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Ovid: Oxford Handbook of General Practice

Editors: Simon, Chantal; Everitt, Hazel; Kendrick, Tony Title: Oxford Handbook of General Practice, 2nd Edition Copyright ©2005 Oxford University Press > Table of Contents > Chapter 7 – Minor surgery Chapter 7 Minor surgery ‘A minor operation: one performed on someone else’ Unaccredited Penguin Dictionary of Humerous Quotations (2001) P.182
Providing minor surgery Under the new GMS contract, minor surgery can be provided as an additional service or directed enhanced service (p.35). Minor surgery as an additional service Includes curettage and cautery and—in relation to warts, verrucae, and other skin lesions—cryocautery. In all cases, a record of consent of the patient to treatment and a record of the procedure itself should be kept. Payment is included within the global sum payment. If a practice does not want to provide this service it must ‘opt out’ and global sum payment is ↓ by 0.6%. Minor surgery as a directed enhanced service Extends the range of procedures beyond those practices are expected to do as an additional service. For the purpose of payment, procedures have been divided into 3 groups:

  • Injections—muscles, tendons, and joints
  • Invasive procedures—including incisions and excisions
  • Injections of varicose veins and piles

Payment Treatments are priced according to the complexity of the procedure, involvement of other staff, and use of specialized equipment. Terms for this must be negotiated locally. Typical figures in 2004/5 are £40 for a joint injection or £80 for a simple excision. Qualification to provide the service Practices can provide this service if they can demonstrate they have the necessary facilities and personnel (partner, employee, or sub-contractor) with the necessary skills. This includes:

  • Adequate equipment
  • Premises compliant with national guidelines as contained in Health Building Note 46: General Medical Practice Premises (DoH)
  • Nursing support
  • Compliance with national infection control policies—sterile packs from the local CSSD, disposable sterile instruments, using approved sterilization procedures, etc.
  • Ongoing training in minor surgery, related skills, and resuscitation techniques
  • Regular audit and peer review to monitor clinical outcomes, rates of infection, and procedure.

Minor surgery in PMS practices PMS contracts are negotiated on an individual basis with the local primary care organization. In most cases however, the contract provides for similar arrangements and payments to those in place for GMS practices. Never attempt a procedure if you are unsure about it—know the boundaries of your experience and abilities. P.183
Location and equipment A suitable room, adequate lighting, the appropriate equipment, and sufficient uninterrupted time is needed for successful minor surgery. An experienced assistant is also a great help. Sterile instruments and gloves and aseptic technique are essential.

  • Basic minor surgery sets: Scalpel; several sizes of blade (e.g. size 11 and 15); toothed forceps; needle holder, fine scissors; artery forceps; skin hook; curette.
  • Additional equipment required: Skin preparation liquid (e.g. chlorhexadine); local anaesthetic (e.g. lignocaine 1%); suitable sized needles and syringes; sterile towels; swabs; sterile specimen pots; suture materials and dressings for the wound. For joint injection, ensure you have steroid and local anaesthetic drawn up and suitable sized needles available before starting.

Always make sure you know how many blades, sutures, needles, and swabs you have and ensure that you have accounted for and safely disposed of them at the end of the procedure. Consent Patient consent for the procedure must be sought and recorded in the notes. This involves giving enough information about the procedure and other possible treatment options to allow the patient to make an informed decision about whether to proceed; the patient and consenting doctor should then both sign the consent form and the form should be filed in the patient’s medical records (p.60) Histological examination All tissue removed by minor surgery should be sent for histological examination unless there are exceptional or acceptable reasons for not doing so. Documentation Maintain full, legible, accurate records. Include:

  • History of the complaint
  • Examination findings
  • Diagnosis
  • Full details of the procedure undertaken—include dose, batch number, expiry date, and quantities of drugs; size and number of sutures
  • Follow-up arrangements.

