staphylococcus aureus, tuberculosis).

 

For minor skin surgery under local anesthesia, blood pressure should be measured but does not need to be monitored unless the patient has a history of hypertension that is not controlled. Uncontrolled hypertension may lead to increased bleeding during surgery. If the blood pressure is significantly elevated, consider postponing the procedure or giving a dose of an appropriate antihypertensive agent prior to the start of the procedure. It is prudent to be more careful with fragile patients, such as the elderly, and to be particularly careful with the use of epinephrine-containing anesthetics in patients with a history of angina, cardiac disease, or sensitivity to epinephrine. It may help to warn these patients that they may develop an increased heart rate or a feeling of anxiety after injection of lidocaine with epinephrine.

Medical Contraindications

Skin surgery is not recommended on patients who have unstable angina because the epinephrine in the local anesthetic can precipitate angina. Although this is unlikely, it is worth having nitroglycerin in the office to deal with this potential situation. Patients who have uncontrolled diabetes mellitus may experience impaired wound healing. Closer follow-up after surgery may help avoid potential problems with these patients.

Informed Consent

Thorough discussion with patients regarding the benefits and risks of any planned surgical procedure and the alternatives to surgery is essential before surgery. It is always best to devote adequate time for this discussion so that all of the patient’s questions can be answered in an unhurried manner. Although the optimal situation is to have the clinician who will perform the procedure provide the informed consent, a well-trained assistant can start the process and the clinician can answer any questions beyond the skills of the assistant. Risks include pain, bleeding, infection, scarring, change in pigmentation, regrowth, slow healing, change in anatomic appearance, skin indentation, skin protrusion, local nerve damage/numbness, loss of muscle function, and need for further treatment. A complete list of risks is listed in Appendix A on the sample consent form titled Disclosure and Consent: Medical and Surgical Procedures.

For many routine minor procedures, such as cryotherapy, a written consent may not be needed. However, clinicians may want to consider obtaining a written consent for any procedure, even as small as cryotherapy, if the procedure is to be performed on a cosmetically sensitive area such as the face or on those for whom scarring may be more of a concern. Written consent is always obtained for procedures that may have more significant adverse consequences, such as scarring or functional effects. Feel free to use or modify the form supplied in Appendix A for your own office.

For larger surgeries, show patients the planned excision before you begin the surgery. You can show the patient and any family in attendance your surgical markings before you start. Keep a handheld mirror nearby for excisions on the face so that your patient knows what you plan to do. This is a helpful method to make sure you truly have informed consent.

Universal Precautions

With the identification of AIDS in the 1980s, measures to prevent the transmission of contagious diseases to medical personnel have come to be known as universal precautions, and their use has been incorporated into every medical clinic, surgical center, or hospital. Diseases of chief concern are hepatitis B, hepatitis C, and HIV/AIDS. However, other contagious diseases, such as tuberculosis and syphilis, also present some potential risk to medical personnel.

The basics of universal precautions include the use of surgical gloves and the use of barrier clothing such as gowns, face masks, and eye protection; proper disposal of sharp, disposable surgical instruments, such as needles and scalpel blades, in special puncture-proof containers; disposal of all contaminated drapes and other soft items in specially marked biohazard containers; and collection and disposal of this material by professional hazardous-waste removal companies.

For skin surgery we have found it especially helpful to practice choreographed surgery, with particular attention paid to any sharp instruments. We handle only one sharp instrument at a time and are aware of its position at all times. All sharps should be counted as they are placed on and removed from the surgical tray. Avoid recapping needles that have been used with a patient. If a recap must be done, use the one-handed recap technique in which the needle sheath is positioned against an inanimate object. When suturing, use an instrument such as Adson forceps to load the needle onto the needle driver rather than your fingers. We take particular care to avoid rushing when performing surgery and also attempt to have extra help available—within earshot—at all times.

Medications

Anticoagulation/Antiplatelet Therapy

The clinician needs to find out which medications the patient is taking in order to determine if there will be an increased risk of bleeding in the intraoperative or postoperative period. This includes warfarin, aspirin, NSAIDs, clopidogrel, and low-molecular-weight heparin. For larger surgeries, one might query patients about their use of any vitamin, herbal, or other over-the-counter supplements because some of these can alter the coagulation profile (see Box 1-1).

Box 1-1

Supplements That Alter Coagulation

Dietary Supplements with Anticoagulant Activity

Bilberry

Black currant

Bladderwrack

Cayenne fruit

Celery plant

Da huang

Danshen

Devil’s claw

Dong quai

Evening primrose seed oil

Feverfew

Garlic

German chamomile

Ginger

Gingko

Ginseng, Panax

Horse chestnut

Kava kava root

Licorice

Meadowsweet

Papaya

Poplar

Red clover

Sweet clover

Tamarind

Vitamin E

Willow bark

Herbal Supplements with Coagulant Activity

Alfalfa

Goldenseal

Green tea

Source: Adapted from Dinehart SM. Dietary supplements: Altered coagulation and effects on bruising. Dermatol Surg. 2005;31:819–826.

The issue of whether to stop anticoagulation/antiplatelet therapy before surgery has been controversial, but the best evidence now points toward continuing these medications. One large study of 2394 patients with 5950 lesions found four independent risk factors for postoperative bleeding:

• Age 67 years or older (odds ratio [OR] 4.7)
• Warfarin therapy (OR 2.9)
• Surgery on or around the ear (OR 2.6)
• Closure with a skin flap or graft (OR 2.7).1

 

Aspirin therapy was not an independent risk factor for bleeding. The researchers concluded that “most postoperative bleeds were inconvenient but not life threatening, unlike the potential risk of thromboembolism after stopping warfarin or aspirin.” They recommended not to discontinue aspirin before skin surgery.1

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