2. Lister bandage scissors

3. Allis clamp – to grasp tissue such as a lipoma

4.Small metal bowl

5.Towel clamps – to secure surgical towels

6.Comedone extractor

Summary: Wound Care Dressing Materials

•The wound care materials necessary for intra and postoperative dressings are discussed.

4.7Wound Care Dressing Materials

Mohs surgery operative rooms should be stocked with wound care dressing materials necessary for intra and postoperative dressings. If space allows, a separate area can be designated for storage of dressing supplies (i.e., on a second mayo stand). A variety of dressing materials is often necessary to accommodate the wide range of surgical procedures and anatomic sites encountered (Table 4.3).

Summary: Equipment Sterilization

•Proper cleaning and sterilization of surgical equipment is important in maintaining infection control standards. Steam autoclaving is the most practical method in an office setting.

4.8Equipment Sterilization

Equipment sterilization depends on the composition of surgical instruments and usage. Proper cleaning and sterilization is important for maintaining infection control standards. Mohs surgery instruments are categorized as critical on the Spaulding scale, because they enter sterile tissue and could transmit microbial disease [11]. Instruments should be cleaned prior to sterilization to remove visible blood and debris and prepare instruments for safe handling. An ultrasonic cleaner is ideal because instruments are placed in a wire basket and submerged in a neutral pH detergent. The ultrasound agitation dislodges

organic material in the hard to clean spaces of delicate instruments [13]. Remember that this process only renders the instruments clean not sterile.

In accordance with Center for Disease Control (CDC) guidelines, surgical instruments should be sterilized with steam if possible, or if heat sensitive, treated with Ethylene Oxide (ETO), hydrogen peroxide plasma, or liquid chemical sterilants if other methods are unsuitable [11]. Steam autoclaving is the most practical method in an office setting because it requires minimal training and has a quick treatment time. Steam autoclaves come in different sizes and the selection is based on volume of anticipated instrument usage and the size of the packaged instrument sets. Instruments that were used earlier in the day can be packaged and sterilized for usage in the afternoon. With steam sterilization, instruments are wrapped prior to sterilization, thereby maintaining sterility after processing and storage. It is a good idea to include a sterilization process indicator strip or heat sensitive tape when wrapping or packing instruments. These strips change color or darken when exposed to heat.

However, keep in mind that heat-sensitive strips confirm that packages were exposed to the sterilization process, but they do not confirm sterility. The strips are highly sensitive and can change color with heat exposure. Packages that are not yet autoclaved should not be left on top of or along the sides of the machine.

Due to federally mandated monitoring guidelines necessary for chemical or gas sterilization, particularly ETO, they are rarely used outside of hospitals. Instruments that require these methods, such as plastic corneal eyeshields can be sent to local facilities for sterilization, or the surgeon may consider purchasing eyeshields than can be autoclaved safely between 50 and 100 times before being discarded.

Summary: Monitoring and Emergency Equipment

•Office-based Mohs surgery is performed under local anesthesia without monitoring. Nonetheless, Mohs surgery offices should be equipped with an emergency kit and the office staff trained in basic life support.

•Oropharyngeal airways

•Laryngoscope with endotracheal tubes of various sizes

•Ventilation (Ambu) bag with airways of various types and sizes

•Oxygen tank

•IV catheters of various sizes

•Bags of intravenous fluids

•Prefilled syringes/ampoules of emergency drugs including but not limited to: epinephrine, atropine, dextrose, lidocaine, sodium bicarbonate, diphenhydramine, and furosemide

Summary: Conclusion

•The careful design and building of a Mohs micrographic surgery suite will provide an environment for comfortable and efficient care of the patient, while meeting regulatory safety standards and the ergonomic needs of the staff.

4.9Monitoring and Emergency Equipment

Although the majority of Mohs surgery cases are performed under local anesthesia without monitoring, routine vital signs such as blood pressure, heart rate and respiratory rate are often recorded. At a minimum, offices should have a thermometer, stethoscope, and manual blood pressure cuff. One can consider purchasing a pulse oximeter with an automatic blood pressure cuff that can also detect oxygen saturation [14].

Mohs surgery offices should be equipped with an emergency cart (“crash cart”) or kit in case of a cardiopulmonary arrest or life-threatening drug reaction. Key office staff should be trained in basic cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS). In addition, an emergency plan for transporting the patient to the hospital if needed is important.

The following is a list of essential items in an emergency cart.

Essential Emergency Cart Items

•Automatic external defibrillator (AED) – these units are universally available and are part of basic CPR training

4.10Conclusion

When designing and building a Mohs surgery suite, consultation with a contractor, architect, interior designer and an occupational health specialist will ensure that the facility will meet the needs of patients and staff. Larger operative rooms will allow for future growth and longevity as will the use of durable materials on ceiling, walls and floor. All key equipment, from the operating table to the surgical instruments, should be sturdy and promote proper ergonomics. Finally, it is important to follow local, state and federal regulations regarding waste disposal, personal protection equipment, and equipment sterilization.

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