If the patient is not registered with the practice undertaking the minor surgery, then a complete record of the procedure must be sent to the patient’s registered practice for inclusion in the GP notes. Follow-up and outcome Should be recorded in the patient’s notes. Advise the patient as to what to expect after the procedure, precautions to take, when to return for suture removal, signs that would indicate the need for reconsultation, and the expected recovery/healing time. Arrange a follow-up appointment for all but the most straightforward procedures. P.184
Basic techniques Local anaesthesia 0.5–2% lidocaine, xylocaine, and procaine are the most commonly used preparations. Epinephrine (1:200,000) added to local anaesthetic ↓ bleeding and prolongs anaesthesia, but do not use epinephrine in areas supplied by end arteries (i.e. fingers, toes, penis, ear, nose). The safe maximum dose of local anaesthetic in adults is 20ml of 1% solution (less in elderly and children)—overdose causes fits or cardiac arrhythmias. Administering local anaesthetic

  • Pre-warn patients that local anaesthetic stings before numbing and that they will still be able to feel pressure—but not pain. If pain is felt, more anaesthetic is needed.
  • Clean the skin, insert a small needle intradermally, and raise a small bleb before infusing more deeply.
  • Always pull back on the syringe plunger before injecting to check that you are not in a blood vessel.
  • Anaesthetic must be infused all around the excision site. This may require several needle insertions—try to do this through an already numb area to ↓ discomfort for the patient.
  • Allow time for the anaesthetic to take effect (2–5min) before proceeding.

Suturing Various techniques for suturing and knot tying can be used (e.g. interrupted, continuous, subcuticular). Always make a careful record of the number of stitches and when they should be removed. Usually stitches need removal after 3–5d., on the face, 7–14d. on the back and legs, and 5–7d. elsewhere. Steristrips can be used instead of or in addition to stitches in some circumstances. Cautery Chemical (silver nitrate) or electrocautery are used alone, or in combination with other methods (e.g. curettage), to secure haemostasis or destroy tissue. Suitable conditions: nose bleeds (p. 1042), spider naevi, telangiectasia. Do not use electrical cautery for patients with a cardiac pacemaker. Implants Subcutaneous implants are prescribed for several conditions (e.g. prostate cancer). Most implants come pre-packaged with an insertion cannula and information leaflet—always read and follow the instructions if administering a new product and ensure position of implant and timing of administration is correct. P.185
Suture types

  • Absorbable e.g. catgut, dexon, vicryl—used to stitch deep layers to help ↓ tension.
  • Non-absorbable e.g. silk, prolene, nylon—used for closure of skin wounds after minor surgery.

Needle types straight, curved, cutting, or round bodied. Surgical site and personal preference dictate which to use—a cutting needle is usually used for skin. Suture thickness (gauge) indicated by a number (10/0 is fine and 2/0 thick). For skin closure: 6/0 or 5/0 is usually used for the face, 3/0 on legs and back, and 4/0 elsewhere. P.186
Removal of skin lesions Ensure that you have had training in the techniques—learning by experience is much better than from a book. There are many courses available.

  • Only remove benign lesions—refer suspicious lesions to a specialist for expert management.
  • Only remove lesions that you are confident that you can cope with (take special care with lesions on the face or lip margin—the scar may be very noticeable).
  • Send all excised lesions for histology—place in formalin and carefully label with the site and side.

Excision of skin lesions

  • Gain written consent—ensure you have warned the patient about the likely size of the scar and the possibility of keloid (especially if the lesion is on a risk area e.g. upper back and chest).
  • Work out the direction of the skin contour lines, clean and anaesthetize the area (p. 184).
  • An elliptical incision—≈3× as long as it is wide—is suitable for most lesions. Place the incision in the skin contour lines if possible (marking the incision line can be helpful).
  • Cut through the skin at right angles to the surface with a smooth sweep of the blade.
  • Use a skin hook to lift the skin from one end of the ellipse.
  • Use the scalpel blade to remove the skin from the subcutaneous fat.
  • Save the excised specimen for histology.
  • Close the wound by carefully apposing the edges (slightly everted) using interrupted non-absorbable sutures. Avoid tension in the sutures and knot securely. Large wounds may benefit from the use of deep absorbable sutures to reduce skin tension.

