1. List below the usual types of instruments found in a surgical pack used to handle normal minor surgery in the office.
2. The best pre-surgical antiseptic mentioned is ___betadyne, unless pt has an allergy__.
3. List at least three surgical uses of a hemostat.
grabbing skin or other tissue
4. Why is shaving of hairy areas of the body prior to surgery not recommended any more?
Because small nicks in skin surface increase the risk of secondary infection. Also, some hair such as eyebrows is slow to regrow and can cause cosmetic issues.
5. What is meant by the term “Sterile Field”?
An area in which no non-sterile matter enters. The patient's area skin and wound are sterilized, and then a drape is applied to limit contact of nonsterile parts. The surgeon's hands and arms are scrubbed such as to limit transfer of microbes from other parts of the body. The instruments are autoclaved and not touched except by the surgeon after scrubbing and gloving. Everything in there should be sterile.
6. Why is it necessary to scrub hands prior to inserting them in sterile gloves?
In case a glove breaks, and to limit contamination of glove edges when donning the gloves.
7. What do you need to include in the description of the procedure section of the report?
A general summary of the procedure and plan, leaving out anything that has been reported in the details part. Wound care instructions and followup may be mentioned.
8. What do you need to talk to the patient about with reference to post-operative instructions?
The patient needs to know how to manage pain and swelling, how much bleeding or wound weeping to expect, and when to contact the doctor. They need to know what, if any meds, to use, and whether or not they can get the wound wet, or change the dressing. They need to know when the stitches come out, and what the general followup plan is.
9. Why do you ask about specific medical conditions before doing the surgery?
The surgeon needs to know how susceptible the patient is to infection, and how well the tissues can be expected to heal, which depends on their general vitality and metabolism. They also need to know if there are any anomalies in bleeding, processing of medicines, and especially if there are severe allergies to any of the agents which might be used for anesthesia or antiseptic.
10. Which class of anesthetics is primarily metabolized by the liver? Ester Amide
Why is this important????
Amides are processed in the ER of hepatocytes, and include bupivicaine, etidicaine, mepivicaine, prilocaine, and lidocaine. It's important to realize this because if the patient has a liver disease or disorder, these meds may not be promptly metabolized, and could cause a toxicity.
Esters are more likely to cause an allergic reaction and have some liver involvement in their metabolism, but are primarly excreted renally. Esters include: norprocaine, procaine, chloroprocaine, and tetracaine.
11. Early warning symptoms of anaphylaxis include:
flushing, tingling or swelling especially in the face and lips
patient may have a sudden sense of worry
soon to be followed by a rash and potentially systemic vasodilation-->incr HR decr BP
12. Why do you not let the patient leave the office immediately following surgery with anesthesia?
Keep them in the office to see if they will develop an allergic reaction to the anesthesias used, and to be certain that they have recovered from any sedative effects and are safe to drive. Also keep an eye on the wound to be sure that the patient's clotting is adequate.
13. What is the purpose of epinephrine being added to an anesthetic???
Epi is a vasoconstrictor which limits the bleeding at the surgical site, and also reduces the redistribution of anesthesia, making it "stay put" longer. This in turn means less anesthetic is required. Epi cannot be used for digits or extremities such as the genitalia because it can cause ischemia and tissue damage.
14. Describe the three phases of wound healing.
1. self-cleaning, involves bleeding, weepling, inflammation to flush out and destroy any pathogenic bacteria
2. walling off, involves collagen deposition to strengthen tissues and keep the insides in and the outsides out
3. remodeling and regeneration, involves continuing collagen deposition and resorption to restructure the tisse as best to approximate the form needed for optimal function
15. What is debridment and why is it important???
Debridement is cleaning the wound, removing any tissues which are dead or damaged, as well as any contaminants. The idea is that by removing all compromised tissues, the remaining vital tissues will heal better and there will be less risk of infection.
16. What is dead space???
Dead space is an empty area left after an excision or injury. It is a place where infection may breed, so it is best to approximate all tissues when closing a wound so as to minimize dead space.
17. What is the difference between a benign tumor and a malignant tumor with regard
a. growth rate: B9 grows slowly, malig may grow much faster
b. spreading: B9 spreads slowly if at all, malig may spread rapidly, invade BVs, and metastasize
c. palpable feel: B9 more likely to be moveable or soft, malig are hard and may be fixed
17. What is an example of a benign tumor of the skin???
actinic keratosis (though this one can turn malignant, it is still classifed B9)
18. What is an example of a malignant tumor of the skin???
BCC, SCC, melanoma
20. What is the most common skin cancer typically found???
21. What is the difference in content of the sac of a sebaceous cyst and an epidermal inclusion cyst?
A sebaceous cyst contains sebum, which is a waxy, fatty or oily exudate from the body which has been unable to exit the body by its usually glandular process due to clogging. An inclusion cyst is caused by something that has gotten into the skin, such as a splinter, which causes an initial inflammatory response, but may be retained in the skin long after any infection has been beaten. Contents are variable depending on the stage of the inclusion, but may be pruritic, or if late in the process look more like lumpy cheese.
