If the practice uses an electronic medical record (EMR) system, consider speaking to information technology personnel about attaching digital photographs to the EMR. Investing in photography software is another way to organize and edit images. One may use the image software enclosed with the camera or purchase an appropriate program. Another option is to purchase dermatology specific photography software. Other items to account for include equipment malfunction and the need for a backup system, such as a Polaroid camera. It is important to backup the digital photography system daily.

4.3.2Laser Safety

For many Mohs surgeons, laser surgery is an integral part of their practice. Since lasers are often stored in the Mohs operative rooms, laser use must adhere to laser safety regulatory standards. In the US, guidance for laser safety is outlined in the ANSI (American National Standards Institute) Z136 series of standards [7]. These standards are produced by the Laser Institute of America and accepted by the US Food and Drug Administration (FDA). Overall, laser-specific goggles should be available for the patient and personnel during treatment sessions. The appropriate sign indicating the laser type must be placed on the door during laser operation. Laser shades are required on windows and must be drawn during laser use. Finally, a fire extinguisher should be easily accessible in the event of a fire.

Summary: Mohs Surgery Operative Room

Equipment

•Surgical equipment for Mohs surgery operative rooms is a significant cost investment. Key items include: surgical table and surrounding ergonomic aids, lights, sink, electrosurgical equipment, suction, mayo stand/ kick bucket, and waste disposal containers.

4.4Mohs Surgery Operative Room Equipment

Surgical equipment for Mohs surgery operative rooms is a significant cost investment and should be chosen carefully for high quality and longevity. Ergonomics is an

applied science that evaluates the characteristics of humans that need to be considered, when designing things people use, to make the interaction most effective and safe. In short, it is important to “buy good quality equipment and save your back” [3]. All key equipment, from the operating table to the laboratory microscope, must be designed to promote proper ergonomics. If possible, it is advisable to test large surgical equipment prior to purchase. For example, it is recommended to lie on the operating table for 10–20 min to determine its comfort since patients will lie on it for longer periods of time. When large equipment is delivered, thoroughly test it to assure proper working condition. Regular maintenance and cleaning will prolong the life of the equipment.

4.4.1Surgical Table

The surgical table is the centerpiece of the operating room and one of the most important equipmentpurchasing decisions. There are two basic types of tables, hydraulic or electric-powered. Hydraulic tables work via a pump that forces hydraulic fluid through hydraulic pistons [6]. The benefit of hydraulic tables over electric tables is that they allow faster table adjustment and last longer. Electric tables can be hand-oper- ated, foot-operated or both. Foot operation is usually preferred, especially for intraoperative adjustments.

Variables to consider when purchasing a surgical table include table width and entry height. While a wider table may be more comfortable for a large patient, a narrower table allows the Mohs surgeon to access the surgical site more easily and maintain good ergonomic posture. Similarly, while armrests may be more comfortable for the patient and safer for senile patients that might roll, it creates a bulky operating table for the surgeon. Surgical tables with a low entry height are very important for the elderly or handicapped patients and facilitate easier transfer from wheelchairs. Other surgical table accessories to consider include headrests, armboards, footboards, and stirrups. Since Mohs surgery is often performed around the head and neck areas, small headrests are preferable for easier access.

Adjustability is another consideration when buying a surgical table. The number of “mobile” joints or break points determines the adjustability of the operating table. The options include: back elevation, foot elevation, table elevation, and tilt elevation [4]. The combination of the four positions allows flexibility in patient positioning and

Back Elevation

Tilt Elevation

Foot Elevation

Table Elevation

Fig. 4.3 Surgical table demonstrating four mobile joints/break points

comfort (Fig. 4.3). Some tables with programmable controls allow, with the push of a single button, configuration to a set position. All tables must allow tilt adjustment to the Trendelenburg position (head below the heart) for managing vasovagal reactions. It is the tilt adjustment that can place the patient into the Trendelenburg position.

ceiling, wall, or floor. Ceiling-mounted track lights are the gold standard due to easy adjustability and not requiring floor space. Ceiling composition and height play a role when choosing surgical lights. Nine-foot ceilings are compatible with many commercial lighting fixtures [6]. Ceiling-mounted track lighting offers the greatest range of motion (360°), but it requires special structural steel beams to accommodate the weight and provide stability (Fig. 4.4). While a ceilingmounted mini O.R. light can be used, the range of motion is limited to 300° and can be difficult to maneuver (Fig. 4.5). To avoid arm and back strain when turning ceiling-mounted lights on and off, a light switch can be placed on the wall.

There are several variables to consider when purchasing surgical lights. The intensity of light output is usually expressed in footcandles, which is related to the type of bulb and filter. Surgical lights range from 3,000 to 8,000 footcandles. Reflective dish diameter and shape (concavity) of the light determines the field size and focus depth. As the dish diameter decreases, the field size also decreases. Depth of field and focal point are related to the degree of the dish’s concavity with some models having a focusing knob that sharpens the intensity of light within the depth of field. Some lights

Operating Table

In a recent survey of American College of Mohs Surgery members, 90% of respondents reported some type of musculoskeletal pain including neck, lower back, shoulders, and upper back (Personal communication, pending publication, Christine Liang, M.D.). Leg edema is a common complaint among Mohs surgeons due to the amount of time spent standing in static positions. In addition to compression stockings and gel insoles in shoes, other aids include: foot rails, which encourage an active stance; and antifatigue mats that reduce static stress in legs by forcing the feet to move to maintain stability [8]. Sit–stand stools and pelvic tilt chairs are other ergonomic aids around the operating table that can reduce leg edema by taking pressure off the legs. In addition, they can reduce neck, shoulder, and back pain, especially when sternal support is included.