Curettage Useful for seborrhoeic warts, pyogenic granuloma, kerato-acanthoma, or single viral warts. Not suitable for naevi. Use only if the diagnosis is certain—scrapings can be sent for histology but the architecture of the lesion is lost. Numb the area with local anaesthetic and remove the lesion with gentle scooping movements using a curette spoon. Finally, cauterize the base of the lesion. Cryotherapy Liquid nitrogen can be used to treat viral and seborrheoic warts and solar keratoses. Local arrangements for delivery of liquid nitrogen differ—often a clinic session to treat all suitable lesions at the same time is helpful. If diagnosis is uncertain, excise the lesion or take a biopsy prior to freezing. A cotton wool bud or nitrogen spray gun can be used to apply liquid nitrogen for ~10s. until a thin frozen halo appears at the base of the lesion. A blister forms <24th. after treatment; the lesion then falls off with the blister. Repeat treatment may be needed after 4wk. Side-effects Pain, failure to remove the lesion, skin hypo-pigmentation, ulceration of lower leg lesions (especially in elderly patients). P.187
P.188
Joint and soft tissue injections Steroids can have a potent local anti-inflammatory effect and dramatically improve certain musculoskeletal problems. Most joint injections are straightforward and can be undertaken within a general practice setting. General rules

  • Always use aseptic technique.
  • Do not inject if there is local sepsis (e.g. cellulitis) or any possibility of joint infection.
  • Never inject into the substance of a tendon—this may cause rupture (in tenosynovitis, steroid is injected into the tendon sheath).
  • Injections should not require pressure on the syringe plunger—if so, the needle is probably not correctly located (tennis elbow is an exception).
  • Undertake as few injections as possible to settle the problem—often 1 is sufficient. If no improvement after 2 or 3, then reconsider the diagnosis.
  • Do no more than 3 or 4 injections/patient /appointment and no more than 3 or 4 in any single joint/y.—more than this ↑ risk of systemic absorption and joint damage.

Preparation for the procedure

  • Take a history, make a careful examination, and have a clear diagnosis before considering injecting steroids.
  • Gather the needles, syringes, a sterile container (for sending aspirated fluid), steroid, local anaesthetic, skin preparation fluid (e.g. chlorhexi-dine), cotton wool, and elastoplast beforehand.
  • The injected joint should be rested for 2–3d. afterwards if possible— certainly avoid heavy activity. Make sure the patient is comfortable, has given informed consent, and knows what to expect.

Steroid preparations (↑ order of potency)—hydrocortisone acetate, methylprednisolone acetate, triamcinolone hexacetonide. Local anaesthetic (LA) e.g. lidocaine 1% can be mixed with the steroid for some injections—LA effect occurs immediately and lasts 2–4h.. The patient may then experience some return of symptoms (pain) before the steroid takes effect—warn the patient. Follow-up

  • Some injections are painful at administration—this is normal for tennis elbow and plantar faciitis.
  • Severe or increasing pain ~48h. after injection may indicate sepsis—advise the patient to return urgently if this occurs.
  • If steroid is injected close to the skin surface (as in tennis elbow), skin dimpling and pigment loss can occur—warn the patient.

Further information Silver T. Joint and soft tissue injection: injecting with confidence. Radcliffe Medical Press Most hospital Rheumatology Departments have a joint injection clinic and are happy to allow GPs to watch to gain experience P.189
Patient information Arthritis Research Campaign (ARC) Patient information leaflet: ‘Local steroid injections’ Tel: 0870 850 5000 http://www.arc.org.uk P.190
Lower limb injections The knee Joint effusions are common (e.g. trauma, ligament strains, OA, RA, gout). Aspiration of fluid can:

  • help make a diagnosis e.g. gout
  • be a therapeutic procedure—draining a tense effusion can relieve pain
  • precede administration of steroids e.g. RA flare

Aspirated fluid should be clear or slightly yellow and not purulent. If aspirating an effusion, send the fluid for analysis. Any sign of infection within the joint prohibits steroid use. Technique for aspiration and joint injection

  • Lie the patient on couch with knee slightly bent (place a pillow under the knee as this relaxes the muscles).
  • Palpate the joint space under the lateral or medial edge of the patella and inject/aspirate just below the superior border of the patella with the needle horizontal—Figure 7.1.
  • Use a green (21 gauge) needle.
  • If aspirating and then injecting steroids, maintain the needle in position and swap the syringe.
  • Normal doses of steroid are triamcinolone 20mg or methylprednisolone 40mg.
  • In prepatella bursitis, aspiration and injection of hydrocortisone 25mg into the bursa can help settle inflammation.