22. What is an advantage of using Marcaine over Lidocaine?
Marcaine lasts a long time, about 3 hours. Aka Bupivicaine, it is concentrated and less anesthesia may have to be administered.
17. What is the function(s) of undermining?
To free the skin from subcutaneous tissues around the wound, allowing the skin to stretch and approximate edges more smoothly. This minimizes scarring.
24. The strength or effectiveness of an antiseptic is determined by the _phenol content_.
25. Describe the steps in doing a vertical mattress stitch.
It is a drawing stitch so if the wound is large, place the first one in the middle to hold the wound together. Begin with a large stitch toward yourself that goes all the way through the epidermis. Next place a small stitch away from yourself that is inside of the original stitch and in line with it. This smaller second stitch goes through the edge of the epidermis to hold the skin surface together. Lastly, tie it off.
26. On what parts of the body would you use the following suture sizes:
a. 3-0, 4-0: bigger, and used for coarser tissues, general body stitches. Absorbable stitches are 4.0.
b. 5-0: medium sized, used for tougher parts of face or more tender parts of body
c. 6-0: smaller, for very thin skin of face or genitalia, where scarring is definitely to be avoided. 7.0 is smallest, for face only.
27. What is your criteria for choosing of the proper anesthetic for the removal of a toenail?
You want a digit block because you cut deeply to remove a toenail. Be sure that your patient is not allergic to the agent chosen, that their liver function is adequate to process it, and that they are not on MAOIs or phenothiazides or any other med that might interact with your anesthetic. You can't use epi because it's an extremity so you can expect some bleeding.
28. List all necessary supplies needed for surgical removal of a lipoma.
everything listed to be sterile
soap, water, betadyne, sterile drape, gloves
needle, anesthetic, table, light, eye protection
scalpel, hemostat, scissor
suture material, gauze, needle
29. What are the pros and cons of using a 30g needle to inject an anesthetic?
30g is small, so it won't hurt much, but you may have to stick them more times to achieve anesthesia. It may take longer.
30. How does the autoclave process work to kill all bacteria, spores and virus particles?
Steam and pressure kills off most stuff, and anything not finished off by those is killed by the ethylene oxide.
31. What concerns do you need to be aware of when using Betadyne as a surgical scrub on your patient?
It can be irritating to the skin and is not indicated for cleaning inside wounds. Beware of possible patient allergies to the product, which may be foreshadowed by previous reactions to shellfish or iodine.
32. Describe how to administer the following anesthetic application techniques.
a. infiltration: inject directly into the wounded tissue on all surfaces, use epi if needed and not contraindicated. Also can use topical to achieve infiltration anesthesia, but it's slower.
b. field block: inject anesthesia in an arc proximal to the site, can use less drug, must know nerve path
c. digit block: inject at nerve leading to extremity to be worked on, can't use epi due to risk of ischemia to extremity
33. What factors do you have to take into account before deciding to do a surgical excision on a patient?
You want to assess their general health and vitality, nutritional status, hepatic and renal function, medications and supplements in use, any known allergies, and any medical conditions which could influence their reaction to the meds or the procedure. You also want to be sure the patient is reliable and will care properly for the wound afterward.
34. Describe the difference between 1st, 2nd and 3rd intention healing and which is the best for minimal scar formation?
1st intention is primary union, occurs when there is prompt closure of the wound, minimal edema, and no infection. Very little scarring.
2nd intention is secondary union. It involves the way the body tries to put itself back together when there is infection, trauma, and/or tissue loss, and the wound does not approximate well. It heals up from an inner layer toward the surface. This works OK for small wounds, or deep wounds that don't have major disruption of the epidermis, such as punctures and abscesses.
3rd intention occurs when you have delayed primary closure. Good for contaminated or infected wounds, and often used in the military. This option is used when there is a need to wait a few days (4 ish) for the body to wall off an infection, rather than closing the wound on top of an infection. It also can be used for such events as a ruptured appendix, when a wick may be left in the abdomen so that the purulent exudates can drain out as the body deals with the infection.
35. What factors determine which method of removal of a lesion is used (i.e. radiosurgery, excision, etc…)?
Factors influencing method decision include: is it B9 or malignant? Deep or shallow? Large or small? One site or many? Vascular area or not? Infection or not? Location: where is it? On the cervix? Or the elbow? Or the nose? Many variables go into the decision.
36. List five common lesions you are likely to see in your practice and give common method(s) of removal of each.
lipoma: excision by incision, undermining, pull it outta there and stitch'em up
paronychia: lift the nail edge and drain exudates, clean the area and trim tissues if needed
seborrheic keratosis: leave it be or snip it off like a skin tag
abscess: lyse the abscess and drain it, leave it open and pack it with something to assist drainage
nevi: do a punch biopsy if suspicious, leave it be if B9 and not cosmetically bothersome, excision by incision may be done if needed