4.5Personal Protective Equipment

OSHA defines personal protective equipment (PPE) as “specialized clothing or equipment, worn by an employee for protection against infectious materials” [12]. Since Mohs surgery exposes surgeons and assistants to blood-borne pathogens, all operative rooms should be equipped with PPE such as masks, eye protection, gowns, and gloves.

4.5.1Masks and Eye Protection

Due to the potential for exposure to blood droplets into the eye, nose, or mouth, the surgeon and assistants must wear a face mask and safety goggles. Masks may tie at the nape of the neck and around the back of the head or fit over the ears. To provide a secure fit and prevent fogging of goggles during surgery, masks should be equipped with an adjustable aluminum nosepiece. Safety goggles that cover the eyes up to the brow bone and have anti-fog and anti-scratch coatings are ideal.

4.5.2Gowns

Gowns offer coverage of the torso, arms, and thigh area. There are a variety of gowns available for medical wear with varying degrees of fluid resistance. Isolation gowns are made of breathable fabric, feature neck and waist ties, and protect the wearer from light splashes. For more fluid resistance, sterile operating room gowns which attach at the nape of the neck and tie around the waist are an option. These offer the highest level of protection against fluid penetration. However, single-use gowns may not be cost efficient.

and comfortable. Scrubs are also easily laundered and look professional.

4.5.4Gloves

There are a variety of medical gloves available including latex, vinyl, nitrile, or neoprene exam gloves and sterile gloves with varying characteristics (Table 4.2). Although Mohs surgery is performed under a clean technique, using sterile gloves during defect reconstruction offers superior protection and durability. Ultimately, patients’ allergies and the wearers’ comfort determine the choice of gloves. For patients with true latex allergies, it is important to stock vinyl exam and sterile neoprene gloves in several sizes.

Summary: Instrumentation and Setup

•High-quality stainless steel instruments are essential in Mohs surgery. The key instruments needed during Mohs surgery, defect closures, excisions and special site surgeries are listed.

4.6Instrumentation and Setup

Given the demands of Mohs surgery, high-quality stainless steel instruments are essential. Ideally, instruments should be stored in the Mohs surgery operative room for easy access. If there is a lack of storage space, the operative room can be stocked with a few basic instrument packages for backup and emergency situations. As the surgical instruments are delicate, they should be handled with care, and cleaned and stored properly after each use.

Scrubs are an alternative option to surgical gowns. Because they are short sleeved, scrubs prevent the contamination of the surgical site from long sleeves dragging into the field. Scrubs also protect the wearers’ body, but they are not impermeable to fluid. They are a great option for office-based surgery as they are loose

The two main scalpels used in Mohs surgery are the Bard Parker #3 and the Siegel handle. The Bard Parker #3 can be flat or rounded with an optional etched ruler on one side. The Siegel handle is smaller, with a hexagonal or round contour and is good for delicate work. It is also easier to use for Mohs surgeons with smaller

4.6.3Standard Mohs Surgery Setup

The Mohs surgery tray for the initial stage usually consists of (Fig. 4.12):

1.4 × 4 gauze and/or cotton-tipped applicator sticks

2.Fenestrated surgical drape

3.Mohs tray to transport tissue into Mohs lab

4.Hemostasis (aluminum chloride, electrosurgery, pressure)

5.Gentian violet pen or ink for tissue orientation markings

6.Fox curette – used to debulk tumors prior to removing the first layer, curette sizes range from 1 to 9.

The number refers to the width of the opening in millimeters

7.Adson forceps – fine teeth minimize tissue damage

8.Scalpel with blade

9.Mohs map with diagram of anatomic site

4.6.4Mohs Surgery Eye Tray

In addition to the items used in a standard Mohs surgery stage tray, the following are useful when working around the eyes (Fig. 4.13):

1.Eye shield remover

2.Plastic corneal eye shield – available in small, medium, or large sizes

3.Scalpel with blade

4.Gradle scissor

5.Adson or Bishop-Harmon forcep – useful in delicate areas to grasp small tissue pieces

6.Suction – Frazier 6 French–size tip is effective

7.Chalazion clamps – to immobilize tissue (not pictured)

4.6.5Excision/Closure Tray for Face

The following items can be used for excisions or closures on the face (Fig. 4.14):

1.Suture cutting scissor

2.Hartman hemostat – to clamp vessels during ligation

3.Needle driver – size may vary depending on surgeon preference and comfort; size should be proportional to size of suture needle

4.Gradle scissors – optional for more delicate closures; shorter with blade slightly curved giving better control [4]

5. Skin hook – a small two-pronged skin hook is recommended to retract skin since it minimizes tissue damage compared to retractors

6. Adson forceps with suture platform – aides in stabilizing the needle while suturing

7.Scalpel handle with blade of choice

8.Miscellaneous items – gauze, cotton-tipped applicator sticks, fenestrated drapes or towels, electrosurgery pencil with a sterile plastic sheath, local anesthesia, sterile light handle cover

4.6.6Excision/Closure Tray for Trunk

For excisions/closures on the trunk, the following modifications are made to the tray (Fig. 4.15):

1.Hemostat – medium or larger size

2.Suture-cutting scissor

3.Medium/Large Needle driver

4.Supercut Par Undermining Scissors

5. Skin hook – 2–4 pronged hook useful in thicker tissue

6.Adson forcep

7.Scalpel handle with blade

2.Nail elevator

3.Nail-pulling forcep

4.Penrose tubing

4.6.7Nail Surgery Instruments

In cases where nail removal is necessary, the following instruments are recommended (Fig. 4.16):

1.Double-action nail splitter – causes minimal damage to the nailbed

4.6.8Miscellaneous Instruments (Fig. 4.17)

1.Blade remover – to safely remove blades; forceps and needle holders should never be used as it can damage delicate instruments and risk injury