Plantar faciitis Painful area in the middle of the heel pad can be helped by steroid injection into the most tender spot—it hurts, so advise analgesia. Mixing lidocaine 1% with the steroid (e.g. triamcinolone 10–20mg) can help. Two methods are commonly used: injection through the tough skin of the sole of the foot (more accurate) or a lateral approach (less painful)—Figure 7.2. Rest the foot for several days and use an in-shoe heel pad. Rupture of the plantar fascia is a rare complication. Tenosynovitis Causes pain and stiffness in the line of the tendon and crepitus over the affected tendon. The most common site is the base of the thumb (DeQuervain’s tenosynovitis). Injecting steroid and local anaesthetic (e.g. hydrocortisone 25mg and 1ml 1% lignocaine) into the space between the tendon and the sheath can help

  • Insert the needle along the line of the tendon just distal to the point of maximum tenderness.
  • Advance the needle proximally into the tendon (felt as a resistance) and then slowly withdraw until the resistance disappears. The tip of the needle is now in the tendon sheath.
  • It is now safe to inject—the tendon sheath may swell.
  • Advise the patient to rest the affected area for several days and avoid the precipitating activity.
Figure 7.1 Knee joint injection. (Reproduced with permission from Oxford Handbook of Clinical Specialties (2003), Oxford University Press, Oxford.)
Figure 7.2 Injection of plantar fasciitis

P.191
P.192
Upper limb injections Carpal tunnel syndrome Can be relieved by steroid injection. Pain may worsen after injection for ≤48h. before it improves—warn the patient. Technique:

  • Sit the patient with hand resting on a firm surface, palm up. Palmaris longus tendon can be seen by wrist flexion against resistance.
  • Insert the needle at the distal skin crease, at 45° to the horizontal, pointing towards the fingers, just radial (thumb-side) to the palmaris tendon. Palmaris longus is absent in 10%—inject between the tendons of flexor digitorum superficialis and flexor carpi radialis—Figure 7.3.
  • Use a green (21 gauge) needle and advance it to about ½ its length. If there is sudden pain in the fingers you have hit the median nerve—withdraw the needle and reposition it.
  • Inject steroid e.g. 10mg triamcinolone. If there is resistance, the needle is not in the right place. Don’t use LA as it causes finger numbness.
  • Rest the hand for several days afterwards.

Shoulder Injection can help rotator cuff problems, frozen shoulder, subacromial bursitis and rheumatoid arthritis. There are several approaches (anterior, posterior, subacromial, or lateral)—the joint space communicates in most cases, so steroid will reach the whole joint whichever approach is used. Anterior approach:

  • Sit patient with the arm relaxed at the side and slightly externally rotated. Palpate the space between the head of humerus and the cora-coid process.
  • Insert the needle (green, 21 gauge) horizontally into that gap ensuring the needle is lateral to the coracoid process—Figure 7.4. The needle will need to be inserted for most of its length to reach the joint space.
  • Typical dose is 1ml steroid e.g. triamcinolone 20mg + 1ml 1% lidocaine.
  • There should be no/little resistance to injecting the fluid. If there is, the needle is wrongly positioned.

AC joint injection Can help the pain of OA. Palpate the joint space—the needle can be inserted anteriorly or superiorly. If you push the needle too far you may enter the shoulder joint. Small joint space means only 0.2–0.5ml can be injected, Use a blue (23 gauge) needle and don’t add LA. Elbow Tennis or golfer’s elbow respond well to steroid injection. Steroid is infiltrated into the tender spots at the tendon insertion, rather than into a joint space. Thus, there is resistance on injection and it can be quite painful, warn the patient. The steroid is injected relatively superficially—so warn the patient about the possibility of skin dimpling or pigment loss.

  • Sit the patient with the elbow flexed to 90° and palpate the most tender spot.
  • Insert the needle into that spot and inject 0.1–0.2ml of steroid (e.g. hydrocortisone 25mg/1ml). Then, without making a new skin puncture, move the needle in a fan shape around the area injecting small amounts of steroid. Try to inject all the tender area—Figure 7.4.
  • Pain of injection may last 48h.—advise resting the arm and analgesia.
Figure 7.3 Injection of the carpal tunnel
Figure 7.4 Injection of shoulder joint and elbow joint. (Reproduced with permission from Oxford Handbook of Clinical Specialties (2003), Oxford University Press, Oxford.)

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