There is a difference between being efficient and being hurried, said Roger I. Ceilley, MD, with Dermatology PC in Des Moines, IA, during his presentation on surgical tips at the 2019 Fall Clinical Dermatology Conference in Las Vegas, NV.
He shared his surgery check list that included key aspects needed prior to and during surgery to help improve efficiency. For example, the list included: whether prophylactic antibiotics were needed and why; record blood pressure; check for special health concerns; signing of the consent form; and verification of the surgical site. Dr Ceilley also recommended several books by Atul Gawanda, which provide ways to make medical practices safer and more efficient.
“We ask patients to take a selfie or picture to verify a biopsy site,” he said, especially if there is a gap between the consultation and when the biopsy is performed.
For leftover sutures, Dr Ceilley said 4-0 or smaller on the skin are not a problem and the suture degradation rate is not an issue. He recommended dyed sutures for scalp procedures. Take home points, he said, were to design the excision properly, undermine widely and evenly, and close simply if minimal tension is present.
Suture-less closures he discussed included staples, steri-stripes/paper tape, Dermabond, liquid band-aid, krazy glue, and tapes and glue work.
According to Dr Ceilley, staples are quick and easy to use, they evert tissue when placed properly, and provide rapid wound closure. He suggested using them on the scalp because they are nonreactive, do not affect the hair; however, they are more painful than sutures during recovery and more painful to remove. Horizontal mattress sutures work well on the scalp, added Dr Ceilley, because they take the tension off and cut down on bleeding. Another suture he recommended on the scalp was the pully suture.
Dr Ceilley also reviewed the use of glue but cautioned using it regularly because patients can become sensitized to it. In addition, he recommended providers have anti-tension clamps and chalazion clamps, which can be extremely useful for lesions in mouth.
Additionally, Dr Ceilley recommended organizing the tray the same way with everything placed in the same order. He also suggested using a foam rubber, available at fabric stores, to manage sharp objects. Putting the sharp end into the foam is not only more efficient but also cuts down on the risk of accidental stabbing, said Dr Ceilley.
He recommended positioning the patient as comfortably as possible with neck support, placing a moist gauze over their eyes, and putting a pillow under their knees. He also recommended surgeons position themselves comfortable as well during procedures. Dr Ceilley said his team implemented a “no fly zone” over the patient’s eyes.
Surgical wound dressing should be done with pride, noted Dr Ceilley. He also reviewed the packet he gave patients post-procedure, which included tape, gauze, and petrolatum. His packet did include some antibiotics; however, “we don’t encourage patients to use them,” he said, “unfortunately, someone the patient knows will ask them if they got an antibiotic.” He provides a small packet for this reason. After surgery, patients can be given custom ice packets that are malleable or can use frozen corn or peas to help with recovery.
In addition to handouts and instructions for post-procedure care, Dr Ceilley recommended warning patients about swelling, hematomas, drainage, and infection risk, as well as consult with them about any activities they are engaged in that could hinder recovery.
One final tip he offered was to place biopsies on cardboard so they dry out before placing them in the bottle for laboratory testing, which shows the margins more clearly. He concluded his presentation by telling providers to document everything.
Ceilley R. Surgical tips. Presented at: 2019 Fall Clinical Dermatology Conference; October 20, 2019; Las Vegas, NV.