MINOR SURGERY COURSE

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MINOR SURGERY COURSE

• Mr Oliver Cassell FRCS (Plast) MS
• Consultant Plastic and Reconstructive Surgeon
• The John Radcliffe Hospital, Oxford
• The Horton Hospital, Banbury

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Contact Details

• Horton Tel 229269 Fax 229670
• JR Tel 231057 Fax 231091
• Private Tel/Fax [phone]

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MINOR SURGERY

• The only thing that is minor is the surgeon!

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AGENDA

• History
• Examination
• What to refer
• Consent
• Local Anaesthetics
• Instruments and dressings
• Complications and management

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HISTORY of LESION
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HISTORY of LESION

• Number
• Site
• Enlargement/Change
• Blood/Discharge
• Odour
• Colour
• Itch
• Pain/Discomfort

• Previous LA excision
• Occupation
• Outdoors/lived abroad
• Radiation

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DRUGS and ALLERGIES

• Immunosuppression
• Bleeding
• Warfarin
• Clopidogrel
• Dipyridamole
• Aspirin

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PMH and FH

• Diabetes
• Previous scars
• FH scarring
• FH of lesions

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EXAMINATION
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EXAMINATION

• Soreness
• Site
• Size
• Surface
• Symmetry
• Skin/Subcutaneous
• Survey

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ASSESSMENT

• Diagnosis
• Proceed
• Refer

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WHAT TO REFER?
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WHAT TO REFER?

• Site
• Patient
• Lesion
• Operator/Set up

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TRICKY SITES

• Face
• Chest
• Joints
• Hands

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TRICKY PATIENTS

• Young!? women!?
• Children
• Demanding patients
• Previous adverse scar
• Previous complication
• Bleeding risk

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TRICKY LESIONS

• Big
• Deep
• Malignant?
• Infected
• Recurrent

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GP MOPS BASIC

• DOPS
• MS course
• Certification
• Dermatology

• Benign skin
• Body
• Simple excisions
• Shaves

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GP MOPS ADVANCED (GPwSI)

• Weekly training
• Log book
• DOPS
• Audit
• 4 LSMDT meets
• Surgery course
• Local governance

• Pre cancerous
• Low risk BCC

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HEATED DEBATE
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CONSENT

• Information
• Verbal
• Written

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CONSENT

• Infection
• Bleeding
• Dehiscence
• Bad scarring
• Recurrence
• Re-excision

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LOCAL ANAESTHETIC
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LOCAL ANAESTHETIC

• Operator
• Number of injections
• Speed of injection
• Equipment
• Needle gauge
• Temperature
• Acidity
• Patient
• Site
• Size of lesion
• Sensitivity

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LOCAL ANAESTHETIC

• Lignocaine 3mg/kg (7mg/kg with adrenaline)
• Bupivacaine 2mg/kg

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TOXICITY FACTORS
Dose Site Rate of injection

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COMPLICATIONS
4m g/ml lightheadedness, tinnitus, circumoral
and tongue numbness anticonvulsant and
antiarrhythmic activity 6m g/ml visual
disturbances. 8m g/ml muscular twitching 10m
g/ml convulsions 12m g/ml unconsciousness

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TREATMENT OF COMPLICATIONS
Supportive Oxygen, IPPV Correct acid base
imbalance Anticonvulsant Phenytoin Antiarrhytmic
Bretylium

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WHY ADRENALINE?
Decreased bleeding toxicity Increased duration
of anaesthesia

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PLANNING

• Appropriate lesion
• Appropriate patient
• Consent
• Prophylaxis

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PLANNING

• Room
• Room set up
• Assistant
• Light
• Couch
• Instruments
• Sutures
• Dressings

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INSTRUMENTS

• Disposable vs non disposable
• Diathermy
• Good instruments make your job easier

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INFECTION CONTROL

• Prophylactic antibiotics (if indicated)
• Handwashing
• Alcoholic prep (not near eyes)
• Sterile drape, gloves, instruments
• Atraumatic tissue handling
• Haemostasis
• Dressing

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COMPLICATIONS

• Infection
• Bleeding
• Dehiscence
• Recurrence
• Further operation
• Scar
• Hypertrophic/keloid
• Stretch

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COMPLICATIONS

• Infection
• S.Aureus
• Antibiotics
• Flucloxacillin/Erythromicin
• Augmentin

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BLEEDING

• Pressure

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DEHISCENCE

• Acute
• Chronic

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COMPLICATIONS

• Immediate dehiscence
• Resuture
• Retape
• Delayed dehiscence
• Dressings
• Reassurance
• Scar revision (6-12 months)

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COMPLICATIONS

• Pathology suggests further operation
• Reoperate
• Refer

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COMPLICATIONS

• Recurrence
• Reoperate
• Refer

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HYPERTROPHIC SCAR Avoidance Treatment
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HYPERTROPHIC SCAR

• Avoidance
• Site
• No Tension
• Orientation
• Suture
• Tape

• Treatment
• Tape
• Massage
• Silicone
• Steroids

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ANY QUESTIONS?
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STRETCH SCAR

• Avoidance
• Treatment