4.4.3Surgical Lights

Proper lighting is extremely important in all surgical procedures. Surgical lights can be mounted on the

light and provides a greater field size. The reflective light also minimizes shadow and produces less heat on the surgical field. Filters can be added for color correction, giving tissue a more natural appearance [3, 9].

Eye fatigue and headaches are partially caused by bright lights and glare. Objects in the surgical field contributing to glare include skin, surgical antiseptic preparations, bloody tissue, and instruments. Reducing glare from the operative field can lessen eye fatigue and suggestions include: drying the surgical site, using goggles and glasses coated with antiglare film, and using brushed steel instead of polished steel surgical instruments [8].

4.4.4Surgical Sink

A surgical sink with foot pedals is preferable for Mohs surgery operative rooms. While more expensive than conventional sinks, they prevent contamination of the hands when turning off sink water controls. They are often paired with foot-operated soap dispensers. A sink with a depth of 18–24 in. is recommended to decrease splash and encourage a good water stream when hand washing [4].

Fig. 4.4 Surgical light: ceiling-mounted track light

Fig. 4.5 Surgical light: ceiling-mounted mini OR light

Fig. 4.6 Monoterminal electrosurgical device (Hyfrecator)

4.4.5Electrosurgical Equipment

Electrosurgery refers to the use of electricity to cause thermal tissue damage in the form of coagulation and tissue dehydration. The two main types are highfrequency electrosurgery and electrocautery. In brief, high-frequency electrosurgery involves the passage of high-frequency alternating current through the skin where it is converted to heat and results in thermal tissue damage. Electrosurgery devices are either monoterminal or biterminal.

In monoterminal machines, commonly referred to as hyfrecators, one electrode delivers current to the patient (Fig. 4.6). The patient briefly stores the energy and then it is shed into the surrounding environment. Since current accumulates within the patient, high voltage is required to sustain current flow. These high voltage machines have low amperage (current) in order to minimize tissue damage. They cause superficial thermal tissue damage with decreased risk of scarring with lower power settings. Higher power settings can be used for electrocoagulation, but also increase the risk for superficial scarring and hypopigmentation.

Conversely, biterminal machines have a second, dispersive electrode which completes the electrical circuit from the patient back to the machine (Fig. 4.7). Thus, a lower voltage can be used to achieve increased amperage. The higher amperage causes a deeper and more thorough destruction. In addition, electrocoagulation can be achieved with less carbonization.

Compared to electrosurgery, electrocautery differs in that direct current is used to heat an electrode that causes thermal damage by direct heat transference to tissue. Whereas the electrode remains cold in highfrequency electrosurgery, in electrocautery, it is hot. Electrocautery uses a low voltage and high amperage and is good for pinpoint hemostasis. It is the preferred electrosurgical device for patients with pacemakers and defibrillators as no current flows through the patient.

Understanding the pros and cons of each electrosurgery system can help one choose the best device for the Mohs surgery operative suite. The monoterminal hyfrecator does not provide cutting current and therefore is primarily a coagulating instrument. In addition, it requires a dry field to work effectively. The biterminal devices provide cutting and coagulating currents. These devices however can be bulky and require use of a grounding pad. Furthermore, the high amperage provided by these machines can lead to scarring when treating benign superficial lesions. A portable, battery-powered electrocautery device works well in a bloody field and can be used in patients with pacemakers and defibrillators since there is no current directly involved. However, they may not be sufficient for extensive surgical procedures and require frequent battery changes [4]. Irrespective of device choice, one must use sterile tips and have a method to sterilize the handle between patients. Disposable tips and handle covers are readily available.

Currently, there are no specific Occupational Safety and Health Administration (OSHA) standards for laser/electrosurgery smoke hazards [10]. Nonetheless, use of a smoke evacuator is recommended for several

reasons (Fig. 4.7). The smell of burning skin can be disconcerting to many patients and surgical plume can lead to respiratory irritation in patients and staff. In addition, while there is no documented transmission of infectious disease through surgical smoke, there is a potential to generate infectious viral particles.

4.4.6Suction

Electrical suction devices remove blood from the operative field during surgery. Suction units are available as mobile or wall-mounted devices. Mobile units on an equipment cart are often preferred due to ease of positioning around the patient. Wall-mounted suction outlets connected to a central suction unit save space and eliminate noise but can be very costly to install and maintain. Overall, the suction should be capable of producing a negative suction of 40–60 mmHg [3]. Disposable supplies for suction units include presterilized suction tubing and tips (Fig. 4.8).

4.4.7Mayo Stand/Kick Bucket

Mayo stands are an essential part of a Mohs surgery operative room allowing easy access to surgical instruments during procedures. Different features on Mayo stands include: platform size and movement, mechanism for raising and lowering the platform, and number of wheels ranging from 2 to 6. Fourto six-wheeled mayo stands are preferred for ease of movement.